A DICTIONARY OF PRACTICAL MEDICIHE: COMPRISING GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES, AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE DIFFERENT EPOCHS OF LIFE. WITH NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED; A CLASSIFICATION OF DISEASES AC- CORDING TO PATHOLOGICAL PRINCIPLES; A COPIOUS BIBLI0GRAPHY, WITH REFERENCES; AND AN of iFontmlae: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE AND A DIGEST OF MEDICAL LITERATURE. BY JAMES COPLAND, M.D., F.R.S., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ? HONORARY MEMBER OF THE ROYAL ACADEMY OF SCIENCES OF I YVEDEN ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; AND OF THE ROYAL ACADEMY OF MEDICINE OF BEL- I GIUM ; LATELY PRESIDENT OF THE ROYAL MEDICAL AND CIIIRURGICAL SOCIETY OF LONDON ; FOR- MERLY CONSULTING PHYSICIAN TO QUEEN CHARLOTTE’S LYING-IN HOSPITAL AND SENIOR PHYSICIAN TO THE SOUTH LONDON DISPENSARY *, CONSULTING, AND LATELY SENIOR, PHYSICIAN TO THE ROYAL INFIRMARY FOB DISEASES OF CHILDREN, ETC. EDITED, WITH ADDITIONS, BY CHARLES A. LEE, A.M., M.D., PROFESSOR OF MATERIA MEDICA AND GENERAL PATHOLOGY IN GENEVA COLLEGE, ETC., ETC. “ ©latilj toolUe f>e lerne anil jjlatils tec^e.”—Chaucer. IN THREE VOLUMES. YOL. II. FEW YORK: HAEPEE & BEOTHEES, PUBLISHERS, FRANKLIN SQUARE. 1859. “ I writ it also out of great good-will Unto my countrymen; and leave my skill Behind me, for the sake of those that may Not yet be born; but in some after day May make good use Of it, without abuse.” T. Mace. Alphonso the Wise, in one of his Laws, entitled “Quales dehen ser los Fisicos del Rey, et que es lo que deb en facer" states that “Physic, according as the wise antients have shown, is the knowledge of understanding things according to nature,—what they are in themselves, and what effect each pro- duces upon other things; and therefore they who understand this well can do much good, and re- move many evils; especially by preserving life and keeping men in health, averting from them the infirmities whereby they suffer great misery or are brought to death. And they who do this are called Physicians; and, as Aristotle said to Alexander, four things are required in them : first, that they should be knowing in their art; secondly, that they should be well approved in it; thirdly, that they should be skilled in the cases which may occur; and fourthly, that they should be J'vht loyal and true.” “ Scribere fert animus multa et diversa, nec uno Gurgite versari semper; quo flamina ducant Ibimus, et nunc has, nunc illas nabimus undas; Ardua nunc ponti, nunc littora tuta petemus. Et quanquam interdum fretus ratione, latentes Naturae tentabo vias, atque abdita pandam, Praecipue tamen ilia sequar quaecunque videntur Prodesse, ac sanctos mortalibus addere mores.” Palingenius. “Non ego me methodo astringam serviliter ulla, Sed temere Hyblaese more vagabor apis, Quo me spes praedse et generandi gloria mellis, Liberaque ingenii quo feret ala mei.” Cowley. “Homo, naturae minister ac interpres, tantum facit ac intelligit quantum de naturae ordine, re, vel (et) mente, observaverit; nec amplius scit ac potest.” Novum Organum. “Men’s qualifications and endowments, though of themselves but slender, and unequal to the work, yet, when properly and regularly used and applied, are capable of bringing such things before the judgment, and into practice, as lie extremely, remote from the ordinary sense and action.” Bacon, Aphorism. 3. “ For there'are wanderers o’er eternity Whose bark goes on and on, and anchored ne’er shall be.” Entered, according to Act of Congress, in the year one thousand eight hundred and forty-six, by HARPER & BROTHERS, in the Clerk’s Office of the District Court of the Southern District of New York. CONTENTS OF THE SECOND VOLUME. Page GALL-BLADDER AND DUCTS .... 6 GANGRENE 9 GASTRO-ENTERIC DISEASE 29 GLANDERS 34 GOUT 87 HAEMORRHAGE—Pathology of .... 72 FROM THE SKIN ... 87 NOSE ... 88 MOUTH AND THE THROAT 94 RESPIRATORY OR- GANS 95 STOMACH . . 108 INTESTINES . . 118 URINARY ORGANS 122 UTERUS . . .127 INTO SEROUS CAVITIES . . 142 THE AREOLAR TISSUE AND SUBSTANCE OF ORGANS . . .143 HAEMORRHOIDS 144 HAIR 159 TRICHOMATOUS—PLICA . . . .164 HEADACHE 167 HEARING 182 HEART AND PERICARDIUM—Diseases of the . 193 HERPETIC ERUPTIONS 267 HICCOUGH 271 HOOPING-COUGH 273 HYDATIDS . 292 HYPERTROPHY 298 HYPOCHONDRIASIS 300 HYSTERIC AFFECTIONS 314 JAUNDICE 341 ICHTHYOSIS 360 IMPETIGINOUS AFFECTIONS . . . .363 IMPOTENCE AND STERILITY . . . .369 IN THE MALE 370 AND STERILITY IN THE FEMALE 373 INDIGESTION 377 INDURATION 400 INFECTION . 401 INFLAMMATION 426 INFLUENZA 489 INSANITY 500 . IDIOTIC 625 Page INSANITY, PUERPERAL 628 , SUICIDAL 636 INTESTINES—Diseases of, etc 658 IRRITABILITY 690 IRRITATION 696 ITCH 716 KIDNEYS—Diseases of, etc. ..... 721 LACTATION—Disorders of 772 LARYNX AND TRACHEA 776 LEPROSY . 807 LEUCORRHCEA 816 LICHEN 826 LIVER—Diseases of, etc 829 LUNGS—Diseases of, etc 878 LUPUS 913 LYMPHATIC AND LACTEAL SYSTEM —Dis- eases of 918 LYMPHATIC GLANDS .923 MAMMA 928 MEASLES 938 MEDIASTINUM 951 MELAENA 953 MELANOSIS 955 MEMBRANES 959 MENSES ) MENSTRUATION I phenomena of • • • • 959 .DELAYED . . . .963 .OBSTRUCTED . . .966 .SUPPRESSED . . . 968 .DIFFICULT . . . .972 .EXCESSIVE . . . .976 MESENTERY 983 MILIARY ERUPTIONS 992 MUSCULAR STRUCTURE—Diseases of . . 993 NERVES 998 NEURALGIC AFFECTIONS 1006 NIGHT-BLINDNESS, ETC. ... . 1029 NOSTALGIA 1033 OBESITY 1035 (EDEMA 1039 (ESOPHAGUS 1041 OSSEOUS SYSTEM 1053 OVARIA 1061 OZ.ENA 1067 APPENDIX OF FORMULAS. In order to prevent repetitions, and to facilitate references, the following collection of For- mulae is here appended and arranged in alphabetical order, in addition to those which it was necessary to give in the body of the work. The author has not added any of the formulae pre- scribed by the three British Colleges of Physicians, as they are already in the hands of every practitioner. The preparations and recipes he has given, both here and at other places, consist ol a careful selection of those which are most approved, contained in the Pharmacopoeias of va- rious hospitals and foreign countries, and from the writings of a number of eminent practical physicians, as well as of those which he has been led chiefly to confide in during a practice of upward of twenty years. He has followed the Nomenclature adopted by the London College in the latest edition of their Pharmacopoeia ; and to avoid circumlocution, he has retained the short and characteristic names usually employed, although many of them are by no means classical. Form. 1. Acetum Antihystericum. (Disp. Fuld.) R Castorei, Asafoetidaj, 55, 3ij.; Galbani, Jss.; Herb® Rut® recentis, Jj.; Aceti Vini, ffiij. Macera bene et cola. Form. 2. Acetum Camphoratum. R Camphorae Pulver. cum Alcoholis pauxillo solutae, Jss.; Sacchari Albi, Jijss. ; Aceti Vini, Jvss. Solve. (Jj. con- tains 3ss. of camphor). Form. 3. Acetum Camphor* et Ammoni*. R Camphorae, 3ij., teratur in mortario vitreo, cum Alco- holis guttis, xx. vel xxx. ; Sacchari Albi, J-ss., tritis adde, Acidi Acetici Fortioris, 3ij.; Liquoris Ammoni® Acetatis, Jiijss. ; Infusi Cinchonas, vel Aqu® Destillat®, Jiijss. Fiat Mist., cujus sumat ®ger Cochlear., ij., ampla secundA vel tertia vel quarta quaque horh. (In the last stage of Febrile Diseases attended with de- pressed powers of life.) Form. 4. Acidum Nitro-Hydrochloricum. ft Acidi Nitrici, Acidi Hydrochlorici, singulorum partes (mensural) ®quales. Dosis A minim., vj. ad Ttlxx., bis, ter, s®piusve quotidie, in Hordei Decocti, Jiv., cum Sirupo Simplice. r'orm. 5. Acidum Nitro-Hydrochloricum Dilutum. ft Acidi Nitro-Hydrochlorici, Aqu® Destillat®, 55, Oj. Misce. (The nitro-hydrochloric acid bath may consist of three ounces of this diluted acid to every gallon of water.) Form. 6. -Ether Phosphoratus. R Phosphori Puri, gr. ij. ; Olei Menth® Piper., 3j.-3ss. Solve, et adde .Ether. Sulphur., Jj. M. Vel, Form. 7. R Phosphori Puri, gr. ij.; .Ether. Sulph., Jjss.; Olei Va- lerian®, Iftxij. M. (In doses of vj. to xij. drops on sugar.) Form. 8. Aqua Cosmetica. R Mist. Amygdal. Amar. vel Dul. colat®, Jiij.; Aqu® Ros® et Aqu® Fior. Aurantii, 55, Jiv.; Sod® Biboratis, 3j.; Tinct. Benzoini comp., 3ij. M. Fiat Lotio. Form. 9. Aqua Styptica. R Ferri Sulphatis, Alumin® Sulphatis, 55, Jjss.; Aqu®, Jxij. Solve et cola ; dein adde Acidi Sulphurici, Jj. Form. 10. Aqua Styptica Cupri et Zinci. R Zinci Sulphatis, Cupri Sulphatis, 55, 3j.; Aqu® Ros®, Jviij. Solve. Form. 11. Aqua Styptica Zinci. , ft Zinci Sulphatis, Alumin® Sulphat. Calcin., 55, 3j. ; Aqu® Ros®, Jvj. Solve. Form. 12. Aqua Traumatica Thedenii. R Acidi Acetici, foiij. ; Alcoholis, foij. ; Acid. Sulphur., fo8s.; Mellis Despumati, foj. Misce. Form. 13. Aqua Vanii.l*. ft Fruct. Vanill® concis. et cont., Jvj.; Potass® Carbon., 3vj. ; Aquae Destil., Oij.; Spirit. Vim Ten., Ojss. Ma- cera leni cum calore per triduum, et cola. Form. 14. Balneum Ioduretum. (Lugol.) R Solut. lodin® Rubefac. (Vide Form, inter Solutions), fj.-fiv. ; Aquae Cong., xj.-l. Form. 15. Balneum Sulphureum. R Magnesiie Sulphatis, 3iv.; Potass® Bitart., 3j.; Potassii Sulphureti, 3j.: tere simul,et solve in Singulis Congjis Aquae Balnei. Form. 16. Balneum Potassii Sulphureti. R Potassii Sulphureti, Jj. ad Jiv.; Aquae Communis, Ibc. ad focc. Solve. (Nearly the same as the sulphureous baths of Bareges. In Chronic Affections of the Skin, and in Chronic Visceral Affections.) Form. 17. Balneum Potassii Sulphureti et Gela- t TIN*. R Potassii Sulphureti, Jij. ad Jiv. ; Aquae Communis, foe, ad ibcc. Solve, et adde Ichthyocollae, Ibj. ad Ibij., in Aquae bullientis solutae, fox. (Dupuytren.) Form. 18. Balsamum Astringens. R Olei Terebinthin® part., ij.; adde guttatim Acidi Sul- phurici, part, ijss., in vase vitreo, ope balnei arenarii calefacto. Liquori refrigerato, adde gradatim Alco- holis, part. viij. Macera per dies septcm. (Dosis 3ss.-3j. vehiculo quovis, idoneo, in Morbis Haemorrha- gicis.) Form. 19. Balsamum Astringens. R Olei Terebinthinae, Acidi Hydrochlorici Concent., 55, part. j. ; agita bene, et post diem adde Alcoholis, part, viij. ; Camphorae, part. ss. Form. 20. Balsamum Succinatum. R Balsami Copaiba;, Terebinthinae Venet., Olei Succim, 55, 3j. Misce. Capiat tllxxx. ter quotidie in quovis vehiculo idoneo. (In Deucorrhoea, Gleet, Emissions, &c.) Form. 21. Balsamum Sulphuris, vel Oleum Sul- phuris. R Florum Sulphuris, partem j. ; Olei Amygdal. Dulc., part, iij.; Olei Anisi, part. ij. Macera per dies septem in balneo arenario. Form. 22. Balsamum Sulphuris Terebinthinatum. (Balsamum Vitos RulandL) R Florum Sulphuris, part. iij.; Olei Lini, part. vij.; Olei Anisi, part. v. Solve in balneo arenario, et adde Olei Terebinthime, part. xx. Misce. (Excitant, diuretic, expectorant, &c. Dose fllx.-xxx.) Form. 23. Balsamum Terebinthinatum. R Olei Olivie, Jvj.; Terebinthime, Jij.; Cerae Flavae, Jj.; Bals. Peruvian., 3ij.; Camphor® rasae, 3jss. Solve Oleum, Terebinth., et Ceram ; dein adde alia. (Near- ly the same as the Balsam of Chiron, a long-celebrated medicine.) APPENDIX OF FORMULAE—Bolus—Decoctum. Form. 24. Bolus Anodynus. R Pulv. Jacobi veri, gr. iv.; Camphor® Pulverizat., gr. iij.; Pulv. Potassae Nitratis, gr. x.; Extracti Hyoscyami, gr. vij. ; Conservae Rosar., q. s., ut fiat Bolus, H. s. s. (In Cerebral Affections, &c.) Form. 25. Bolus Ante Spasmos. R Pulveris Castorei Optimi, 3ij* i Pulv. Radicis Valerian®, fss.; Camphor® ras®, 3j. Misce accurate, et adde Sirupi Papaveris satis quantum ut fiant Boli granorum duodecim : involvantur pulvere Stigmatorum Croci Sativi. Form. 26. Bolus Arnic®. R Pulv. FIot. Arnic® Montan., Camphor® ras®, 55, gr. iv.; Conserv® Rosar., q. s., ut fiat Bolus. Form. 27. Bolus Bismuthi Compositus. R Moschi, gr. x. ; Bismuthi Trisnitratis, gr. iij.-viij.; Opii Puri, gr. ss.-j.; Conserv® Rosar., q. s., ut fiat Bolus, pro re nath sumendus. Form. 28. Bolus Cambogi®. R Cambogi® Gummi Resin®, gr. viij.: tere cum Olei Ju- niperi, Ttliij., et adde Potass® Bitart., gr. xx.; Pulv. Scill®, gr. j.; Sir. Zingiberis, q. s., ut fiat Bolus. Form. 29. Bolus Camphor®. R Camphor® ras® et ope Alcoholis subact®, gr. iij.-x.; Pulv. Flor. Arnic® Montan®, gr. iij.-vj.; Confect. Rosa Canin®, q. s., ut fiat Bolus, quarta vel sexta qadque hora sumendus. Form. 30. Bolus Catechu Thebaiacus. R Catechu Ext. contriti, gr. xv.; Confectionis Opii, gr. viij.; Pulv. Cret®, gr. iv.; Sirupi Aurantii, q. s., ut fiat Bolus, bis, ter, sapiusve in die deglutiendus. Form. 31. Bolus Ferei. R Ferri Sesquioxidi, gr. x.-xx.; Pulv. Aromatici, gr. v.; Sirupi Zingiberis, q. s., ut fiat Bolus, bis terve quotidie deglutiendus. Form. 32. Bolus Guaiaci Ammoniati. R Guaiaci Gum. Resin®, gr. viij.-xij.; Camphor® ras®, Ammoni® Sesquicarbon., 55, gr. iv.; Pulv, Acacia, gr. iij.; Confect. Ros®, q. s., ut fiat Bolus, horh sonmi su- mendus. Form. 33. Bolus Guaiaci Compositus. R Guaiaci Resin, cont., 3j.; Ipecacuanha Rad. Pulv., gr. j.; Opii Puri, gr. j.; Confectionis Ros® Canin®, q. s., ut fiat Bolus, semel, bis, terve quotidie capiendus. Form. 34. Bolus Kino Thebaiacus. R Pulv. Kino Compos., gr. v.-x. ; Pulv. Cret® Compositi, gr. xv. ; PuIy. Opii, gr. ss.; Sir. Zingib., q. s., ut fiat Bolus, bis, ter, sapiusve in die sumendus. Form. 35. Bolus Moschi Compositus. R Moschi, gr. xxiv.; Pulv. Rad. Valerian®, 3ij.; Cam- phor® ras®, gr. xx.; Conserv® Rosar., q. s., ut fiant Boli, iv. Capiat unam 4t5 quaque hora. Form. 36. Bolus Nitro-camphoratus cum Opio. R Camphor® ras®, gr. iij.-vij.; Potass® Nitratis, gr. x.-xv.; Opii Puri, gr. ss.-jss. ; Conserv® Rosar., q. s., ut fiat Bolus, hora sornni sumendus. Form. 37. Bolus Rhei Compositus. R Rhei Pulv., gr. x.-xv.; Pulv. Cret® Comp., gr. vij.; Pulv. Ipecacuanha Comp., gr. iij.-vij.; Sirupi Zingiberis, q. s., ut fiat Bolus, hora somni sumendus. Form. 38. Bolus Sedativus. R Acidi Boraeici, 3j.-3ss.; Conserv. Rosar. et Sirupi, q. s., ut fiat Bolus, pro re nata sumendus. Form. 39. Bolus Sudorem Cjens. R Camphor® ras®, gr. j.-iij.; Potass® Nitratis, gr. xij.; Pulv. Ipecacuanha, et Pulv. Opii Puri, 55, gr. j.; Sirup. Zingib., q. s., ut fiat Bolus. Form. 40. Bolus Valerian.® cum Ferro. R Ferri Sesquioxidi, gT. v.-3j.; Pulv. Valerian®, 3ss.; Sirupi Zingib., q. s. Fiat Bolus. Form. 41. Cataplasma Ioduretum. R Cataplasm. Farina Semin. Lini tepid., q. s.; Solut. lo- din® Rubef., q. s. Sit Cataplasma. Form. 42. Cataplasma Sinapeos Fortius. R Pulv. Sinapeos, Ibss.; Pulv. Capsici Annui, Pulv. Zin- giberis, 55, 3j.; Acidi Acetici Pyrolignei, q. s., ut hat Cataplasma ; dein adde Olei Terebinthin®, fij. Misce. Form. 43. Cataplasma Sinapeos Minus. R Cataplasmatis Lini, part. ij.; Farinie Sinapeos, pars j. M. Form. 44. Confectio Mekth® Viridis. R Menths Viridis Fol. recent., fiv.; Sacchari Purificati, fxij. Folia in mortario lapideo contunde : turn, adjec- to Saccharo, iterum contunde, donee corpus sit unum. (Sprague.) Form. 45. Confectio Sennas Composita. R Sulphuris Sublimati, Potassae Sulphatis, 55, fss.; Con- fectionis Senn®, fij.; Sirupi Aurantii, q. s. Capiat, 3j•—3'j-> P™ dose. Form. 46. Conserva Acetosell®. R Fol. Acetosellae, fiv.; Sacchari Purificati, fxij. Coi1.- tunde probe simul, et fiat Conserva. Form. 47. Decoctum Alth®®. R Althaeas Radicis exsiccat® incis., fij.; Rad. Glycyrrhiz® contus., 3iij.; Aquae Destillatae, Ojss. Coque leni igne ad Oj., et cola. Form. 48. Decoctum Arctii Lapp®. R Rad. Arctii Lappae, f jss.-f ij.; Aquae, fxvj. Coque ad fxij., et cola. Form. 49. Decoctum Arctii Lapp.® Compos. R Rad. Arctii Lap. recent., fij.; Lign. Sassafras, Dulca- mara, 55, 3iij.; Rad. Glycyrrh., 3jss.; Aquae, Ojss. Coque ad Oj., et exprime. Form. 50. Decoctum et Infusum Beccabuns®. R Herbae Veronicae Beccabungae reeentis, fiij.; Aquae Fer- ventis,Oj. Macera per horas binas, vel coque perquar- tam hora partem, et exprime. Capiat fij. ter quaterve quotidie ; vel utatur externe pro embrocatione, super Ulcerationes Strumosas applicata. Form. 51. Decoctum Calumb® Comp. R Rad. Calumb®, Lign. Quassiae ras., 55, 3ij. y Corticis Aurantii exsic., 3j. ; Rhei Pulv., 3j. ; Potassae Carb., 3j.; Aquae, fxx. Coque ad fxv., et cola; dein addo Tinct. Lavandul. Comp., fj. (Niemann.) Form. 52. Decoctum Cacuminum Pini Compositum. R Cacum. Pini Sylvest., fij.; Radicis Symphyti Majoris. fj.; Aquae, ibij. Coque per hora partem quartam , exprime, et cola. Form. 53. Decoctum Cinchon® Aperiens. R Corticis Cinchonae Pulv., fj. ; Aquae, Ibij. Coque pel partem hora quartam, et adjice Fol. Sennae, fss.; Rad. Zingiberiscont., 3j.; Sod® Sulphatis, fss.; Ilydrochlor. Ammonite, 3j. Macera per horas binas, et adde Tinct. Sennae Comp., fj. M. Form. 54. Decoctum Cinchon® Compositum R Cinchonae Lancifol. Cort. contus., fss. Coque ex Aquae Pura, fxvj., ad consumpt. dimid., adjectis sub finem coctionis Serpentariae Radicis contus®, 3ij. Stent pel horam, et cola; dein adde Spirit. Cinnamons. Comp., fjss.; Acidi Sulphur, dilut., 3jss. M. Sumantur fij., sextO quOque hora. Form. 55. Decoctum Cinchon® et Rhei. R Corticis Cinchonae Oblongifol. contusae, 3iij.; Radicis Gentianae incisae, 3ss.; Radicis Rhei Palmati, 3ijss. ; Carbonatis Potassae, 3j.; Aquae Fontanae, s. q. Coque per horam unam ut obtineantur colatura unciae duode- cim, et cola. R Liquoris Colati, fvss.; Tinctura Canells, Spirit. Anisi, 5a, 3jss.; Sirupi Aurantii, fss. M. Capiat Cochlear j. vel ij. aropla. Form. 56. Decoctum Cinchon® et Serpentari®. R Cort. Cinchonae pulveriz., 3yj.; Rad. Serpentari®, fss.; Corticis Aurantii sic., 3ij.; Aquae, ibjss. Coque ad Ibj., et adde liq. colato, Tinct. Cinnamom., fj. Form. 57. Decoctum Cydoni® Comp. R Semin. Cydon. contus., 3ij. ; Rad. Glvcyrrh. contus., Fici Caricae Fruet., 55, f j.; Aquae Bui., Oj. Coque cum igne leni per partem hora quartam, deinde cola. R Hujus Decocti, fvjss.; Bi-boratis Sodae, 3j.; Potass® Tart., 3ij. ; Spirit. Nit., 3ij.; Sirupi Mori vel Sue. Inspiss. Samb. Nig., fss. M. Fiat Mist., cujus capt. Coehlearia, ij., larga, secundis vel tertiis horis. (In the irritative Inflammation of the Mucous Surface of the Digestive Organs, Dropsy, &c.) APPENDIX OF FORMULA—Decoctum—Electuarium. Form. 58. Decoctum Deobstruf.ns. R Radicis Taraxaci, Herb* Fumari®, Fol. Sisymbrii Nas- turt., Fol. Ch*rophylli Sylvest.,55, fj. Omnibus bene concisis, adde Seri Lactis, fxxxij. Coque per minuta hor®, vj.; et posteam acera ad refrigerationem ; dein cola. Colatur* adde Sod® Potassio-Tartrat., fss.~3vj.; Mellis Optimi, fj. M. Capiat Cyathos Vin. ij., vel iij., vel iv., in die. (Van Swieten.) Form. 59. Decoctum Depurans. R Caul. Dulcamar®, Herb® Fumari® Officin., Cort. Ulmi contusi, Rad. Arctii Lapp® cone., Rad. Rumicis Pa- tienti® concis., aa, fss. ; Aqu® Font., ftnjss. Coque ad Ojss., et cola. Liq. colato adde Sirupi Sarz®, fij. M. Capiat fj.-fjss., ter quaterve quotidid. Form. 60. Decoctum Dulcamara R Stipitum Dulcamar®, fj.; Corticis Aurantii, 3ij.; Aqu® Ibjss. Coque ad Ibj., et cola. Form. 61. Decoctum Dulcamara Comp. R Caul. Dulcamar®, Radicis Arctii Lapp®, 55, 3yj.; Ra- dicis Glycyrrh., Lign. Sassafras ras., Lign. Guaiaci ras., 55, 3ij.; Aqu® Font., Ibij. Coque ad colatur®, fxx. (Augustin, Rheumatism, Syphilis, Cutaneous Affec- tions, &c.) Form. 62. Decoctum Filicis Compositum. R Radicis Filicis Maris, f j.; Rad. Inul® Helenii, 3ij. ; Fo- iior. Absinthii, fss.; Seminum Santonic® cont., 3iij.; Aqu®, Ojss. Coque ad Oj., et cola. Liq. colato adde Sirupi Rhamni, fj. M. Form. 63. Decoctum Gall*. R Gallarum contusarum, fss.; Aqu® Destillat®, Oijss. Decoque ad oct. ij., et liquorem cola. Turn adde Tinc- tur* Gall®, fj. (This decoction, used as a fomenta- tion, enema, or injection, is of considerable use in the treatment of Prolapsus Ani, Hsmorrhoids, and in Leu- corrhoea.) Form. 64. Decoctum Gentian* Comp. R Radicis Gentian® Lute® incis®, fss. ; Aqu® Fontan®, ibij. Coque per semihoram, deinde infunde quantum sufficit super Radicis Calami Arom., 3iij.: cola, et post refrigerationem adde vEtheris Sulph., 3ij.; Sirupi Au- rantii, fss. Misce. Form. 65. Decoctum Guaiaci et Dulcamar* Comp. R Rasur. Ligni Guaiaci, fjss. ; Stipit. Dulcamar®, fjss. ; Rad. Lauri Sassafras concis., Flor. Arnic®, Rad. Cala- mi Arom., Rad. Glycyrrh., 55, fss.; Semin. Fceniculi, 3ij.; Aqu®, Ibiij. Coque ad Ibij., et cola. Capiat 5j-_5'ij-> ter quarterve quotidie. Form. 66. Decoctum Helenii Comp R Rad. Inul® Helenii, fj.; Summit. Hyssopi Officin., 3iij.; Fol. Heder- Terrest., 3ij.; Aqu®, q. s., ut sint Colatur®, fxij. Coque per partem hor® quartam, et cola: adde liq. colato, Potass® Carbon., 3j. ; Sirupi Tolutani, Si- rupi Alth®®, 55, fj, M. Capiat fj.-fij., ter quaterve quotidie. (In Chronic Catarrhs, the Pectoral Affec- tions of Debility, Asthma, Chlorosis, Amenorrhoea, &c.) Form. 67. Decoctum Inul* Compositum. R Rad. Inul® Helen., fjss.; Hyssopi Officinalis, Flor. Tili® Europ*®, 55, 3iij.; Fol. Heder. Terrest., 3ij.; Aqu®, Ibij. Coque ad Ibjss.; exprime, et cola. Colatur® adde Spirit. A3ther. Nit., fss.; Potass® Nitratis, 3j.;; Sirupi Scill®, 3ij.; Sirupi Alth®*, fss. M. Form. 68. Decoctum Pectorale Elsneri. R Rad. Glycyrrh., Croci Stig., Rad. Inul® Helenii, Rad. Iridis Flor., Semin. Anisi, Hyssopi Officin., 55, fss.; Aqu®, Ibij. Coque ad Ibjss.; cola, et adde Tinct. Bals. Tolutani, fj. ; Sirupi Tolutani, fj.; Mellis, fj. M. Capiat fj.-fij., 4tis vel 6cis horis. Form. 69. Decoctum Punic* Granati. R Corticis Radicis Punic* Granati recent, et exsic., fij.; Aqu® Com., Oij. Macera sine calore per horas, xxiv.; dein coque ad Oj., et cola. (The whole to be taken in three doses within two hours.) Form. 70. Decoctum Quassi* Comp. R Ligni Quassi® rasi, fss. ; Flor. Anthemid., 3vj. ; Potass® Carbon., 3ijss.; Aq. Fontan., Ibij. Coque ad dimidium, et cola. Form. 71. Decoctum Santonici. R Santonici Semin, contus., fij.; Aqu® Destillat®, fxx. Coque lento igne ad Oj., et cola. (In Ascarides.) Form. 72. Decoctum Sarz* Compositum. R Sarz® Radicis, concis® et contus®, fjss. ; Glycyrrhiz® Radicis contus®, fss.; Coriandri Seminum contus., 3ij.; Liquotis Potass*, 3j. (vel sine); Aquae Ferventis, Oj. Macera per horas, xxiv., in vase leviter clauso, ct cola: liquoris colati sumat partem 3tiam ter quotidid. (Spkaque.) Form. 73. Decoctum Secalis Cornuti R Secalis Cornuti, 3ij. ; Aquae, fvij. Decoque ad fiv. Ab igne remove, et paulo post e faecibus efFunde. Form. 74. Decoctum Senega. R Senegas Radicis cont., 3vj.; Aquae, Oij. Coque ad Oj. ; et sub tinem coctionis adde Glycyrrh. Rad. contusae, fss. Exprime, et cola. Form. 75. Decoctum Scoparii Cacuminum. R Scoparii Cacuminum concisi, fj.; Aquas Destillatae, Oj. Decoque ad octarium dimidium, et cola. Form. 76. Decoctum Taraxaci Comp. R Radicis Taraxaci, fiv.; Bitart. Potassae, Bi-boratis Sod*, aa, fss.; Aq., Ibiij. Coque ad ibij.; et adde, ut sit oc- casio, vel Spirit. ASther. Nit., vel Tinct. Scillae, vel Spirit. Juniperi Comp., vel Oxymel Scillae. Form. 77. Decoctum Taraxaci Comp. Stollii. R Rad. Taraxaci, Rad. Tritici Rep., aa, fij.; Aq., Ibiij. Coque ad Ibij. : cola, et adde colatur*, Potassae Sulph., fss.; Oxymel, fj. M. (In Visceral Obstructions.) Form. 78. Decoctum Tormentill*. R Tormentillae Radicis contusae, fj.; Aquas Destillatae, Ojss. Coque ad octarium, et cola. Form. 79. Electuarium Alkalino-ferratum. R Sesquioxidi Ferri, fss.; Potassae Carbonatis, 3j.; Car bonat. Calcis, 3ij.; Pulv. Zingiberis, 3jss.; Sirupi Au- rantii, fiijss. M. Fiat Elect, cujus capiat Coch., j., minim, mane nocteque. (Chlorosis, Chorea, &c.) Form. 80. Electuarium Anthelminticum. R Pulv. Valerianae, Semin. Santonicae coutus., aa, fss., Potassae Sulphatis, 3iij.; Pulv. Jalap., 3iv.; Oxymel. Scillae, fiv. ; Pulv. Glycyrrh. (vel Extr. Glycyrrh.), fij. M. ut fiat Electuarium. (For children, one to two drachms ; and for adults, fss., three or four times daily.) Form. 81. Electuarium Antispasmodicum. R Pulv. Cinchon®, fj. ; Pulv. Valerianae, fss.; Confect. Rutae, fj.; Confect. Ros. Gall., fss.; Confect. Aurantii, 3iij.; Olei Cajeputi, 3ss. ; Sirupi Aurantii, f ijss.; vel q. s., ut fiat Electuarium molle. Capiat 3j.-3iij., mane nocteque. (In Epilepsy, Chorea, Hysteria, Flatulen- cy, &c.) Form. 82. Electuarium Aperiens. R Magnesias, Potassae Bitart., Flor. Sulphuris, Pulv. Rad. Rhei, Pulv. Flor. Anthemidis, 5a, gr. vj.; Sirupi Au- rantii, 3iij.; Olei Pimentae, TRij. M. Sit Electuarium pro dose. (Hecker.) Form. 83. Electuarium Aperiens. R Mann®, 3vj.; Sirupi Sennae, 3iij.; Olei Amygdal. Dulc., 3ij. Tere bene, et adde Aquae Foeniculi, 31'j.; Sacchari Albi, 3jss. Sit Electuarium, cujus capiat infans, 3j.-3ij., pro dose. Form. 84. Electuarium Arnicas Composit. R Pulv. Flor. Arnicae, 3iij.; Pulv. Cinchonae, fss,; Pulv. Rad. Serpentariae, 3iij.; Confect. Aromat., 3j.; Sirupi Aurantii, fiij. Misce. Capiat 3j.-3ij., 2 dis horis. Form. 85. Electuarium Bechicum. R Mannae Optimse, fj.; tere cum Aq. Flor. Aurantii, q. s., et adde gradatirn Pvlv. Acaciae, fss.; Extr. Glycyrrh., 3j.; Sirupi Tolutmi, q. s. Sit Electuarium molle, cu- jus capiat pauYillum urgenti Tusse. Interdum adde Pulv. Ipecacuanha, Extract. Conii, vel Extr. Lactucae. Form. 86. Electuarium Cinchona: Aperiens. R Cinchonae Lancifol. Cort. in Pulv., fj.; Valerianae Rad. Pulv., 3iij.; Confectionis Sennae, fjss.; Confect. Aro- mat., 3ij. (vel Confect. Piperis Nigri, 3iij.); Sirupi Sennae, fijss., vel q. s., ut fiat Electuarium molle, cu- jus devoret Cochlear., j.,vel ij., minima mane, meridie, ct nocte. (In Ague, Diseases of Debility, &c.) Form. 87. Electuarium Cinchon* Compositum. R Cinchonae Cordif. Corticis Pulv., fj.; Confectionis Ros® Gallics, fss.; Acidi Sulphurici diluti, 3j. ; Sirupi Zin- giberis, fjss. M. Fiat Electuarium. Dosis 3j.~3ij., ter quaterve in die. Form. 88. Electuarium Cinchon* dum Ferro. R Cinchon® Cort. Pulv., fj.; Ferri Sesquioxidi, 0ij.-3ij.; APPENDIX OF FORMULAE.—Electuarium—Emplastrum. Sirup. Zingiberis, q. s., ut fiat Electuarium. Dosis 3j—3 ij., bis terve quotidid. Form. 89. Electuarium Deobstruens. R Potass® Bitart., fjss. ; Sulph. Pr®cip., fj. ; Sod® Bibo- ratis, 3ijss.; Sirupi Zingiberis, q. s., ut fiat Electuar. Cochlear, j. vel ij., minima h. s. Form. 90. Electuarium Febrifugum. R Pulv. Cinchon®, fij.; Pulv. Rad. Serpentari®, Pulv. Cort. Canell®, aa, 3ij.; Camphor® ras®, 3ij. ; Opii Puri, gr. iv. ; Sirupi Zingiberis, et Sirupi Aurantii, 55, q. s., ut fiat Electuarium, cujus capiat 3ss.-3jss. pro dose. Form. 91. Electuarium Febrifugum Hoffmanni. R Pulv. Cinchon®, 3vj.; Pulv Flor. Anthemid., 3ij■; Ca- ryoph. in Pulv., Ext. Centaurii Min., 55, 3SS* (vel Pulv. Centaurii, 3jss.); Succi Inspiss. Sambuci Nig., fss. ; Sirupi Limonis, fjss. M. Capiat 3j., 4tis horis. Form. 92. Electuarium Febrifugum Trilleri. R Cinchon® Pulv., f j.; Pulv. Flor. Anthem., 3ij.; Potass® Nitratis, Ferri Ammonio-Chloridi, 55, 3j.; Sirupi Au- rantii, fijss. M. Fiat Electuarium, cujus capiat Coch- lear., j.—ij., min. pro dose. Form. 93. Electuarium Ferri Ammonio-Chloridi Compositum. R Myrrh® Pulv., 3jss.; Ferri Ammonio-Chloridi, gr. xxxv.; tere simul, et adde Pulv. Radicis Rubi®, 3jss. ; Pulv. Castorei, 3ij.; Sir. Zingiberis, fjss., vel q. s., ut fiat Electuarium ; de quo sumatur, bis quotidie, ad Myris- tic® Nuclei magnitudinem. Form. 94. Electuarium Febri Potassio-Tartratis. R Potass® Bitart., fij.; Ferri Potassio-Tartratis, 3iij. ; Zin- giberis, 3j. ; Sirupi Aurantii, q. s., ut fiat Electuarium molle, cujus capiat, 3j.—3ij., bis terve in die. Form. 95. Electuarium Nitri Camphoratum. R Camphor® ras® et ope Alcoholis pulverizat., gr. vj.-xij. ; Potass® Nitratis, 3jss.; Confect. Roe® Gallic®, fjss.; Sirupi Simp., q. s., ut fiat Electuarium. Dosis, moles Myristic® Nuclei subinde capiatur. Form. 96. Electuarium Purgans. R Confectionis Senna:, fij. ; Pulver. Jalap®, 3j.; Potass. Bitart, pulv., fss.; Sirupi Zingiber., fj. M. Sumat Cochl., j., min. bis vel ter die. Form. 97. Electuarium Scill.® Compositum. R Potass® Bitart, contrit., fiij.; Juniperi Bac.et Cacumin. pulv., f j.; tere bene simul, et adde terendo Pulv. Ja- lap®, 3ij.; Oxymellis Scill®, fij.; Sirupi Zingiberis, q. s., ut fiat Electuarium. Dosis 3j.~3iij., bis, ter, qua- terve in die. Form. 98. Electuarium Senn.e Compositum. R Senn® Fol. pulver., fss.; Potass® Bitart, pulv., 3vj. ; Pulv. Jalap® Rad., 3ij.; Sod® Bi-boratis, 3j.; Sirupi Zingiberis, fij. Misce. Dosis 5 3j.-3ij., pro re natfi. Form. 99. Electuarium Terebinthin®. R Pulv. Tragacanth., 3iv.; Aq. Pur®, fj. M. Fiat mu- cilago ; tunc gradatim adde 01. Terebinth., fj.; et con- tere cum Sacch. Purif., 3ij.; Pulv. Curcum®, gr. x., ut fiat Electuarium. Form. 100. Electuarium Terebinthinatum. R Olei Terebinthin®, vjj,; Mellis Despumati, fij.; Pulv. Rad. Glycyrrh., q. s., ut fiat Electuarium. Form. 101. Electuarium Valerian.® Compositum. R Pulv. Rad. Valerian. Minor., jj. ■ Pulv. Sem. Santonic®, 3ij.; Pulv. Rad. Jalap., gr. xrX.-xl.; Oxymel. Scill®, q. s., ut fiat Electuarium. Form. 102. Electuarium Veiimifugum. R; Potass® Bisulphatis, Pulveris Radicis Jalap®, Pulveris Radicis Valerian®, 55, 3j. ; Oxymellis Scillitici, fiv. M. Sumantur adulti, fss., quatuor vices de die, et pucri, 3j. ad 3ij. (Stoerk.) Form. 103. Elixir Aloes Compositum. R Croci Stig., part. j.; Potass® Acet., Aloes, Fellis Tauri Inspiss., 55, part. ij.; Myrrh®, part. ij. ; Spirit. Vini (vulgo Brandy diet.), part. xxiv. Infunde et macera secundum artem, et cola. 3j.~3ijss. pro dose. Form. 104. Elixir Pectoralis Wedellii. R Asafcetid®, 3ij.; Acidi Benzoici, Opii Purif. Camphor®, Croci Stig., Rad. Scill®, Olei Anisi, 55, 3ij.; Balsami Peruv., fss.; Spirit. Vini Rect., Tbijss. Macera, et cola. Form. 105. Elixir Proprietatis Rhubarb'arirum. R Aloes Socotrin., fj. ; Rhei, 3vj.; Myrrh®, 3i 1 jss.; Croci Stigmat., 3iij.; Carb. Potass®, jijss. ; Vini Madeiren- sis, Ibj.; Alcohol., fiij. Macera per dies septem, et cola. (In dos. 3j.-3ij. Vermifuge, emmenagoguer&c.) Form. 106. Elixir Roborans. R Aloes, Myrrh®, 55, 3ij.; Summit. Absinthii, Sum. Cen- taurii Minoris, Cinchon® in Pulv., 55, fss.; Corticis Aurantii Amari, 3iij.; Croci, 3ij.; Vini Albi Hispair., Ibij. Macera in sole per horas, xlviij.; dein adde Sac- char. Alb., fviij., et cola. Form. 107. Emplastrum Ammonias. R Ammonias Hydrochloratis, 3j*; Saponis Duri, 3ij.; Em- plastri Plumbi, fss.: Emplastrum et Saponem simul liqua, et paulo antequam eoncrescant immisce Salem in pulverem tenuem tritum. Extensum super alutam parti affect® quamprimum applicator, et pro re nata repetatur. Form. 108. Emplastrum Anodynum Fortius. (Richter). R Emplastri Galban. Comp. (vel. Emp. Cumini), fj.; Cam- phone, 3j.; Ammon. Sesquicarbon., Opii Puri, 55, 3ss. ; Olei Cajeput., gtt. xl. Fiat Emplastrum secundum artem. Form. 109. Emplastrum An.ticolicum. R Gum. Ammoniaci, Gum. Galbani, 55, fj.; Terebinthin. Venet., et Terebinthin. Common., 55, 3x.: lento igne liquefactis, adjice Asafcetid®, fjss.; Croci Stigm.,3iij.; Olei Mentha: Pip., et Olei Rut®, 55, 3ss.~3j., et omnia mi see. Form. 110. Emplastrum Antihystericum R Galbani, Sagapeni, 55, fj.; Asafostid®, fss.; Olei Rut®, 3ss.~3j.; Aceti Vini, q. s., ad Gum. Resin, liquefacien- dum: dein adde Terebinthin® Commun., fj.; Cer® Flay®, fiij.; Pulv. Myrrh®, fss. ; Pulv. Castorei, 3jss.; Olei Succini, 3SS* Misce. (The Wurtemberg and Manheim Pharm.) Form. 111. Emplastrum Aromaticum Compositum. R Emplast. Arom. (Ph. Dub.) vel Emp. Cumini, fss.; Sul- phuris Sublimati, 3ij.; Olei Macis, Ttlxxxv. Fiat Em- plastrum. Form. 112. Emplastrum Belladonnas. R Extr. Belladonna, part. iij.; Ammon. Sesquicarbon. Pulv., part. j. Misce, et fiat Emplastrum. (To very painful parts.) Form. 113. Emplastrum Camphor,*;. R Olei Oliv®, fxij.; Plumbi Binoxidi, fviij. Liqua, et mass® refrigerat® adjice Camphor®, fijss., solut® in pauxillo Olei. Misce bene. (Stahl.) Form. 114. Emplastrum Defensivum. R Plumbi Binoxidi, fviij.; Aceti, fiv.; Olei Oliv®, Ibj, Liqua, et adde Cer® Flav®, fij.; Camphor®, fss Misce bene. Form. 115. Emplastrum Deobstruens. R Potassii Sulphureti, Pulv. Conii, 55, 3ijss.; Camphor® Pulveris, Terebinthin® Vulg., 55, fiv. ; Saponis Albi, 3ss.; Cer® Flav®, fj.; Emplast. Simp., fiv. M. Form. 116. Emplastrum Picis. R Picis Abietin® vel Nigr®, fvj.; Cer® Flav®, fj. ; Tere- binthin® Vulg., 3iij. ; Liquefac simul, et fiat Emnlas- trum. Form. 117. Emplastrum Resolvens. R Emplastri Ammoniaci cum Ilydrarg., Emplast. Picis, Emplast. Galbani Comp., 5a, partes aquales. Fiat Emplastrum. Form. 118. Emplastrum Robobans. R Emplastri Picis, Empl. Galban. Comp., Empl. Cumini 55, partes binas; Ferri Sesquioxidi, Thuris, 55, partem unam; Olei Piment®, q. s., ut fiat Emplastrum Form. 119. Emplastrum Rubefaciens. R Emplast. Aromat. Comp. (F. Ill), fss. Forma in Em- plast., dein asperge cum Antimonii Potassio-Tartratis 3j. i Camphor® Pnlveriz., 3j.; Sulphur. Sublimati! 3ss., in unum admixtis. Form. 120. Emplastrum Stibiatum. R Emplast. Picis, part. xj.; Terebinth. Venet., part. iv. • Antimon. Potassio-Tartratis in Pulv., part. j. Liquefac Emplastrum et Terebinthinam, et adde Antimonium (Niemann and Augustin.) APPENDIX OF FORMULAE.—Emulsio—Extractum. Form. 121. Emulsio Amygdalo-Camphorata. R Amygdal. Dulc. decortic., fss.; Amvgdal. Amar. No., iij.; Aqu® Fontan®, fvijss. Fiat Emulsio, cui adjice Pulv. Gummi Arabici, 3ij. ; Camphor® (cum paux. Al- cohol. subact*), 3j. ; Sirupi Papaveris Albi, 3ss. M. Et sit Emulsio, de qua sumat quovis bihorio Cochleare unum, pr®gressa phial® commotione. Form. 122. Emulsio Anticatarrhalis. R Sem. Phelland. Aquat. con., fj.; Gum. Acaci®, fj.; Aq. Ferv., fix. Macera, et cola. Colat® adde Sirupi Al- th®®, fss.; Vini Ipecac., 3ij. M. Capiat Coch., ij., larga 3tiis vel 4tis horis. Form. 123. Emulsio Camphorata. R Olei Amygdal. Dulc., fss.; Gum. Acaci®, q. s.; Cam- phor®, gr. x.-3j.; tere bene simul, et adde Aqu® Fm- niculi et Aqu® Laurocerasi, fij.; Sirupi Altha®, fss. M. Fiat Emulsio. Form. 124. Emulsio Camphorata Anodyna. R Camphor® Subact®, gr. xvj.; Amygdal. Dulc., fss.; Acidi Hydrocyanici, Itlxii.; Aqu® Flor. Sambuci, fvj. Form. 125. Emulsio Camphorata Composita. R Camphor®, gr. x.-3j.: subige in Alcoholis, 3ss.; et adde terendo Mucilag. Acaci®, 3ij.; Olei Amygdal. Dulc., fss.; Sirupi Alth®®, fss.; Aqu® Laurocerasi, Aqu® Fmniculi, 55, fijss. M. Capiat Coch., j. vel ij., 3tiis vel 4tis horis. lnterdum adjiciatur vel Vinum Ipecacuanh®, vel Vinum Antimonii, vel Potass® Nitras, vel Sirupus Papaveris Albi. Form. 126. Emulsio Nitro-Camphorata. R Camphor® Subact®, Potass® Nitratis, 55, 3j.; Pulv. Gum. Acaci®, 3j.; Infusi Pectoralis vel Aqu® Flor. Aurantii, fvjss. ; Sirupi Altha®, fj. M. Form. 127. Emulsio Pectoralis R Spermaceti, 3j.; Gum. Acaci®, 3ij.; Olei Amygdal. Dulc., fss. ; Acidi Hydrocyanici, Ttlx.; Sirupi Simp., Sirupi Tolutani, 55, fss.; Aq. Fmniculi, fivss. M. Form. 128. Emulsio pro Tussi. R Olei Amygdal. Dulc., fss.; Vitellum Ovi unius ; Aqu® Flor. Aurantii, fvj.; Mucilag. Acaci®, fss.; Vini Ipe- cacuanh®, 3jss.; Sirupi Altha®, fss. M. Form. 129. Emulsio Sedativa. R Mist. Amygdal. Dulc., Mist. Camphor®, 55, fiijss.; Mu- cilag. Acaci®, fss. ; Morphia Acetatis, gr. j.-ij.; Sirupi Tolutani, fss. Solve Morph. Acetat. in Olei Amygdal., Itlxx.; deinde adde alia. Form. 130. Enema Alces et Asafj- Form. 228. Infusum Caryophylli Comp. R Caryoph. contus., 3j.; Cort. Aurantii Sic., 3ij.; Semin. Coriandri et Sem. Anisi cont., 5a, 3ss.; Aqu® Ferven- tis, Ibj. Macera per semi-horam, et cola. Form. 229 Infus. Cinchon® cum Quin® Sulphate. R Cinchon® Cordifol. Corticis in Pulv., 3vj.; Confectionis Ros®, Jjss.; Aqu® Ferventis, Oj. Tere bene, et di- gere per horas duas in vase clauso ; dein cola. R Liq. Colati, Jvj. ; Sulphatis Quin®, gr. viij.; Acidi Sul- phur. Diluti, 1lj,xxiv. Fiat Mist., cujus Coch. ij., larga tertiis vel quartis horis sumenda. Form. 230. Infusum Conii. R Conii Fol. exsiccat., 3ij.; Anisi et Coriandri Semin, contus., 33, 3jss. ; Aqu® Ferventis, Oss. Macera per horas duas, et cola. (Dosis 3j. ad Jij., bis, ter, qua- terve in die.) Form. 231. Infusum Diosm® Crenat®. R Fol. Diosm® Crenat®, Jss., Aqu® Ferventis, Oss. Ma- cera per horas quatuor, et cola. (Dose Jj.-Jjss.) Form. 232. Infusum Gentian® Alkalinum Compos. R Radicis Gentian® concis®, 3ij.; Corticis Aurantii Sic., 3j.; Semin. Coriandr. contus., Jj.; Rorismarini Cacu- min., 3j.; Potass® Carbon, (vel Sod® Carb.), 3j. ; Aqu® Ferventis, Jxij. Macera per horas duas, et cola. Form. 233. Infusum Guaiaci Compositum. R Guaiaci Ligni ras., Ibss. ; Glycyrrhiz® Radicis contus®, 5j. ; Sassafras Corticis Ver® concisie, ifss.; Coriaudri Seminum contusorum, Jj.; Liquoris Calcis, Ovj. In- funde per dies tres, deiu cola ; cujus sumat ®ger qua- tuor sexve uncias pro dose, et bis die repetatur (Sprague.) Form. 234. Infusum Glechom® Hederace®, cum Acido Hydrocyanico. R Glechom® Hederace®, vel Hederae Terrestris, J ss.-3yj., Radicis Glycyrrhizae, 3iij. ; Aquae Ferventis, Oj. Ma- cera per horas tres, et cola. B Liq. Colati, Jjss. ; Acidi Hydrocyanici, Tflj.—iij.; Sirup Althaeas Officin, jjss. M. Fiat Haustus, sext& vel oc tava qu5que liorh sumendus. Form. 235. Infusum Juniperi. R Juniperi Baccarum contusarum, Jij. ; Aquae Ferventis, Oj. Macera in vase leviter clauso per horas duas, et cola; dein adde Spiritus Juniperi Compositi, Jj. ; et in- super, pro re nata, Potassae Bitartratis, 3ijss. (Dosis, fluidunc. ij. ad iv., ter quaterve quotidie.) Form. 236. Infusum et Mistura,Juniperi Composit. R Baccarum Junip. contus., 3ijss. ; Semin. Anisi Contus., Semin. Foeniculi cont., 53, 3jss.; Aquae Ferventis, Oj. Macera per horas tres ; dein cola. R Liq. Colati, Jxiij. ; Potassae Nitratis, 3jss.; Sodae Car- bon., 3jss.; Tinct. Scillae, 3jss.; Spirit. Junip. Co., 3ijss.; Tinct. Opii, 1H,xxv. Fiat Mist., cujus capiat Cyathum subindd. Form. 237. Infusum Marrubii. R Marrubii Herbae exsic., Jss.; Aquae Destillat® Ferventis, Oss. Macera per horatn, et cola. R Liq. Colati, Jjss.; Tinct. Camphorae Comp., 3j.; Ext. Glycyrrh., gr. x. M. Fiat Haustus, ter in die sumen- dus. (Chronic Bronchitis, and Catarrh with inordinate Secretion.) Form. 238. Infusum Melissa Compositum. R Melissae Officinalis exsic., Radicis Glycyrrh. contusae, 55, 3ijss.; Sem. Anisi cont., Sem. Foeniculi, Sem. Coriand. cont., 33, 3ss.; Aquae Bullientis, Ibij. Infunde per ho- ram, et cola. Form. 239. Infusum Menth® et Caryophyli.i. R Folior. Menthae Virid. Sic., 3iij.; Rosas Gallicae Petal. Sic., 3jss. ; Caryophyllorum contus., 3jss. ; Aurantii Cort. Sic., 3jss.; Aquae Ferventis, Oj. Macera per horam, et cola. Form. 240. Infusum Menth® Compositum. (1.) R Fol. Menth. Virid. exsic., Radicis Glycyrrh. concis. e cont., aa, Jss. ; Semin. Anisi et Semin. Coriand. con- tus., 33, 3j. ; Aquae Ferventis, q. s., ut fiat Colaturae Oj. (Adde Magnes. et Sacch. Album pro tormimbus infantum ; aut interdum Acidi Sulphurici Arom., 3j., pro nausea vel vomitu.) Form. 241. Infusum Menth.® Compositum. (2.) R Menthae Viridis exsiccat. contusae, J jss.; Rosae Gallicte Petalorum exsiccatorum, 3j. ; Aquae Ferventis, Oj. ; Acidi Sulphurici Diluti, 3ij.; Sacchari Purificati, Jjss. Menthae et Rosae Petalis superinfunde Aquam cum Acidi dimidio mistam. Macera; dein Liquorem effunde, et Saccharum, et Acidum reman, adjice. (Dosis 3 flu- idunc. j. ad ij., bis, ter, saepiusve quotidie.) Form. 242. Infusum Menyanthis. R Menyanthis Foliorum, Jss.; Zingiberis Radicis concis., 3ij.; Aquae Ferventis, Oss. Macera in vase clauso per horas duas, et cola. (In doses of Jj. to Jjss., with Spir- ittis iEtheris Nitrici, 3j. ad 3ij., in Rheumatism, Ar- thritic Affections, and in Cachectic and Cutaneous Dis- eases.) Form. 243. Infusum Millefolii Compositum. R Herbae Millefolii, 3ij.; Herbae Rorismarini, Herbae Thymi Vulg., 53, 3j. ; Semin. Coriand. cont., 3j. ; Aq. Fer- ventis, Ibj. Infunde per horam, et cola. R Liquoris Colati, Jjss. ; Spirit. Rorismarini, 3ss.; Tinct. Aloes Comp., 3j.—jij. Fiat Haustus, primo mane quo- tidie capiendus. (In Chlorosis, Amenorrhoea, ,Aq. Fervid., fix. Macera per horas. binas, et cola. Liq. colato adde Acidi Sulph. Arom., 3jss.; Si- rupi Papaveris, fss. M. (Fevers, Hysteria, and other Nervous Affections.) Form. 271. Infusum Zingiberis. R Zingiberis Radicis concis., 3jss. ; Aqu® Ferventis, Oss. Macera per horas duas in vase leviter elauso, et cola ; turn adde Tinct. Zingiberis, Sirupi ejusdem, aa, fss. (This is the best vehicle for giving the Liquor. Ferri Oxygenati, and it is also a very grateful aromatic in cases of Flatulency.) Form. 272. Injectio Aceti Pyrolignei. R Acidi Pyrolignei, part, j.-ij.; Mist. Camphors, Aq. Ros®, aa, part, ij.-iij. ; Tinct. Camphor® Co., part, ss.-j. Form. 273. Injectio Argenti Nitratis. No. 1. No. 2. No. 3 ft Argenti Nitratis . 3j. 3ij. 5J- Aq. Destillatae • fiij- fiij. Solve. Form. 274. Injectio Astringens. R Infusi Quercus, ut supra, f iv.; Pulv, Gallarum, gr. xxz. Tinct. Catechu, jij. Fiat Mist., ex quo injicitur paux ilium, vel per vaginam yel per anum, jao Leucorrbcea vel Sanguinis Fluxu. Form. 275. Injectio Boracica. R Aq. Rosa, fiv.; Aq. Flor. Aurantii, fij. ; Bi-boratis Soda, 3j. ; Tinct. Camphor® Comp., 3ij.—fss. M. Fiat Injectio. Form. 276. Injectio Zinci Acetatis Composita. R Zinci Sulphatis, Plumbi Acet., 55,3ss.; Camphor®, 3ss.; Opii, 3ij. Solve in Aq. Bullientis, Oj.; cola, et fiat Injectio, ter quaterve in die utenda; phiala agitata. Form. 277. Iodidum Hydrargyri. (Internally, in doses of from one grain to three, and exter- nally in ointments.—(Vide Unguent. Iod. Hyd.) For the best account of the preparations and uses of Iodine, consult Dr. O’Shaughnessy’s translation of Lugol on Scrofula.) Form. 278. Iodidum Plumbi. (Internally, in doses of from half a grain to five grains; and externally.—Vide Ung. Iod. Plumbi.) Form. 279. Julepus Sedativus. R Camphor®, gr. vj. ; Spirit. Alther. Sulphur. Comp., 3jss.; Potass® Nitratis, gr. xij. ; Aq. Flor. Aurantii, fiij.; Sirupi Althaa, 3iij. ; Sirupi Papaveris, 3ij. M. Fiat Mist., cujus capiat tertiam partem omni horft, vel bihorio. (Pierquin.) Form. 280. Linctus Acidi Hydrochi.orici. R Mellis Rosa, 3x.; Acidi Hydrochlorici, 1fixx. i Sirupi Rhoeados, 3ij. M. Simul agita, ut fiat Linctus. Form. 281. Linctus Boracicus. R Cetacei, 3ijss.; Pulv. Tragacanth® Comp., 3iij. ; Sirupi Tolutani, fj. ; Bi-boratis Soda, 3jss.; Confect. Rosa, 3v.; Sirupi Althaa, fj., vel q. s. Fiat Linctus, de quo lambat pauxillum sape. (Sore Throat, CEsopha- gitis, &c.) Form. 282. Linctus Camphoraceus. R Camphor®, gr. xij.; Pulv. Gum. Acacia, 3j. ; Sirupi Al- thaa, fij. Misce bene. (Niemann.) Form. 283. Linctus Chlorureti Calcis. R Chlorureti Calcis, gr. iij.; solve in Aq. Destil., f j.; et adde Mellis, fjss. M. Capiat infans Cochleare unum minimum subinde. (In Softening of the Digestive Mu- cous Surface.) Form. 284. Linctus Demulcens. (1.) R Olei Amygdal. Dul., Sirupi Althaa, 55, fij.; Sirupi Pa- paveris, 3xj. ; Vini Ipecacuanha, 3jss.; Vitellum Ovi unius. M. Fiat Linctus. Form. 285. Linctus Demulcens. (2.) R Cetaoei, 3ijss.; Pulv. Tragacanth® Comp., 3jss.; Sirupi Papaveris et Sirupi Tolutan., 55, fss.; Potass® Ni- tratis, 31j. ; Confect. Rosar., 3vj.; Sirupi Simp., q. s., ut fiat Linctus, de quo lambat pauxillum pro re natfi. Form. 286. Linctus Demulcens et Aperlens. R Sirupi Viol®, fijss.; Olei Amygd. Dul., fj.: Sirupi Scilla et Sirupi Senna, 55, fss. M. Fiat Linctus. (Infantibus.) Form. 287. Linctus Emolliens. (Brendellii.) R Saponis Venet., 3 iv.; solve in Olei Amygdal. Dulcis, fjss.; Mann® Purif., fss.; Potass® Bitart., 31'j.; Sirupi Althaa, f j. M. Fiat Linctus. Form. 288. Linctus Myrrh® et Ipecacuanh®. R Myrrh® G. R , 3j*4 Pulv. Ipecacuan., gr. vj.; Oxymel. Scilla, Mucilag. Acacia, Sirupi Althaa, 55, 3vj. Fiat Linctus, de quo lambat pauxillum sape. Form. 289. Linctus Oleosus. (1.) R Olei Amygdalarum, Sirupi Mori, aa, fjss.; Confect. Fruct. Rosa Cauin®, fij.; Pulv. Tragacanth. Comp., 3iij. Misce. Cochleare minim, subindd deglutiatur. Form. 290. Linctus Oleosus. (2.) R Olei Oliva, fjss. ; Oxymellis Scilla, Sirupi Papaveris, 5a, fj. Dosis, Cochleare parv. j., urgenti Tusse. (In common Catarrhal Cough, with Sore Throat.) Form. 291. Linctus Opiatus. R Sirupi Papaveris, fij.; Mucil. Acacia Ver., fjss.; Conf. Fruct. Rosa Canma, fj. ; Acidi Sulph. Diluti, 3ij. Misce. Dosis, Cochleare minim, subindd. Form. 292. Linctus Opiatus cum Scill®. R Sirupi Papaveris, fj.; Sirupi Mori, 3vj.; Sirupi Limo- APPENDIX OF FORMULA.—Injectio—Linimentum. nis, fss.; Oiymellis Scilla, fss. Misce. Dosis Coch leare minim. Tusse urgenti. Form. 293. Linctus Pectoralis. R Pulv. Sem. Anisi, Pulv. Sem. Fceniculi, Extr. Glycyrrh., 5a, fss. ; Pulv. Sem. Carui, 3ij.; Potass® Nitratis, 3j. 01. Anisi, Jss.; Sirupi Althaa, fvss. M. Fiat Lino tus. Capiat 3j., pro re nath. Form. 294. Linctus Potassae Niteatis. R Potass® Nitratis contr., 3jss.; Mellis Ross, fj.; Oxy mellis Simplicis, fjss. M. Capiat Coch. minim., pro re nat4. Form. 295. Linimentum Ammonia cum Oleo Tere- BINTHIN®. R Liquoris Ammon., fss. ; Olei Oliva, fj. ; Olei Tere- binthina, f ss.; Olei Limonis, 3ss. Agita simul donee misceantur. Form. 296. Linimentum Ammoni® et Terebinthin® Comp. R Liquoris Ammon., fj.; Olei Oliva, fij. Misce ben6, et adde Tinct. Camphors, fij.; Olei Terebinth., fiij. ; Saponis Duri, 3v. Misce bend, dein adde, Olei Cajeputi, 3j.; Olei Limonis, 3jss. M. Form. 297. Linimentum Anodynum. (1.) R Opii, fj.; Camphors, fij. ; Liq. Ammon., fiv.; Saponis Duri, fiv. ; Olei Terebinth., fviij. ; Olei Limonis, fss. ; Spirit. Rorismarini et Spir. Lavandul., 55, fxij Misce. Form. 298. Linimentum Anodynum. (2.) R Linimenti Saponis Comp., fj. Liquoris Ammonia, 3iij., Olei Caryophylli, 3j.; Tinct. Opii, fss. M. Fiat Linimentum. Form. 299. Linimentum Camphor® Fortius. R' Camphor® rasas, 3ijss.; solve in Tinct. Cantharidis, 3ij., et Tinct. Capsici Annui, 3jss.; dein adde Linimenti Saponis Comp., fss. ; et gradatim, miscendo, Liquoris Ammon., 3vj. ; Olei Oliva;, 3xj. M. Fiat Linimen- tum, cum quo illinatur pars affecta bis terve quotidid. Form. 300. Linimentum Cantharidum Comp. R Tinct. Cantharid., 3iij.; Olei Terebinth., fj. ; Ammonia Liq., 3jss.; Saponis Duri, 3j.; Olei Cajeputi, 3ss. M. Fiat Linimentum. (Altered from Augustin.) Form. 301. Linimentum Febrifugum. R Antimonii Potassio-Tartratis, gr. xxv.; solve in Aqua Destil., 3ij., vel q. s. ; deinde tere bene cum Adipis Prapar., f]., et fiat Linimentum. (The antimony is partially absorbed without producing any Phlogosis.) Form. 302. Linimentum Iodinii. R Linimenti Saponis Co., fj.; Iodinii, gr. viij. vel x. Misce. Form. 303. Linimentum Phosphoratum. R Olei Olivarum Optimi, fviij.; Phosphori excisi, gr. xx. Solve cum calore, cola ex frigido, et fiat Linimentum. (In Paralyse locale, Marasmo, Rheumatismo, et Arthri- tide Chronico. Form. 304. Linimentum Pyrethri. R Tinct. Pyrethri, 3vj.; Linimenti Camphor®, 3iv.; Li- quoris Ammon., 3ij. Misce. Fiat Linimentum. Form. 305. Linimentum Rubefaciens. R Camphor®, 3j.; Olei Oliva et Liq. Ammon., 55, f j.; Olei Macis, Ttlxxxv. Misce. (Externally to parts in deep- seated Inflammation.) Form. 306. Linimentum Saponis et Camphor® Comp. R Saponis Med., fj. ; Alcoholis Rect., fvj.; Camphor® et Aq. Destil., 55, fj. Solve leni cum calore, et adde Olei Rorismarini, 3iv.; Olei Thymj, 3j. ; Liquoris Ammo nia, fij. Misce bene. Form. 307. Linimentum contra Spasmos. R Olei Oliva, Olei Terebinthina, Liquoris Ammon., Tinct. Opii, Linimenti Saponis Compositi, 55, fss Fiat Lin- imentum. Form. 308. Linimentum Stimulans. R Linimenti Camphor® Compositi, Linimenti Saponis Com positi, 55, fjss.; Olei Crotonis, 3j.; Olei Cajeputi, 3jss. Fiat Linimentum. Form. 309. Linimentum Sulphuro-Saponaceum. R Potassii Sulphureti, fiij. ; Saponis Albi, Olei Oliva, 55, fcj.; Olei Volat. Thymi,3j. M. (Jadelot.) APPENDIX OF FORMULAE.—Linimentum—Mistura. Form. 310. Linimentum Tabaci. R Tabaci Foliorum, fj.; Axungiae Porcinae, Ibj. Simul li- quefac et macera prope ignem donee friabilia sint folia ; tunc exprime. (Ph. Amst.) Form. 311. Linimentum Terebinthin* Comp. R Linimenti Saponis Co., Linimenti Camphoric Co., 53, fjss.; Olei Terebinth., fij.; Saponis Duri, 3ij. ; Olei Limonis et Ol. Cajeputi, 3j.~3ij. M. Fiat Lini- mentum. Form. 312. Linimentum Terebinthino-Phospho- ratum. R Olei Terebinth., fij.; Camphorae rasae, 3ij.; Linimenti Ammon. Fort., fij.; Saponis Medicin., 3ij. ; Phosphori Puri, gr. x.-xij., prius soluti in Olei Cajeputi, vel in Olei Caryophyl., 3ij., vel q. s. M. (In Chronic Rheu- matism and Epidemic Cholera.) Form. 313. Linimentum Thebaiacum Compositum. R Opii Puri, 3ij.; Camphorae, Succini, 35, 3ss.; Spirit. Vini, fvj. Misce pro Linimento. Form. 314. Linimentum Volatile. R Olei Olivae, fiv.; Camphorae, 3ij.; Liquoris Ammon., fij. Misce. Form. 315. Liquor Acetatis Morpiii*. R Morphiae Acetatis, gr. xvj. ; Aq. Destillatae, 3vij. ; Acidi Acetici, 1tlx.; Spirit. Pimentae, 3v. Solve. (Dosis a Fiv. ad Fjxxx.) Form. 316. Liquor Antimonii Potassio-Tartratis. R Antimonii Potassio-Tartratis, gr. xxxij,; Aq. Destillata;, fxiv.; SpiritOs Rectificat., fij.; Uvarum Passarum, demptis acinis, fij. Macera per hebdomadam, et cola. Form. 317. Liquor Balsamico-Aromaticus.—Balsa- mum Vita Hoffmanni. R Balsami Peruviani, 3j.; Olei Succini, Olei Rutae, Olei Rorismarini, Olei Lavand., Olei Caryoph., Olei Pimentae, 53, 3ss.; Spirit. Vini Rectificati, fxjss. Misce bend. (In doses of from 10 to 30 drops on Sugar, or in a suita- ble vehicle.) Form. 318. Liquor Bi-boratis Sod* Comp. R Bi-boratis Sodae, Potassa; Bitart., 33, fss. ; Aq. Destil., Oj. (Dosis 3j.—3iij., pro Infantibus ; et f ss.-f iij., ter die pro Adultis.) Form. 319. Liquor Calcii Chloridi. (Beddoes.) R Acidi Hydrochlorici, Aq. Destillatae, 53, fiv.; Marmoris Albi Pulv., q. s., ad saturandum. Form. 320. Liquor Camphor* jEthereus. R Camphorae rasae, 3j.; iEtheris Sulphurici, fj. Solve. Capiat Flxx.-xl., super Saccharum vel in Vini Hispan. Cyatho. (Proposed by Bang, and adopted in most of the Continental Pharm.) Form. 321. Liquor Ferri Oxygenati. (Beddoes.) R Ferri Sulphatis, fss. ; Acidi Nitrici Fortissimi (per pond.), fss. Tere probe simul in mortario vitreo donee effervescentia peracta ; dein adde gradatim Aq. Destil- latae, fjss. Postea per chartam cola. Dosis a quatuor ad decern guttas, ter quaterve, quotidie, in Quassiae, vel Zingiberis, vel Caryophylli, Infusione. (In Worms, Haemorrhages, &c.) Form. 322. Liquor Hydrargyri Bichloridi. R Hydrargyri Bichloridi, gr. iv. ; Acidi Hydrochlorici, Flvj.; Aq. Destillatae, fj.; Spirit. Tenuioris, 3yj.; Tinctune Croci, 3ij. Tere probe simul in mortario vitreo ut fiat Solutio. Incip. sumendo, Flxx., nocte maneque ex haustu InfusOs Lini, vel Decocti Glychyrrhizie ; poste- aque pro re nat3 augeatur. (Sprague.) Form. 323. Liquor Potassii Iodidi. R Potassii Iodidi, gr. xxiv.; Aq. Destillata;, fj. Solve te- rendo in vase vitreo. (Dosis Flx.-xxx.) Form. 324. Liquor Potassii Iodidi Ioduretus. R Potassii Iodidi, gr. xxxvj.; Iodinii, gr. x.; Aq. Destillata, 3x. Solve terendo in vase vitreo. (In doses of 10 drops to 30, thrice daily.) Form. 325. Liquor Morphi* Citratis. R Morphiae Purae, gr. xvj.; Acidi Citrici Crystal., gr. viij. ; Aq. Destillata;, fj.; Tinct. Cocci, q. s. Solve. (Dosis Fiv.-xxv.) Form. 326. Liquor Plumbi Acetatis Dilutus. R Liquor Plumbi Acetatis, 3j. ad 3ij.; Acidi Acetici Diluti, 3iij.; Spirit. Rectificati, 3jss. ; Aq. Destillatae, fxiv Misce. Form. 327. Liquor Potass* Chloratis. R Potassse Chloratis, 3j.; Aq. Destillat., fxij. (In indolent Sores as a Lotion, and internally in three times its bulk of vehicle.) Form. 328. Liquor Potassii Iodidi Ioduretus Con- CENTRATUS. (LUGOL.) R Iodinii, 3j.; Potassii Iodidi, 3ij. ; Aq. Destillatae, 3vij. Solve. (This solution contains one twenty-fourth part of Iodine. Dose for an Adult, six drops in sugared Wa- ter in the morning fasting, and six an hour before din- ner ; increasing the dose, every week, two drops, until it reaches to thirty or thirty-six daily.) Form. 329. Liquor Potassii Iodidi Ioduretus Dilu- tus. (Lugol.) No. 1. No. 2. No. 3. B: lodinii . • gr- % gr. j. gr- j£ Potassii Iodidi . . . gr. jss. gr- ij. gr. ijss. Aq. DestiUatffi . Solre. . . fviij. fviij. fviij. Form. 330. Liquor Zinci Acetatis. R Zinci Sulphatis Purif., gr. xxiv.; Aqua; Destillatae, fiv. Solve. R Plumbi Acetatis, gr. xxxij.; Aq. Destillatae, fiv. Solve. Misceantur Solutiones ; quiescant paulisper; dein co- letur Liquor. Form. 331. Lotio Acidi Hydrocyanic!. R Acidi Hydrocyanici, fss.; Spiritus Rectificati, fj.; Aq. Destillatae, fxss. Misce, et fiat Lotio, diligenter utenda. Form. 332. Lotio Antiphlogistica. R Liquoris Plumbi Diacetatis, 3vj.; Liquoris Ammon. Ace- tatis, fiv.; Aq. Purse, Ibij. Misce. Form. 333. Lotio Antipsorica. R Potassii Sulphureti, fiv. ; Aquae, Oj.; Acidi Sulphurici, 3iv. Misce. Fiat Lotio, bis terve quotidie utenda. (Dupuytren.) Form. 334. Lotio Boracica. R Bi-boratis Sodae, 3j. ; Aq. Kosae, Aq. Flor. Aurantii, 55, 5iij. M. Fiat Lotio. Form. 335. Lotio Evaporans. R iEtheris Sulphur., Liquor. Ammon. Acet., Spirit. Vini Rect., 55, fjss. ; Aq. Rosse, fiijss. M. Fiat Lotio. Form. 336. Lotio Evaporans Astringens. R Ammoniac Hydrochloratis, 3ij. ; Liquoris Ammon. Acet., fiij-1 Aquae Purse, f xij. Misce. Form. 337. Lotio Flava. R Hydrargyri Bichloridi, gr. xv. ; Liquoris Calcis, Ibj. Misce. Form. 338. Lotio Hydrargyri Camphorata. R Hydrargyri, 3j.; Acidi Nitrici, fij.; Aq. Destillatae, Ov. Hydrargyrum digere cum Acido Nitrico, et Aquam De- stillatam adde, dein Camphorse, 3SS* ad adjjce. (In Chronic Cutaneous Affections, applied twice daily.) Form. 339. Lotio Sedativa. R Acidi Hydrocyanici, 3j.~3ij.; Mist. Amj>dal. Amarse, gvijss.; Hydrarg. Bichloridi, gr. iij.-v. Fiat Lotio, ope spongis psirtibus alfectis applicanda. Form. 340. Lotio Terebinthin* et Camphors. R Camphorae, 3iv.; Spirit. Vini Rect., Olei Terebinthinae, aa, fiv. M. Fiat Lotio, in Morbis Cutaneis Chronicis utenda. Form. 341. Lotio Terebinthinata. R Olei Terebinthinae, Alcoholis, 55, fiv.; Camphorse, 3vi. Fiat Lotio. (In Pityriasis, j. M. Dosis Jjss., ter quaterve, aut sspius, quo- tidi8, urgentilius Languoribus. APPENDIX OF FORMULAE.—Mistura—Pilulas. Form. 449. Oleum Camphor*. R Acidi Nitrici quantum velis; Camphor®, q. s., ad Aci- dum saturandum. Serva in vase bene obturato. (Fee.) Form. 450. Pilul* Aloes cum Ferro. R Aloes Spicati Extract!, 3jss.; Myrrh® Gummi Resin, pulv,, 3ij.; Extracti Gentian®, 3iv.; Ferri Sulphatis, 3ij-; Theriac® Purificat., q. s. Simul contunde, et in Pilulas exx., divide. Dosis a ij. ad iv., seinel vel bis quotidie. Form. 451. Pilule Aloes cum Ferro Cchsposit*. R Mass® Pilul. Aloes cum Myrrh8, Pilul.Ferri Comp., Pt- lul. Galban. Comp., 55, CD ij.; Sod® Carbon, exsic., 3j.; Olei Junip. Sabin., hliv. Contunde simul, et fiat massa lequalis, in Pilulas xxx., distribuenda. Capiat ®gra binas, mane nocteque. Form. 452. Pilul® Aloes et Ferri. R Ferri Sulphatis, Potass® Carbonat., an, 3j.; Myrrh® pulver., jj. ; Aloes pulver., 3ss. M., et divide in Pi- lulas xxx. Capiat ij. vel iij., node maneque. Form. 453. Pilul® Aloes et Moschi Composit®. R Pilul. Aloes cum MyrrhS, 3j.; Camph. rasie, gr. xij.; Moschi, gr. xxviij.; Balsami Peruviani,q. s. M. Fiant Pilul. xxiv., quarum capiat binas omni node. Form. 454. Pilul® Aloes et Scammoni* Comp. R Aloes Spicat., 3j. ; Scammon., gr. xij. ; Extr. Rhei, 3ijss.; Baccar. Capsici pulv., gr. viij.; Olei Caryoph., Ttlvj. M. Fiant Pilul. xviij., quarum sumantur bin® hor8 decubitfls. Form. 455. Pilul® Alterativ®. (1.) R Mass® Pilul. Hydrarg. Chloridi Comp., 3ij.; Saponis Caslil., 3ss. ; Extr. Sarz® et Extr. Taraxaci, 83, 3jss Misce ben£, et divide in Pilulas lx., quarum capiat bi nas vel tres, ter quotidie. Form. 456. Pilul® Alterativ®. (2.) R Scillse Radicis exsic., gr. vj. ; Pulv. Fol. Digitalis, gr. xij. ; Hydrarg. Chloridi, gr. vj.; Myrrh® Pulv., 3j. Tere simul, et adde Asalbetid., 3ss.; Extr. Gentian., q. s. Fiat massa squalis, et divide in Pil. xviij., qua- rum capiat unam mane, meridie, et node. Form. 457. Pilul® Ammoniaci Composit® R Gummi Ammoniaci, 3j.; Saponis Castil., Fellis Bov. Jn- spissat., Pilul. Hydrarg., Pulv. Folior. Conii, Extracti Conii, 5a, 3ss. ; Ext. Taraxaci, 3U- > Antimonii Oxy- ■sulphureti, 3j.; Theriac® Purif., q. s. Contunde in massam ®qualem, et divide in Pilulas lxxx., quarum capiat binas vel tres, ter quotidid. (Deobstruent, dis- solvent, &c.) Form. 458. Pilul® Ammoni® et Anthemidis R Ammon. Sesquicarbonatis Pulver., Extracti Anthemidis, aa, 3ss. Fiat massa, in Pilulas xij., dividenda, quarum sumatur una bis vel ter die. Form. 459. Pilul® Ammonio-Sulphatis Cupri Comp. R Cupri Ammonio-Sulphatis, Oxydi Zinci, 88, gr. vj.-xij.; Sacchari Albi, Pulv. Tragacanth., 88, gr. xij. ; Muci- lag. Acaci®, q. s., ut fiant Pilul. xij., quarum capiat unam bis terve quotidie. (Epilepsy, Chorea, j-1 Rad. Zing, concis., 3j.: Aqu* Ferventis, ibij. Macera per horas viginti quatuor loco in calido, et cola. Liq. colato adde Mann*, f iij.; Sacch Purif., Ibiijss. Fiat Sirupus. Form. 691. Sirupus Senn* et Mann*. R Fol. Senn*, fiv.; Semin. Foeniculi cont., fjss. ; Sem. Anisi cont., 3iij.; Radicis Zingiberis, 3jss. ; Aq. Fer- ventis, Oiij. Digere per horas quatuor; exprime et cola. Dein colaturae adde Mann* Optim*, fvj.; Sac- chari Albi, fxxij. ; et fiat Sirupus. Form. 692. Sirupus Sulphureti Sodii. R Sod* Pur* (cum Alcoh. pr*p.), 3j., Aq. Destiliat., 3v., No. 1. No. 2. No. 3. R Iodinii • gr. ij- gr. iij. gr. iv. Potassii Iodidi . . gr. iv. gr- vj. gr. viij. Aquie Destil. . . . ibj. ibj. ibj. Solve. (Chiefly for external use ; for injections in Scrofulous Fistul*, &c.) Form. 672. Solutio Iodinii Caustica. (Lugol.) R Iodinii, fj.; Potassii Iodidi, fj.; Aqu* Destiliat*, fij. Solve. Form. 673. Solutio Iodinii Rubefaciens. (Lugol.) R Iodinii, 3iv. ; Potassii Iodidi, fj.; Aqu* Destiliat*, fvj. Solve. Form. 674. Solutio Morphi* Hydrochloratis. R Morphi* Hydrochlorat., gr. x. ; Aqu* Destiliat. Calid., Til 1000. Solve. (Dose, twenty-five minims—equal to i gr. of the Hydrochlorate.) Liquefac. leni igne, et adde Sulphuris Puri quantum solvi potest. R Liquoris, Jj. ; Sirupi Communis, Jxxxj. Misce bene in vase bene obturato. (Dosesof3j.-3iy.nirinfanta,fj.-fiij. for adults.) Form. 693. Tinctura Acetatis Ferri Comp. R Acetatis Plumbi, Jss. ; Ferri Sulph., 3iij., Aceti, Alco- holis, 5ii, §ij.; Aq. Rosie, 3vj. Solve Acet. Plumbi in Aceto cum lento igne ; dein adde Sulph. Ferri in Pulv., cui post solutionem, infunde Alcohol, cum Aq. Rosie permistuin. Form. 694s Tinctura- Acetatis Moiiphi® Composita. R Morphne Acetatis, gr. xvj.; solve in Aq. Destil., 3iij. ; Acidi Acetici, Tllv.; Tmct. Lavandul. Co., 3Yj- ; Spirit. Myristic®, vel Tmct. Cmnanioin. Comp., 3vij. M. Do- sis, 1tlx.-3j. Form. 695. Tinctura JEtherea Valerian®. R Radicis Valerian, pulver., Jj. ; -Etheris Sulphurici 11011- rectificat., 3vj.; Alcohol. Rectif., Jj. Macera per tri- duum et cola. Form. 696. Tinct. Aloetica Alkalina. (Saxon Ph.) R Croci Stigmat. in pulv., part. j.; Aloiis Socot. in pulv., part. jss. ; Myrrh® pulv., part. lj.; Carb. Potass®, part, iv. Misce, et pone in locum humidum ut dehquescat; dein infunde Aq. Ferventis, part. xij. Macera per ho- ras duodecim, et adde Alcoholis Concent., part, duode- cim. Digere leni cum calore per dies Ires, et cola. In dos. 3SS.-3JSS. Form. 697. Tinctura Alkalina Potass®. R Potass* Hydratis, Jss.; Alcoholis Concent., Jiv. Ma- cera per dies septem in balneo arenario. Form. 698. Tinctura Alkalina Stibiat®. R Autimonii Crudi, J j.; Potass* Carbon., Jij. Melt in a crucible, and reduce them to yellowish scori®; then powder them immediately in a hot iron mortar, and pour upon them rectified Alcohol, Jvj. Macerate for three days, and filter. Form. 699. Tinctura Amara. R Aloes Socot., Jiv. vel. v.; Gum. Myrrh®, Mastiches, Benzoes, Ilftd. Calumb® concis., aa, Jij.; Rad. Gen- tian®, Jjss.; Croci Stigm., Jj. ; Spirit. Vini Gallici (Brandy), ibix.; Spirit. Vini Hollandii (Hollands), Iblij. Macera per mensem, et cola. (The celebrated “ Drogue Amere” of the Jesuits, and au excellent tonic and ape- rient.) Form. 700. Tinctura Ammoniaci Alkalina. R Gummi Ammoniaci, Jiij.; Liq. Potass® Carbon., Jijss. ; Myrrh®, Jj. ; Alcoholis, Oj. Macera per dies septem, et cola. Dosis, 3ss.~3jss. Form. 701. Tinctura Balsamica. (1.) R Olei Terebinth., J; Tinct. Myrrh®, fij.; Tinct. Ben- zoini Comp., Jiv. Macera in loco calido. (Internally, and to Indolent Sores, &c.) Form. 702. Tinctura Balsamica. (2.) R Balsami Toiutani, jss. ; Balsami Peruviani, Styracis Bal- sami, Acid. Benzoic., Myrrh®, 55, 3iij ; Croci Stigmat., 3ij. ; Spirit Vim Rect., Jxx. Macera per dies tres, et cola. ( Wirtemburg Ph. nearly.) Form. 703. Tinctura Balsami Tolutani. R Balsami Tolutani, Jj. ; Semin. Anisi cont., Jj.; Acidi Benzoici, Jss. ; Spirit, Rectificat., Oj. Digere, donee solvatur Balsamum ; dein cola. Form. 704. Tinctura Bei.ladonn®. R Belladonn® Folioruin exsiccatorum, jij. ; Spiritils Te- nuioris, Oj. Macera per dies quatuordecim, et cola. Form. 705. Tinctura Benzoica Anodyna. R Camph, ras®, 3jss. ; Ipecac., Balsami Tolutani, aa, Jss. ; Acidi Benzoici, 3ij. ; Opii Puri, Croci Stig., aa, 3iqss, ; Olei Anisi, 3j ; Spirit. Vini Ten., Ibij. Macera 1*1®, et cola. Dosis, 1llvj.-xxx. (The Tinct. Opii Benzoica Compos, of the Ausr. PhaR., and Tinct. Anodyno Su- dorific. of various foreign Pharmacopoeias.) Form. 706. Tinctura Bruoi®. R Bruci* Pur®, gr. xij. ; Alcoholis (s. g. 837), J j. Solve. (3j. contains gr. jss. of Brucine. Dose 3ss.-3ij.) Form. 707. Tinctura Calami. ft Calami Radicis contusi, Jiv.1 Spiritus Tenuioris, Oij. Macera per dies quatuordecim, et per chartam cola- APPENDIX OF FORMULAE. —Siritpus—Tinctura. Form. 708. Tinctura Camphor.® Thebaic®. R Opii Pulveriz., jiij.; Camphor®, 3vj. ; Corucis Canellffi contus., Croci Stigmat., aa, jij.; Caryophyllorum, Pulv. Capsici, aa, Jjss ; Potass® Carbon., 51J. ; Olei Anisi, 3jss. ; Spirit. Viiii Tenuior. (vel Sp. Vini Gallic®, vel Sp. Vini Hollandii), Oij. Macera leni cum calore per dies viij. ad xij. ; dein exprime et cola. Form. 709. Tinctura Caryophyllorum. R Caryophyllorum contus., Jiij.; Spirit. Vini Tenuior., Oij. Macera bene, et cola. Form. 710. Tinctura Cascarill® Alkalina. R Corticis Cascarill® cont., ;iv.; Potass* Carbon., jss. ; Spirit. Tenuior., ibij. Macera bene, et cola. Dosis, 3j-3»ij- Form. 711. Tinctura Castorei Alkalina. R Castorei contus., jfiij.; Potass* Carbon., 3iij. ; Croci Stigm., 3ij. ; Spirit. Rorismarini, Ibij. Macera per tri duum, et cola. M. Dosis, 3ss.-3ij. Form. 712. Tinctura Centaurii Cacuminum. R Centaurii Cacumin. (flowering tops of Centaury), Jiij. , Spiritfis Tenuioris, Oij. Digere per dies quatuorde- cim, et cola. Form. 713. Tinctura Cinchoni® Sulphatis R Cinchoni* Sulphatis, gr. xxxvj. ; Alcoholis Rect., Jiij. Solve. Dosis, 3j.-3iij. Form. 714. Tinctura Conii. R Conii Foliorum exsrccatorum, Jij.; Cardainomi Seminum contusorum, 3iij. ; Spiritus Tenuioris, Oj. Digere per dies septem, et per chartam cola. Form. 715. Tinctura Digitalis zEtherea. R Fol. Digitalis exsic. et pulv., part. j.; JEther. Sulphur., part. lv. Macera per triduum, et cola. (Dosis, lll.xx.-xxx. ter die. Several Continental Pharmaco- poeias) Form. 716. Tinctura Diosm® Crenat®. R Fol. Diosm® Crenatie, fij. ; Spirit. Tenuioris, Oj. Ma- cera per dies septem, et cola. (Dose 3j.~3iij.) Form. 717. Tinctura Diuretica. R Olei Juniperi, 3ss. ; Spirit. -Etheris Nitrici, Tinct. Digi- talis JEtbere®, aa, 3iij. M. (Dosis, 3ss.~3j., ter qua- terve in die. IIufeland.) Form. 718. Tinctura Ferri .Ether®a. R Acidi Ilydrochlorici, Jij.; Acidi Nitrici Dilut., Jjss.; Ferri Limatur®, q. s. Dissolve ihe iron in the acids ; evaporate to dryness ; afterward deliquesce the residue by exposure to the air, and mix the deliquesced liquor with double its weight of Sulphuric iEther, agitating the mixture frequently until it assumes a golden yel- low colour; then decant, and add double the quantity of rectified Alcohol. This Tincture may be used pre- viously to the addition of the Alcohol, or subsequently. In the state of .Ether the dose is from 16 to 20 drops ; in that of .Ethereal Tineture, from 20 to 30 drops. It is useful in Diseases of Debility, and in Spasmodic Af- fections. Form. 719. Tinctura Fructus VAnill®. R Fructus Vanill* concis. et contus., part. j. ; Alcoholis, part. vj. Macera leui cum calore per dies octo, et cola. (Nervine, Analeptic, Excitant, &c. Pfaff.) Form. 720. Tinctura Gai.bani Composita. R Galbani Gummi Resinas Jjss. : Pimentie Baccarum con- tus., jj. ; Cardaniomi Semin, contus., Jss. ; Spirit. Rectif., Oj, Aq Destil., Oss. Macera per dies qua- tuordecnn, et cola. Form. 721. Tinctura Gall®. R Gallarum contus., Jij. ; Spirit. Tenuioris, Oij. Macera per dies octo, et per chartam coia. Form. 722. Tinctura Iodinii Fortior. R Iodinii, 3ij. ; Spirit. Rectificat., Jj. Solve, terendo in vase vitreo. (3j- contains five grains of Iodine.) Dose Til vj.-xxiv. Form. 723. Tinctura Iodinii Mitior. R Iodinii, gr. xxiv. ; Spirit. Rectif., Jj. Solve, terendo in vase vitreo. M. (3j. contains gr. iij. of Iodine.) Form. 724. Tinctura Lobeli® Inflat®. R Herb. Lobeli® Inflatie exsic., Jij. ; Spirit. Vini Ten., Oj Digere per dies decern, et cola. (Emetic in doses of 3j. to 3ij. ; Antispasmodic in doses of filxx. to jss. ; and Diuretic in smaller quantities.) APPENDIX OF FORMULAS.—Tinctura—Unguentum. Form. 725. Tinctura Myrrha Alkalina. R Myrrhs, fj.; Potass® Carb., 3vj. ; Aq. Ferventis, fiij. Tere ; deiu macera in balneo aren. ad mellis crassitud., et adde Spirit. Tenuioris, fx. Macera bene, et cola. Capiat 3j.—3ij. ex Infuso Anthemidis. (In Scrofula, &c.) Form. 726. Tinctura Nervosa. (Riemerii.) R Spirit. Cornu Cervi Rect., part. iv.; adde gradatim Al- cohol. Rect., part. xvj.; Camphors, part. ij. ; Olei Ju- nip., partem j. Solve. Form. 727. Tinctura Nucis Vomica. R Extracti Nucis Vomics exsic., gr. iv. j Alcoholis (36°), f j. Solve. (3j. Tinct. ad gr. ss. Extracti.) Form. 728. Tinctura Opii Camphorata. (Sive Elixir Paregoricum Pharm. Pristin.) R Camphors, 3ij.; Opii Crud. in pulv., Acidi Benzoici, 55, 3j.; Olei Anisi, 3ss.; Potass. Carbon., 3j. Omnia in mortario simul optimfi terentur; paulatim affunde Spiritus Tenuioris, Oij.; stent in digestione per dies decern ; turn adde Radicis Glycyrrh. incisa, fiv.; di- gere iterum per dies septem, et cola. Form. 729. Tinctura Opii Composita. (Vel Laudanum Liquidum Verum Sydenhamii.) R Opii Puri contrit., fij.; Croci, fj.; Cort. Canells, Cary- ophyllorum, 55, 3jss. ; Spirit. Vini Rect., fiv.; Vini Ilispan., ibj. Macera cum leni calore per dies xvj. ; dein exprime et cola, (lllxv. equal to 1 grain of pure opium.) Form. 730. Tinctura Phellandrii. (Marcus.) R Semin. Phellandrii Aq., fss.; Alcoholis, fvj. Macera per horas xxiv., et adde Vini Burgundis, fvj. Macera per dies tres, et cola. Capiat 1tlx.-lx. (In Chronic Bronchial and Pulmonary Affections.) Form. 731. Tinctura Quina Sulphatis. R Quins Sulphatis, gr. viij.; Spiritus Vini, f j. M. Fiat Tinctura. Form. 732. Tinctura Quina Sulphatis Acid. R Quin® Sulphatis, gr. xlviij.; Tinct. Aurantii Comp., fvss.; Acidi Sulphurici Dilut., 3ij. M. Fiat Tinctura. (Dosis, 3ss. ad 3ij.) Form. 733. Tinctura Riiatania. (Sprague.) R Krameris Radicis contus., fiij.; Spiritils Tenuioris, Oij. Digere per dies octo, et per chartain cola. (This Tincture is strongly impregnated with the medi- cinal virtues of the root. It is a very grateful tonic, when given according to the following formula: R Infnsi Rosa,,3x. ; Acid. Sulph. Aromat., lllxv-; Tinct. Rhatanis, Sirupi Rhceados, 55. 3j. M. Fiat Haustus, ter in die hauriendus.) Form. 734. Tinctura Rhatania Aromatica. R Krameris Radicis contus., fiij.; Canells Corticis contus., fij.; Spiritfis Tenuioris, Oij. Digere per dies decern, et per chartam cola. The following is an agreeable method of exhibiting this tincture: R Infusi Aurantii Compositi.fvj. ; Tinct. Rhatanis Aromat., Sirupi Zingiberis, 5a, f j. Misce. Fiat Mistura; cujus sumat cocli. ampla iij. ter m die, urgeute Languore vel Flatu. (Sprague.) Form. 735. Tinctura Rhei Anisata. R Radicis Rhei concis., Radicis Glycyrrh. concis., 55, fij. ; Seminum Anisi contus., Sacchari Purif., 55, fj. ; Spiri- tfis Tenuioris octarios, ij. Macera per dies quatuorde- cim, et cola. Form. 736. Tinctura Rhodii. R Rhodii Ligni ras., fiv.; Spiritfis Rectificati, Oj. Macera per dies quatuordecim, et per chartam cola. Form. 737. Tinctura Sabina Alkalina. R Olei Essent. Sabin®, 3ij.; Tinct. Alkalin®, fvij. et 31'j. (F. 696). Solve. Dosis, 1tlxx.-xxx. Form. 738. Tinctura Senna Amara. R Fol. Senna, part. vj.; Radicis Gentian® concis., part. iv.; Corticis Aurantii exsic., part. ij.; Cardamom. Semin, contus., part. j.; Spirit. Vini Ten., partes xlv. Macera per dies quatuordecim, et cola. Form. 739. Tinctura Stramonii. R- Datura Stramonii Seminum contus., fij.; Spiritfis Te- nuioris, Oj. Macera per dies quatuordecim, et cola. Form. 740. Tinctura Strychnia. R Strychnia Purse, gr. ij.; Alcoholis (sp. gr. 838), fj. Solve. Dosis, Ttlviij. ad xxx. Form. 741. Tinctura Tabaci. R Fol. Nicot. Tabaci, fij.; Alcohol. Rect., Oj. Macera per (lies septem ; exprirae et cola. Form. 742. Tinctura Tabaci Composita. R Tabaci Foliorum concis., fss. ; Camph. rasa, 3iij.; Spirit Rectif., Aq. Destil., 55, fiv. Macera per dies octo, et cola. Form. 743. Trochiscus Catechu Extracti R Catechu Extracti Pulv., fiij. ; Cinnamomi Corticis in pulv., 3jss. ; Olei Cinnamomi, Itlv.; Sacchari Purificati, Jxiv.; Mucil. Tragacanth.. q. s. Fiat massa in Tro- chiscos formanda. (Spraoue.) Form. 744. Trochiscus Ipecacuanha. R Ipecac. Radicis Pulv., 3iv.; Sacchari Purificati, Iblj., Mucil. Tragacanth., q. s. Misce secundum artem ut fiat Troch. 480. (Each lozenge contains half a grain of Ipecacuanha. In recent Coughs and in Diarrhoea.) Form. 745. Trochiscus Lactuca. R Extract. Lactuca Concentrat. (Probart’s), Extracti Gly cyrrh., Pulv. Acacia; Ver., 55, 3iv. Hasc optime terantur simul, et cum A quit fiat massa, in Trochiscos formanda. Form. 746. Trochisci Nitro-Camphorati. R Extr. Opii, gr. vij.; Camph. rasa;, gr. xxvj. ; Potass® Nitratis, 55ijss.; Sacchar. Purif., 3iij.; Mucilag., q. s. Misce bene, et divide in Tabulas 1., quarum capiat vj.-x. per diem. (Chaussier.) Form. 747. Trochiscus Potassa Nitratis R Potassa; Nitratis Pulv., fiv.; Sacchari Purificati, Ibj Hac optime terantur simul, et cuin Mucil. Tragacanth fiat massa in Trochiscos formanda. Form. 748. Trochiscus Zinci Sulphatis. R Zinci Sulphatis Purif., 3iv.; Sacchari Purificati, ftlj Ha;c optime terantur simul, et cum Mucil. Tragacanth fiat massa in Trochiscos formanda. (This mass should be equally divided, so that each lozenge may contain gr. £ of the Zinc.) Form. 749. Unguentum Antimonii Potassio-Tartra tis, vel Febrifuoum. (1.) R Antimonii Pot.-Tart., gr. xxv. Solve in Aq. Destil., q s.; dein adde Antimonii Pot.-Tart. in pulv. subtiliss redacti, 3jss.; Adipis Praparat., 31. Misce bene, et fiat Unguentum. (Produces Phlogosis, and its anti- mony is partially absorbed.) Form. 750. Unguentum Antimonii Potassio-Tar- tratis. (2.) R Antimonii Pot.-Tart. in pulv.,3j. ; Adipis Praparat., fj.; Camph. rasa; et subact., 3j.; Olei Cajeputi, fllxv.! Moschi, gr. iij. Misce bend. Form. 751. Unguentum Antimonii Potassio-Tar- TRATIS. (3.) R Antimonii Pot.-Tart., 3jss ; Adipis Praparati, fj. j Bal sami Peruviani, lllxv. M. Form. 752. Unguentum Argenti Nitratis. R Argenti Nitratis Pulv., gr. xl.; Adipis Prapar., fj.; Liq Plumbi Di-acet., 3ij. M. Fiat Unguentum. Form. 753. Unguentum Balsami Peruviani R Balsami Peruviani, 3j.; Unguenti Elemi Comp., 3vij. Unguento balneo in aquoso liquefacto, adjice Balsamum Peruvianum, et fiat Unguentum. Form. 754. Unguentum Belladonna. (1.) R Belladonna; Fol. recent., Adipis Praparata, 55, fiv. The leaves are to be bruised in a marble mortar ; after which the lard is to be added, and the two incorporated by beating. They are then to be gently melted over the fire ; and after being strained through a cloth, and the Belladonna well pressed, the ointment is to be stirred till quite cold. (Sprague.) Form. 755. Unguentum Belladonna. (Chaussier.) (2.) R Ext. Belladonna, 3ij.; Aq. Destil., fjss. Tere cum Un- guenti Simp., vel cum Axungia, fijss. M. Form. 756. Unguentum Calomelanos et Camphora. R Calomelanos, Camphors, 55, 3j. ; Olei Caryoph., flliv.; Unguent. Simp., 31'j. M. Form. 757. Unguentum Calomelanos cum Camphora. R Calomelanos, 3ij.; Camphors, 3j.; Unguenti Simp, (vel Ung. Sambuci Flor.), 3vj. M. Fiat Unguentum. Form. 758. Unguentum Camphora Compositum. R Saponis Albi rasi, fjss.; Camph. rasa, 3iij ; Olei Tere- ADDENDA TO APPENDIX.—Balsamum—Bolus. binthin., fss. Misce paulatim, et adde Liq. Ammoni®, 3j- M. Form. 759. Unguentum Comitiss*. R Olei Fiment®, Olei Oliv®, 55, fijss.; Cer® Flavse, fj. Solve, bt adde Pulv. Piment®, 3iij.: Pulv. Gallarum, Pulv. Nucis Cupressi, Pulv. Sem. Plantaginis, Pulv. Fol. Toxicodend., 55, 3jss. ; Sulphatis Aluminis, 3j.; Camphor® ras®, 3ij. Misce bene, et sit Unguentum. Form. 760. Unguentum Cupri Acetatis. R Cupri Acetatis, Hydrargyri Chlorid., 55, 3j.; Cerati Re- sin®, fj.; Terebinth. Vulgaris, fss. Liquefac. Resin® Ceratum in balneo aquoso, ct Terebinthinam adjice ; tunc Cupri Acetatem et Hydrargyri Chloridum (prius commistos) insperge, et omnia misce. Form. 761. Unguentum Deobstruens. (1.) R Ammon. Hydrochlorat. pulveriz., 3j. ; Unguenti Hydrarg. Fort., f j.; Extr. Cicutte, 3jss. Misce bene, et fiat Unguentum. (Dr. Hunefeld. Tumours, Indura- tions, &c.) Form. 762. Unguentum Deobstruens. (2.) R Unguenti Hydrarg. Fort., part. xciv. ; Ammon. Hydro- chlorat. pulveriz., part. vj. Misce bend. (M. Dupuy- tren.) Form. 763. Unguentum Gall* Opiatum. R Gallarum in pulv. subtil., 3iij.; Opii Crudi Pulver., 3j. Unguenti Plumbi Acetatis, fiij. M. Fiat Unguentum. Form. 764. Unguentum Gall.® Opio-Camphoratum. R Pulv. Nucis Gallarum, 3j.; Camph. ras® et subact® in pauxillo Alcoholis, 3j.; Pulv. Opii Puri, Potass® Ni- tratis pulveriz., 55, 3ss.; Adipis Prsparat®, 3iij. ; Olei Piment®, Ttlxii.—xvj. Misce bene, et sit Unguentum ter quaterve in die applicandum. Form. 765. Unguentum Hypochloridis Sulphuris. R Sulphuris Hypochloridis, 3j.; Unguenti Simplicis, fj. Misce bend. (For Lepra, Psoriasis, and other Chronic Eruptions.) Form. 766. Unguentum Potassii Iodidi. R Potassii Iodidi, 3ss.; Adipis Pr®parat®, fjss. Form. 767. Unguentum Iodinii. R Iodinii, gr. xij. ; Potassii Iodidi, 3iv.; Adipis Suill® re- cent. pr®par., fij. M. Form. 768. Unguentum Iodinii Opiatum. R Iodinii, gr. xv. ; Potassii Iodidi, 3j.; Adipis recent. pr®p., fij. Misce bend, et adde Extr. Opii, gr. xxx.; Tinct. Opii, 3j. Sit Unguentum Form. 769. Unguentum Iodidi Hydrargyri. No. 1. No. 2. No. 3. R Iodidi Hydrarg. . . 3ij. 3iij. 3iv. Adipis Suill® recent. . fij. fij. fij. Misce. Form. 770. Unguentum Iodidi Plumbi. R Iodidi Plumbi, 3ij.~3iij.; Adipis Suil. recentis prapar., fij. Misce. Form. 771. Unguentum Nervinum. R Unguenti Alth®® (vel Ung. Sambuci), fiv. ; Liq. Ammon., fj.; Camphor®, Petrolei, Spirit. Terebinth., 55, fss. ; Olei Rorismarini, 3ij. ; Olei Bergamii, 3j. M. (Hufe- land.) Form. 772. Unguentum Populeum. R Gemm® vel Oculor. Populi Balsamifer® vel Nigr® con- tus., Ibss. ; Butrei recentis, Ibj. Liquefac simul lento igne, vel in balneo arenario, et exprime. Form. 773. Unguentum Populeum Compositum. R Gemmas Populi Bals. vel Nig. recentis, tbjss. Contunde cum Adipis Prteparat., Ibiij., et adde Fol. recentis Hy- oscyami Nigri, Fol. recentis Belladonnas, 5a, fiv. Con- tunde simul, et macera leni cum calore donee dispareat humiditas; dein exprime. (All the German Pharma copceias.) Form. 774. Unguentum ad Porriginem. (1.) R Sulphuris Sublimati, Unguenti Picis Liquid®, 55, fjss. ; Saponis Mollis, Ammon. Hydrochloratis, 55, fss. Misce. Fiat Unguentum. Form. 775. Unguentum ad Porriginem. (2.) R Hydrargyri Chloridi, 3ij.; Aluminis Exsiccati, Plumbi Carbonatis, 55, fss. ; Terebinth. Venet., 3vj. ; Ceratx Cetacei, fjss. Misce. Fiat Unguentum. Form. 776. Unguentum Sulphureti Iodinii. R Sulphureti Iodinii, gr. xv.-xxv.; Axungite, fj. M. Form. 777. Unguentum Zinci Iodatis. R Zinci Iodatis, 3j.; Adipis Prteparat®, fj. M. Form. 778. Vinum Aloes Alkalinum. R Aloes Socot., Croci Stigm., Myrrh®, 55, fj.; Potass® Carbon., f ij.; Vini Alb. Hispan., Ibij. Macera per dies xij., et cola. In dos. 3ij•—5j- (In Pyrosis, Dyspepsia, &e.) Form. 779. Vinum Aloes et Sod,® Compositum. R Sod® Carbonatis, fiij.; Ammon. Sesquicarbonatis, 3ivss.; Myrrh®, 3vj. ; Aloes Extracti, 3vj.; Vini Albi (Skerry, Anglice), fxxiv. Macera per dies septem, et cola. (The dose is from one fluid drachm to half a fluid ounce.) Form. 780. Vinum Anthelminticum. R Extr. Aloes, Asafcetid®, Radicis Gentian®, Camphor®, Corticis Aurantii sic., Castorei, 55, 3j. ; Croci Stig., 3j. ; Spirit. Vini Ten., Ibiij.; Vini Oporto, Ibiij. Ma- cera leni calore, et post horas xij. cola. Capiat 3ij.~3ij. in Decocto Anthemid., &c. Form. 781. Vinum Diureticum Anti-arthriticum. R Potass® Carbon., 3ijss.; Pulv. Rhei, Juniperi Baccar cont., 55, 3jss. ; Rad. Zedoarii concis. et contus., 3ij. ; Canell® in pulv., 3iij. ; Scill® Rad. exsic., 3j. ; Vini Xer®, fxxxij. Macera bene, et cola. Capiat fj.-fij., bis terve quotidie. Form. 782. Vinum Ferri Citratum. (Phar. Wirtem.) R Ferri Limatur®, fiv.; Aurantiorum Amar., No. iv. Ex- corticatis Aurantiis, cortices et succulenta caro fruc- tuum cum Limaturis Ferri in pastam redigantur mor- tario in lapideo. Dies post tres infunde Vini Madei- rensis, fxij.; Tinct. Aurantii, fij. Macera per diem integrum, et cola. Dosis, 3ss.-3jss. Form. 783. Vini Ferri Comp. R Ferri Sesquioxidi, fj., vel Ferri Fragmentor., fiij.; Ra- dicis Calami Arom., fij. Infunde Vini Albi Hispanici, Ibij., et stent in digeslione per dies 6-8. Exinde su- mantur quotidid uncia una vel du®, et suppleatur vinum. Form. 784. Vinum Quin*. R Vini Madeirensis, f viij.; Quin® Sulphatis, gr. xvj. M. ADDENDA TO APPENDIX OF FORMULAE. Form. 785. Balsamum Odontalgicum. R Opii Puri, Camph. ras®, 55, 3j. ; solve in Spirit. Rect. Terebinth., 3jss. ; Olei Caryoph. et Ol. Cajeputi, 55, 3ss. ; Balsam. Peruvian., 3ij. Misce bene. Form. 786. Bolus Camphor,® Compositus. R Camphor®, gr. v.-xv. ; Hydrarg. Chlorid., gr. v.-xx. ; Opii Puri, gr. j.-iij.: Conserv. Rosarum, q. s., ut fiat Bolus. f orm. 787. Bolus Camphor.® et IIyoscyaMi. R Camph. subact®, gr. v.-xij. ; Extract. Ilyoscyami, gr. v.-x.; Potass® Nitratis, gr. v.-viij.; Conserv. Rosar., q. s. M. Fiat Bolus, hor5 sormii sumendus. (In Puerperal Mania, and in Mania after Evacuations, to be accompanied with cold sponging the head.) Form. 788. Bolus Catechu. R Catechu Extr., gr. viij.-xij.; Confect. Aromat., gr. viij., Sirup., q. s. M. Fiat Bolus. Form. 789. Bolus Moschi et Camphor.*. It Moschi, gr. v.-x. ; Camph, rasie, gr. iij.-viij. ; Spirit. Rect., 1tlj. ; Confect. Ros. Gall., q..s. Camphoram. cum Spiritu tere, et deinde, secundum artem, fiat Bolus. ADDENDA TO APPENDIX.—Electuarium—Haustus. Form. 790. Electuarium Deobstruens. ft Potass® Bitart., fj. ; Biboratis Sod®, 3iij.; Sulphur. Pr®cipit., 3vj.; Coufcotionis Senior, fjss.; Sirup. Zin- giberis, yvj. ; Sirup. Papaveris. rUJ- M. Fiat Elec- tuarium, cujus capiat-cochlearia duo minima omni nocte. Form.791. Electuarium Ferri Sesquioxidi ft Ferri Sesquioxidi, Sirupi Zingiberis, dd, yss.; Confectio- nis Aurautiorum, fij. M. Fiat Electuarium, de quo capiatur moles nucis moschat® bis vel ter quolldid. Form. 792. Emplastrum Antimonii Potassio-tar- tratis. ft Emplast. Picis Comp, quantum velis ; super Alutam ex- tende, et Antimon. Pot.-Tart. pulvere leviter insperge. Fiat Emplastrum. Form. 793. Emplastrum Picis et Petrolei. ft Picis Liquid®, fij. ; Galbani, fj.; Sulphuris, Succini, dd, 3ij.; Semin, curnini emit., Pulv. Flor. Anthemidis, aa, 3jss. ; Petrolei. fss. Liquefac Galhanum cum Aceti, q. s., idque misce cum Pice liquida; dein adde alia, et misce bene. Form. 794. Enema Commune. ft Sodii Chloridi, 3vj.-fj. ; Decocti Aven®, fx.; Olei Lini, fjss.-fijss. M. Fiat Enema. Form. 795. Enema Ipecacuanhie. ft Rad. Ipecac, contrit., 3j. ; Aq. Ferventis, fx. Macera per horani et fiat Enema. F-orm. 796. Fotus Conii. R Conii Folior. exsic., fj. Coque ex Aqu®, Oijss. ad Oij., et cola. Form. 797. Gargarisma Capsici. ft Capsici Baccarum contus., gr. xv.; Aq. Ferventis, fix. Infu tide per boras tres, et cola, ft Liquoris Colati, §vijss.; Acidi Hydrochlorici, Tllxxv. ad Tlixxxv. , Tinct. Myrrh®, yiijss. ; Mollis Ros®, fss. M. Fiat Gargarisma. (The Biboras Sod®, Extractum Cat- echu, or any other astringent, may be substituted, ac- cording to circumstances, in the place of the Hydro- chloric Acid.) Form. 7s. ad 3ij. pro dosi. Form. 802. Guttje -Ethere* Absinthii. ft Olei Absinthii, ?ss. ; Spirit. Etheris Sulphurici Comp., et Spirit. Vini Rect., dd, 3ij. M. Sumat ®ger gut. xx.-xxx. omni hold, aut ornrii bi aut trihorio. Form. 803 Gutt* Antispasmodicie. ft Tinct. Ammon. Comp., 3vj. ; Ether. Sulphur., fj.: Olei Anthemidis, 3j.; Tinct. Opii Comp , 3ij. ; Extr. Papa- veris Albi, 3j. M. Capiat lllxx.-xlv. in cyatho Infos. Anthemidis, vel Infus. Flor. Samhuci, vel Decoct. Hor- flei Comp., &c. (Grimaud.) Form. 804. Gutt* Odontalgic*. R Opii Puri et Camphor®, dd, gr. x. Solve in pauxillo Al- coholis, et adde Olei Caryophyl., 3j.; Olei Cajepnti, ?j. Misce bene.—Vel, ft Camph. ras®, 38s. ; Tinct. Opii, 3j. ; Creasoli, 3j. Misce bene. Form. £05. Haustus Chlorin*. ft Solutionis Chlorin®, 3ss. ; Aq. Destillat , 3xij. ; Sirup. Papaveris Albi, 3ss. M. Fiat Haustus, 5tis vel 6tis h.iris sutuendus. • Form. 806. Haustus Arsenicalis. ft Confectionis Aromatic#, 3j. ; Aq. Menth Sativ®, fj., Tinc.t. Opii, Liquoris Potass# Arsenitis, da, Hlyj. M Fiat Haustus, ter quotidie sumendus. Form. 807. Haustus Balsami Peru-viani. R Balsami Peruviani, TTlv. ad 3j. ; Mucilag. Aeaci®, 3jss Tere sitnul; et adde, Mist. Camphor#, 3vj. ; Spiritus Anisi, 3jss.; Aq. Auethi (vel Aq. Ciunam.), fss. Fiat Haustus, ter quaterve de die capiendus. Form 808. Haustus Belladonna et Cinchona. R Decoeti Cinchon®, 3xiv.; Extracli Cinchon®, gr. x.; Tinet. Beliadonn®, Ttlxx. (See F. 704); Tinct. Auran- tiorum, 3jss. M. Ft. Haustus, ter in die capiendus. Form. 809. Haustus Diaphoreticus. R Vini Ipecac., Vini Antimonii Pot.-Tart., dd, lllx. ; Liq. Ammon. Acet., 3ijss.; Mist. Camphor®, f j. ; Tinct. Hy- oscyami, Tllxxv. ; Spirit. .Ether. Nit., 3ss. ; Sirupi Au rantii, 3j. M. Fiat Haustus, quartis horis capiendus. Form. 810. IIaostus Emmenagogus. R Decocti Aloes Comp., fj.; Bibnratis Sod®, 3ss -3j. ; Tinct. Alo6s Comp., 3j.; Tinct. Castorei, 3.i-. Tinct. Croci, 3ss. ; Aqu® Cinnam., 3ij. Fiat Haustus, omni noc.te sumendus. Form. 811. Haustus Hyoscyami et Anisi. R E.xtracti Hyoscyami, gr. iij.-v. ; Tinct. Scill®, Ttlx.-xij., Spirit. Anisi. 3jss.; Aq. Anisi, fjss.; Acidi Nilrici, Hlviij. Fiat Haustus, horis tertiis vel quartis durante paroxysmo Dyspnoeas, &c , capiendus. Form. 812. Haustus Nervinus. R Spirit. Ammon. Fcetid., Tinct. Colchici Comp., Spirit. Ether. Nit., S3, 3ss. ; Liquor Ammon. Acet., 3ij. ; Mist. Camphor®, fj.; Sirupi Croci, 3j. M. Fiat Haus- tus, bis terve in die sumendus. Form. 813. Haustus Pectorai.is. R Balsami Peruviani (vel Bals. Tolutani). 3ss.~3ss. ; Olei Anisi, Hlv.-x.; Extr. Comi, gr. iij.-vj.; Mucilag. Gum- mi Acaci®, 3ij.; Aq. Piment® et Aq. Fceniculi, ad, fss. M. Form. 814. Haustus Quassi* et Ferri. R Tinct. Ferri Sesquichlor., Tllvj.-xij. ; Irifusi Quassi®, Aq. Cinnam., da, 3vj. ; Tinct. Calumb®, 3j. M. Fiat Haus- tus, mane et meridie sumendus. Form. 815. Haustus Salinus. R Potass® Carbonntis, 3j.: Succi Limonum recentis, fss. ; Mist. Camphor®, fj. ; Potass® Nitratis, gr. x. ; Sirupi Rhceados, 3j. M. Fiat Haustus, quartd qudque hord sumendus. Form. 816. Haustus Salinus Aromaticus. R Potass® Carbonatis, 3j. ; Succi Limonum recentis, fss. vel q. s. ; Aqu®, fj.; Spirit. Myristic®, Sirupi Aurantii, da, 3j. M. Form. 817. Haustus Salinus Demulcens. R Mist. Amygdal. Dulc., Mist. Camph., ad, fss.; Vini Ipe cac., IRx. ; Potass® Bicarbonatis. gr. xv. ; Sirupi Scill®, 3j. M. Sumatur cum Succi Limouis coch. uno am- plo, in effervescenti® impetu ipso. Form. 818. Haustus Salinus Sedativus. R Potass® Nitratis, gr. vj.-xv. ; Sod® Carbon., gr. x.-3jss. ; Tinct. Hyoscyami, 3s*. (vel Tinct. Camphor® Comp, pristin., 3j.) ; Mist. Camphor®, Aq. Menth. Virid., dd, 3vj. ; Sirup. Croci, 35s. M Fiat Haustus, tertiis vel quartis horis sumendus. Form. 819. Haustus Sedativus. R Ammon. Sesquicarbonatis, gr. xv. ; Aq. Destillat., fj. ; Spirit. Myristic®, 3j.; Sirupi Aurantii, f.ss.; Extr Cunii, gr. iij.-vj. Fiat Haustus, ter quaterve quotidid sumendus, cum Succi Limonis recentis cochleari uno maguo, in effervescenti® impetu. Form. 820. Haustus Sedativus cum Magnesia. R Magnes. Carb., yss. : Aq. Menth. Virid., 3xj. ; Spirit. Anisi. 3jss.; Olei Caryoph., Olj. ; Sirupi Zingib., Jss. M Fiat Haustus. Form. 821. Haustus Sedativus et Refrigerans. R Potass® Nitratis, gr. x.; Tinct. Opii, Tllvj.; Sirupi Pa- pav All)., 3ij.; Mist. Camphor®, 3X. Misce. Fiat Haustus, omni 6td hora sumendus. Form. 822. Haustus Tonicus Alkalinus. R Potass® Bicarbonatis, 3j. ; Infusi Gentian® Compos., Aq. PimetittB, dd, 3vj. ; Tinct. Rhei, 3j. M. Fiat Haus- tus, meridie et hora sonini sumendus. ADDENDA TO APPENDIX.—Infusum—Mistura. Form. 823. Infusum Angelic* Sylvestris. R Radicis Angelic. Sylvest., Calam. Aromatici, 33, 3iij. ; infunde cum Aq. Font. Ferventis, Jvj. Stent per ho- ram in vase clauso; cola, et adde Liquoris Ammon. Ac itat., Jss. ; Hltheris Sulphur., 3jss.; Sirupi Cort. Aurantii, 31 ij. M. Fiat Mist. Capiat ®ger qualibet hora cochleare unum. Form. 824. Infusum Anisi Compositum. R Seminum Anisi, 3jss.; Foliorum Meliss® Officinalis, 3j.; Aq. Communis Calid®, Ibij. Infunde per quad- rantem horse ; cola, et adde Sacchari Albi quantum libet. •Form. 825. Infusum Gall*. R Gallarum contus., Jij. ; Aq. Ferventis, tbj. Macera per horas viginti quatuor, et cola. Form. 826. Infusum Serpentari*. ft Radicis Serpentari®, 3iij.; infunde cum Aq. Ferventis, Jviij., ebull. paul. Cola, et adde Hither. Sulphur., 3ij.; Tinct. Camphor® Comp., 3j. M. Capiat ®ger quhiibet hora cochleare unum. Form. 827. Infusum Turionum Pini Abietis. ft Turionis Pini Abietis, 3iij.; infunde Aq. Fervid., Jx. per semi-horam ; dein exprime, cola, et adde vel Potass® Carb., vel Potass® Sulphatem, vel Spir. Hither. Nit., vel Sp. Junip. Comp., ut sit oecasio. Form. 828. Injectio Astringens. ft Quercus Cort. cont., 3vj.; Aq. Destil., Jx. Coque per partem hor® sextam, et cola. ft Liquoris Colati, Jiv.; Infusi Lini, Jiv. ; Extr. Coaii, 3jss. ; Biboratis Sod®, 3j. M. Form. 829. Linctus cum Ipecacuanha. ft Olei Amygdalarum, Sirupi Limonum, sing., Jj.; Pulveris Ipecac., gr. vj.; Confectionis Ros® Canin®, Jj. ; Pulv. Tragacanth. Comp., 3iij. Misce. Cochleare minimum subinde deglutiatur. Form. 830. Linctus Refrigerans. ft Pulp® Tamarindorum, Sirup. Alth®®, 33, Jij.; Potass® Bitart., 3ijss.; Potass® Nitratis, 3jss. M. Sumat omni trihorio duo cochlearia parva. Form. 831. Linctus Terebinthin*. ft Olei Terebinth., 3ij.-Jj.; Mellis Despumati, Jj.-Jijss. ; Pulv. Radicis Glycyrrh., q. s., ut fiat Linctus, de quo sumatur cochleare parvum vel medium, nocte, mane meridieque. Form. 832. Linimentum Opiatum. ft Tinct. Opii Comp., Jss.; Camphor®,3»j. ; Olei Amygdal. Pile., Jij. M. Sit Linimentum. Form. 833. Lotio Acidi Hydbocyanici. ft Acidi Hydrocyanici, 3ij-; Plumbi Acetatis, gr. xvj. ; Aq. Destill., Jvijss. ; Spirit. Vin. Rect., 3ij. Fiat Lotio, parti affect® applicanda. (Thompson, in Cutaneous Eruptions.) Form. 834. Lotio Acidi Nitro-Hydrochlorici. ft Acidi Nitro-Hydrochlor. Diluti (F. 5), yij.-Jss. ; Aq. Ca- lid®, Jxvj. M. Fiat Lotio, quamprimum pr®parata, sit, ope spongi®, ulenda. Form. 835. Mistura Alkalina Anodyna. ft Sod® Sesquicarhonatis, 3j. (vel Potass® Bicarb., gr. xvj.) ; Mistur® Amygdalarum, Jjss. ; Tinct. Hyoseya- mi, ITl.xx.-3ss. ; Tinct. Cardam. Comp., 3ss. Fiat Haustus, bis vel ter die sumendus. Form. 836. Mistura Ammoniaci et Conii. R Acidi Nitrici, 3j.; Aq. Pulegii, 3iv, Misce; dein tere cum Ammoniaci, 3j., et adde Extr. Conii, 3SS.; Sirupi Tolutani, Jss. M. Capiat coch. unum in Decocto Al- tllffi®, &c. Form. 837. Mistura Anodyna. ft Aq. Menth. Virid., Jvjss. ; Potass® Nitratis, 3ij.; Spirit. Hltheris Nit., 3ij. ; Tinct. Ilyoscyami, 3jss ; Sacei Inspissati Samb. Nig., 3jss. ; Extracti Taraxaci, Sirupi Aurantii, 3ft, 3ij. M. Fiat Mist., cujus capiat cochJe- aria duo larga, ter quotidie. Form. 838. Mistura Ante Cardialgiam. ft Magnesi®, 3j. ; Aq. Anethi, Jivss.; Potass® Nitratis, 'jss.; Liquor. Potass®, 3j.; Tinct. Calumb®, 3ij.; Spirit. Carui et Spirit. Anisi, 3a, Jijss. ; Tinct. Lavand. Comp., 3j.; Sirupi Zingiberis, 3ij. Misce. Capiat cochleare unum amplum subinde in cyatho Decoct. Hordei Comp., prius agitata phialA Form. 839. Mistura Anti-Dysenterica. (1.) ft Hither. Sulphurici, 3ij.; Tinct. Opii Comp., 3iij.; Snc- chari Alb., Jss. ; Gum. Acaci®, jijss.; Olei Anthemi- dis, ttlxv.; Extr. Humuli, 3jss.; Extr. Catechu, 3j.; Pniv. Canell® Cort., 3j. ; Aq. Menth. Virid., Jvjss. Misce bene. Capiat cochlearia duo, tertiis vel quartig horis. Form. 840. Mistura Anti-Dysenterica. (2.) ft Mist. Camphor®, Jv.; Liq. Ammon. Acet., Jij. ; Spirit .Ether. Nit., 3ijss.; Vini Ipecac., 3ijss.; Tinct. Hu muli, 3ijss. ; Extr. Humuli, 3j. ; Sirupi Papaveris, 3iij M. Fiat Mist., cujus capiat cochlearia duo larga, ter- tifi quSque horft. f Form. 841. Mistura Anti-Icterica. ft Potass® Acetat., Extracti Taraxaci, 3a, Jss.; Extr. Conii, gr. x.-xx.; Aq. Fceniculi, Jvjss.; Sirupi Sarz® et Si- rupi Senn®, 33, Jss. M. Capiat cochlear, ij. vel iij. ampla, 4tis horis. Form. 842. Mistura Asafcetid* et Conii. ft Asafcetid®, 3ij.; solve in Liquoris Ammon. Acet., Jjss. ; Aq. Fceniculi, Jiijss.: Extr. Conii, 3j.~3ss.; Sirupi Seneg®, Jss. Misce. Form. 843. Mistura Balsami Peruviani Comp. ft Balsami Peruviani Ver., 3ij.; Mellis Despumati, 3vj. Misce, et adde gradatim, Mist. Myrrh® (F. 422), Jvj.; Tinct. Aurantii, Jj. M. Fiat Mistura, cujus capiat coch. j .ad iij., ter quaterve in die. Form. 844. Mistura Beeladonn*. ft Extracti Fol. Belladonnas, gr ij. ad iv.; Moschi Optimi, gr. vj. ad xij. ; Sacchari Albi, satis quantum ut terendo obtiueatur puivis congener ; deinde adde, paulatim miscendo, Infusi Frigidi Rad. Valerian®, Jiv.; Spirit. Hither Sulphur. Comp., 3j.; Sirupi Papaveris, 3iij. M. Capiat ®ger cochlear, ij. vel iij. larga, 3tiis, 5tis, vel 6tis horis. Form. 845. Mistura Camphor* Ammoniata. ft Camphor®, 3j. ; Alcoholis, filvj. ; tere, et adde Moschi, 3ss.; tere cum Sacchari Albi, 3j. ; Mist. Amygdal. Dulc., Jiv. ; Spirit. Ammon. Arom., 3ij.; Sirupi Au- rantii, Jss. M. Capiat Jss.-Jj., 4tis horis. Form. 846. Mistura Cardiaca. ft Potass® Bicarbonate, 3jss. ; Mist. Camphor®, Jvss.; Confectionis Aromatic®, 3ij.; Spiritfis Myristic®, J3s. M. Fiat Mistura, cujus sumantur cochlearia tria am- pla cum cochleari uno Succi Limonuiu recentis, in actu effervescent!®. Form. 847. Mistura Chloratis Potass* et Sod*. ft Liq. Sod® Chlorinate Jss.; Aq. Destil., Jiv.; Potass® Chloratis, 3j„; Aq. Piment®, Jiijss. M. Capiat coch, j.—iij-, 2dis, 3tiis, vel 4tis horis. Form. 848. Mistura Cinchon* cum Acido. ft Infusi Cinchona', 5vij. ; Acidi Hydrochlorici Diluti, 3j. r Tinct. Capsici, 3SS-1 Tinct. Croci vel Serpentariae, 3iij.; Sirupi Papaveris, 3ijss. M. Fiat Mist., cujus capiat coch. ij. vel iii. ampla, 4t& q. q. horh. Form. 849. Mistut,* Cinchonas et Acidi Sueph. ft Decocti Cinchon®, Jvs3.; Acidi Sulphur. Aromat., 3j.; Tinct. Opii, lllxxx. M. Capiat tertiam partem tetr quotidie. Form. 850. Mistura Copaib*. ft Copaib® Ver., 3iij. ; Mucilaginis Acacia; Ver., Jjss Misce. Adde gradatim, Aq. Cinnamomi, Jiijss. ; Sod® Carbonatis, 3j.; Tinct. Lavandula; Composite, 3jj.; Tinct. Opii, 3j. ad 3jss. Misce. Fiat Mistura, cuju capiat unc. j., ter quaterve in die, agitata phialA Form. 851. Mistura Cydoni* Infusi Comp. ft Seminum Cydoni® contus., 3ij.; Radicis Glycyrrh. con- tus., Jj. ; Fici Carie® Fructus, Jj.; Aq., Oj. Coque leni igne per partem hor® sextain ; dein cola, ft Hujus Decocti, Jvjss..;. Potass® Bitart., 3ij.; Biboratis Sod®, 3j. ; Spirit. Hither. Nit., 3ij.; Sirupi Mori vel Sir. Limonis, Jss. M. Fiat Mist. Form. 852. Mistura Decocti Cinchon*. ft Decocti Cinchon®, Jvss.Tinct. Cinchon®, 3iij. ; Con- fect. Arom., 3jss. ,- Spirit. Ammon. Arom., 3jss. M. Form. 853. Mistura Decocti Genistas. ft Scoparii Cacumin., Jj.; Aqu®, Oj,; coque ad Jviij.,ct ADDENDA TO APPENDIX.—Mistura—Pilule. Form. 869. Mistura Stomachica. (1.) R Calumb® Radicis contus., 3ss. ; Calami Aromatici emit., 3j.; Capsici Annui Bac. cont., gr. x.; Aq. Ferventis, fviij. Macera per horas duas ; deinde cola. R Liquoris Colati, fvss. ; Liquoris Potass® Carbon., Jijss.; Tinct. Myrrh®, jj.; Extract! Conii, gr. xv.; Sirupi Cort. Aurantii, 3ij. M. Form. 870. Mistura Stomachica. (2.) R Infusi Cascarill®, f vij. ; Soda; Carbon., 3ijss.; Tinct. Calumb®, fss.; either. Sulphur., 3ij.; Tinct. Aurantii Co., 3iij. M. Fiat Mist., cujps capiat cochlear, ij. larga, bis quotidid. Form. 871. Mistura contra TeneSmum. R Mist. Camph., fv.; Liq. Ammon. Acet., fij.; Vini Ipe- cac., 3ij.; Tinct. Humuli, 3ijss. ; Tinct. Camph. Com., fss.; Extr. Humuli, 3ss.; Sirupi Papnveris, 3iij. M. Fiat Mist., cujus capiat cochlearia • -rga, tertiff qudque hora. Form. 872. Mistura Tonico-Aperiens. R Decocti Cinchona, Infus. Senna, 55, fiijss. ; Potass® Sulphatis, 3iijss. ; Tinct. Senn®, fss. M. Fiat Mist., cujus capiat cochlear, iij. larga, bis quotidie. Form. 873. Mistura Tonico-Deobstruens. R Extr. Taraxaci, 3iij. ; Extr. Gentian®, 3j.; Soda; Car- bon., 3j. ; Aq. Aurantii, fvij.; Spirit. JEther. Sulph. Co., Sirupi Ros®, 55, fss. M. Capiat fj.-fjss., ter die Form. 874. Mistura Zinci Composita. R Zinci Sulphatis, gr. iv. ad vj.; Infus. Ros® Comp., f vij., Vini Ipecac., 3jss.; Extr. Lactuc®, 3jss.; Sirupi To- lutani, 3ij. M. Fiat Mist., cujus capiat cochleare unum vel duo larga, tertiis vel quartis horis. Form. 875. Mistura Zinci Opiata. R Aq. Rosae, Aq. Cinnamom., 55, fiijss.; Zinci Sulphatis, gr. vij.; Tinct. Opii, fllxxxvj.; Tinct. Cinnamom. Co., 3ij.; Sirupi Aurantii, 3jss. M. Fiat Mist., cujus ca- piat cochlearia ij. ampla, bis die. Form. 876. Pilul* Alkaline Anobyn*. R Sod® Carbon, exsic., 3j.; Saponis Duri, 3j. ; Extracti Hyoscyami, 3ss.; Olei Jump., q. s. M. Fiant Pilul. xl., quarum capiat binas vel tres omni nocte. (For Nephritic and Calculous Affections.) Form. 877. Pilul* Aloes cum Ferro Composite. R Aloes, 3ij.; Asafoetid® et Myrrh®, 55, 3ss.; Ferri Sul- phatis, 3j. ; Caryophyllorum in pulv., 3j. ; Pulv. Cap- sici, gr. xxvj. ; Bals. Canad., q. s. M. Fiant Pilul. lxvj., quarum capiat binas vel tres pro dose. (In Chlo- rosis, &c.) Form. 878. Pilule Anobyn*. R Pulv. Jacobi Veri, gr. iij.; Extr. Stramonii, gr. ss.; Extr. Hyoscyami (vel Conii), gr. iij. Fiaut Pilul. ij., horSi somni sumend®. (In painful Cutaneous Eruptions.) Form. 879. Pilul* Anodyno-Alterativ*. R Camph. rasa, gr. vj. ; Hydrarg. cum Creth, gr. xij.; Sod® Carbon, exsic., gr. x. ; Pulv. Acaci®, gr. iv. ; Extr Hyoscyami, gr. xv. ; Sir. Simp., q. s. M. Fiant Pilul xij., quarum capiat tres statim, et hor& somni Form. 880. Pilul* Aperientes. R Pulv. Radicis Rhei, 3ss. ; Extracti Alods Aquosi, gr. xviij.; Saponis Medicati, 3ss.; Sirupi Simp., q. s. M. Fiant Pilul. xx., quarum sumantur bin® vel tres, bis in die, Form. 881. Pii.ul* Aperientes cum Hyoscyamo. R Extracti Gentian®, 3ss.; Extracti Colocynth. Comp., 3ijss.; Pulv. Ipecac., gr. viij.; Pilul. Hydrarg., 3j. ; Extr. Hyoscyami, 3ij.; Saponis CastiL.gr. xij. M. Fiat massa ®qualis, et divide in Pilulas xxxvj., quarum capiat binas vel tres hora somni. Form. 882. Pilul* Astringentes. R Aluminis contnti, gr. v. ; Myristic® Nucl. conti., gr. iv.; Extr. Gentian®, q. s. (vel adde etiam Opii Puri, gr. j.) Fiant Pilul. du® pro dose. Form. 883. Pilul* Belladonn* Extracti et Cin- chon*. R Extracti Belladonn®, gr. j. ad ij. ; Extracti Cinchon®, 3j. M. Fiant Pilul. viij. Capiat ij. 6tis horis. Form. 884. Pilul* Cambogi*, Aloes, et Ammoniacl R Cambogi®, Aloes, et Ammoniaei, in pulvere, partes ®quales: solve in Aceto; dein liquorem cola, et ccn- sume donee crassitudinem idoneam habeat. Divide in adde Acetatis Potass®, 3ijss.; Spirit. Juniperi Comp., 3vj. M. Capiat coch. ij. vel iij. larga, ter quotidie. Form. 854. Mistura Diaphobetica. R Vini Ipecac., 3jss.: Spirit. yEther. Nit., 3ijss. ; Liq. Am- mon. Acet., fij. ; Liq. Antimon. Fot.-Tart., 3jss.; Mist. Camphor®, fivss. ; Sirupi Papaveris, 3iij. M. Capiat cochlear, j. vel ij. tertia quilque hora. Form. 855. Mistura Diaphoretica Anodyna. R Mist. Superscript. (F. 854), fvijss.; Tinct. Hyoscyami, 3jss. (vel Tinct. Camph. Comp., 3yj., vel Extr. Conii, 3ss.) Fiat Mist. Form. 856. Mistura cum Digitale et Kerm. Miner. R Kermis Mineral., gr. vj. ; Munilag. Acaci®, fiij.; Infusi Digitalis, f iv.; Sirupi Alth®a>, fj. M. Capiat coch- leare unum amp. omni bihorio. (In Pneumonia, Pleu- risy, &e., by Brera.) Form. 857. Mistura Expectorans. U Asafmtid®, 3ijss.; trituratione solve in Aq. Menth. Virid., fivss. ; et adde Vini Ipecac., 3j.; Spirit. JEther. Nit., 3ij. ; Tinct. Castorei, 3ij.; Sirupi Tolutani, f j. Fiat Mist., cujus capiat cochleare unum amplum, 2dis vel 3tiis horis. Form. 858. Mistura cum Potassii Iodido et Acido Hydrocyanico. R Aq. Destil., fivss.; Solutionis Potassii lodidi, Itlxv,; Acidi Hydrocyanici Medicin., lllx.-xij.; Extracti Lac- tuc®, gr. xij.; Sirupi Alth®®, §j. M. Capiat 3ij.-3iij. omni hora, vel fss. omni bihorio. Form. 859. Mistura contra Hybropem. R Fol. Digitalis, 3j.; Corticis Cinchona Pulv., 3vj.; Aq. Ferventis, ?xij. Macera per horam, et cola. Liquori Colato adde Potassse Bitart., 3iij.; Biboratis Sod®, 3j.; Tinct. Cinnam. Co., Spirit. Junip. Co., 5a, 3iij.; Tinct. Opii Co., Tfl/xxv. M. Capiat cochlearia duo larga, ter quaterve quotidie. (Nearly as Augustin.) Form. 860. Mistura Infusi Anthemiois Comp. R Flor. Anthemidis, 3ij. ; Pulv. Rad. Valerian., 3iij.; in- funde Aq. Fontan. Calid®, f viij. Macera paulisper, et cola. R Hujus Infusi, fvij.; Tinct. Camph. Comp., Tinct. Cas- torei, 55, 3ij.; Sirupi Aurantii, Jss. M. Capiat ®ger qu&libet hora cochleare plenum. Form. 861. Mistura Infusi Calumb* et Hyoscyami. R Infusi Calumb®, fvijss.; Tinct. Hyoscyami, 3ij. ; Sod® Carbon., 3jss.; Tinct. Aurant. Comp., 3ijss. M. fss. ter quaterve in die. (In Diseases of Irritability.) Form. 862. Mistura Infusi Calumb* Comp. R Infusi Calumb®, fiv.; Aq. Menth. Piper, vel Aq. Anethi, fiij.; Spirit. Anisi, 3ij. ; Liquoris Ammon, vel Liquor. Potass®, 3ij. ; Sirupi Cort. Aurantii, Jss. M. Form. 863. Mistura Infusi Valerian*. R Infusi Valerian., fvss.; Liq. Ammon. Acet., fjss. ; Liq. Antimonii Pot.-Tart., 3jss.; Tinct. Hyoscyami, 3jss. ; Aq. Piment®, fss. M. Fiat Mist., cujus capiat ffiger alterfi. quSque horS cochlearia duo. Form. 864. Mistura Hybrochlor. Ammoni*. R Ammon. Ilydrochlor., 3jss.; Acidi Hydrochlor., 3ss.; Decocti Hordei Comp., Rj. M. Capiat cochlear, iij. ampla, 2dis vel 3tiis horis. Form. 865. Mistura Salina Sebativa. R Potass® Nitratis, 3ss.~3ij.; Sod® Carbon., 3j.~3ijss. ; Mist. Camph., Aq. Menth. Virid., 55, fiijss. ; Extr. Hu- muli, 3 ij. ; Sirupi Zingiberis, 3»j. M. Fiat Mist. (Interdum adde Tinct. Hyoscyami, vel Tinct. Cam phor® Co.) Form. 866. Mistura Sebativa. R Mucilaginis Acaci®, fj. ; Olei Amygdalarum, Sirupi Pa- paveris Albi, 55, fss.; Tinct. Hyoscyami, 3jss. ; Vini Ipecac., 3ij.; Aq. Destil., fvss.; Acidi Citrici, q. s., ad gratam acidulationem. Misce. Fiat Mist., cujus sumat coch. unum medium subindd. Form. 867. Mistura cum Sob* Biborate. R Mist. Camphor®, Aq. Anethi, 55, fijss. ; Biboratis Sod®, 3ij.; Vini Ipecac., 3jss.; Sirupi Papaveris, 3jss. M. Fiat Mist., cujus capiat cochlearia ii. vel iij. quartis horis. Form. 868. MisTunA cum Son* Potassio-Tartrate. ft Sod® Potassio-Tartrat. pulver., 3vj. ; Mist. Amygdal®, fss. ; Spiritus Myristic®, fss. M. Sumat tertiam partem, secundh quaque hora. ADDENDA TO APPENDIX.—Pilul^e.—Pulvis. Pilulas gr. iv. Capiat binas ad quatuor pro dose. (Diu- retic, Purgative.) Form. 885. Pilul* Camphor* et Ammoniaci. R Mass® Pilul. Alogs cum Myrrhs), 3j. ; Gummi Ammoni- aci, 3j.; Camphor®, gr. x. ; Sirupi Simplicis, q. s. Misce. Fiant Pilul. xx. Omni mane capiat tres vel quatuor. (Stoll.) Form. 886. Pilul* Camphor* et Opii. R Camphor®, Potass® Nitratis, 55, 3ij. ; Saponis Hispan., Jss. ; Extr. Opii Aquos., 3ss.; Sirupi Tolutani, q. s. M. Fiant Pilul. cxx., quarum binas vel tres ter quo- tidie capiat. (Cadet de Gassicourt.) Form. 887. Pilul* Camphor* et Quinin*. R Camph. ras®, 3j. ; Quin® Sulphatis, 3ij. ; Mass® Pilul. Alogs cum Myrrhfi, 3jss. ; Sirupi Zingiberis, q. s. M. Fiat massa ®qualis, et divide in Pilulas xxxviij., qua- rum capiat unam bis quotidie. Form. 888. Pilul* Chalybeat*. R Ferri Sesquioxidi, Jss. ; Pulv. Canell® Alb®, 3iij.; Alogs Socot., 3jss. j Sirupi Croci, q. s. M. Fiat massa squalis. Form. 889. Pilul* Colocynthidis cum Sulphur*. R Extr. Colocynth. Comp., 3j.; Sulphur. Sublimati, 3j. ; Potass® Sulphatis, 3iv.; Sirupi, q. s. Divide in Pi- lulas L. Form. 890. Pilul* Colocynthidis Extr. et Hy- oscyami. R Extracti Colocynth. Compos., 3ij.; Extract. Ilyoscyami, 3j. Misce, et divide in Pilulas xij. Sumat unam vel duas pro re natfi. Form. 891. Pilul* Deobstruentes. (1.) R Saponis Venet., 3j.; Pilul. Hydrarg., gr. viij.-xij.; Gum- mi Ammon., 3®s.; Mass® Pilul. Alogs cum Myrrh&, 3j.; Terebinth., q. s. M. Fiant Pilul. xxx. Capiat tres vel quatuor de die. Form. 892. Pilul* Deobstruentes. (2.) R Pulv. Gummi Guaiaci, 3j.; Pulv. Gummi Ammoniaci, 3j. ; Ammon. Sesquicarbonatis, gr. xv.; Mass® Pilul. Alogs cum Myrrhfi, 3ijss.; Tinct. Alogs Comp., q. s. M. Divide in Pilulas xl.; e quibus sumantur tres ter in die cum vasculo Infusi Anthemidis. (Altered from Stoll.) Form. 893. Pilul* Diuretic* et Antispasm. R Pulv. Fol. Digitalis, Pulv. Rad. Scillae, 55, gr. xij.; Extr. Ilyoscyami, 3j. Divide in Pilulas xij. Capiat binas tertiis horis. (Brera.) Form. 894. Pilul* Diuretic* cum Hydrargyro. R Gummi Ammoniaci, Extracti Taraxaci, Saponis Venet., aa, 3j ; Pulveris Scill®, gr. vj.; Pilul. Hydrargyri, gr. xv.; Olei Junip., q. s. M. Fiant Pilul. xviij. Form. 895. Pilul* Expectorantes. R Pulveris Scill®, 3j.; Ammoniaci Gum. Res., 3jss.; Ex- tract. Conii, 3ij. Contunde simul, et divide massam in Pilulas ®quales triginta ; quarum sumat duas sextis horis. (In Asthma and Chronic Catarrh.) Form. 896. Pilul* Gentian* et Aloes. R Aloes Ext. Purif., Gentian® Extr., 5a, 3j. ; Saponis Cas- til., 3jss. M. Divide in Pilulas xxxvj. Capiat unam ad tres pro re nata. Form. 897. Pilul* Guaiaci et Aconiti. R Ext. Aconiti, gr. j.; Pulv. Guaiaci, gr. viij. ; Olei Caje- puti, q. s., ut fiant Pil. ij. Capiat unam mane nocteque. Form. 898. Pilul* IIumuli Comp. R Ammon. Sesquicarb., gr. vj.; Extr. Rhei, gr. viij.; Extr. Humuli, gr. xij. M. Fiant Pilul. vj., quarum capiat tres horfi somni. Form. 899. Pilul* Hydrargyri Composit*. R Pilul. Hyd. Chlorid. Comp., 3ss.; Pulv. Jacobi Veri, gr. xij. ; Extracti Conii, gr. xxij.; Saponis Castil., gr. vj. Contunde simul, et divide massam in Pilulas xij. ®quales, quarum bin® omni nocte sumantur. Form 900. Pilul* Ipecacuanh* Comp. R Pulv. Ipecac., gr. vj.; Pulv. Ipecac. Comp., Extr. Papa- veris, &a, 3j. ; Extr. Humuli, 3ss.; Olei Anisi, q. s. M. Fiant Pilul. xxiv., quarum capiat unam quartis ho- ris, vel binas aut tres horft somni. Form. 901. Pilul* Morphi* et Ferri Sulphatis. R Sulphatis Morphi®, gr. ij.; Olei Amygdal., q. s.; ad solut. dein adde Ferri S llphatis, gr. vj. ; Pulv. Glycyr., gr. viij.; Mellis, q. s., ut fiant Pilul. viij. Capiat unara tertid quaque hor£t. Form. 902. Pilule Morphine Hydrochloratis. R Hydrochloratis Morphia, gr. j.; Pulv. Ipecac., gr. iij. , Extr. Aconiti, gr. vj. ; Olci Amygdal. Dul., Tfl,vj ; Pulv. Glycyrrh. ef Mellis, 5a, q. s., ut fiant Pilul. viij. Ca- piat unam 3tiis vel 4tis horis. Form. 903. Pilul* Moschi Composite. R Moschi, Potassa Nitratis, aa, gr. vj.; Camph. rasa, gr. vj.; Conserv. Ros., q. s. Fiant Pilul. vj. Form. 904. Pilul* Calcii Chloridi et Conii. R Calcii Chloridi, gr. ij.; Extr. Conii, gr. iij.-v. Fiant Pi- lul. duse, bis in die suinend®. (In Scrofulous Obstruc- tions.) Form. 905. Pilul* Nervine. (1.) R Asafcetid®, 3ss.; Castorei, gr. vj.; Extract. Ilyoscyami, gr. x. ; Extract. Anthemidis, 3j.; Sirupi Papaveris, q. s. M. Fiant Pilul. xij. Capiat aegra duas mane nocteque. Form. 906. Pilul* Nervin*. (2.) R Asafcetid®, 3ij.; Camph. Subact®, gr. xvj.; Moschi, gr. vj.; Mucilag. Acacia;, q. s. M. Fiant Pilul. xvj., e quibus sumatur una omni bihorio. Form. 907. Pilul* Nucis Vomic* et Aloes. R Pilul. Aloes cum Myrrha, 3iv.; Extracti Nucis Vomic®, gr. x. M. Fiant Pilul. xxxvj., quarum capiat unam ad duas, mane nocteque. Form. 908. Pilule Sarz* Composite. R Mass® Pilul. Hydrarg., gr. viij.; Extr. Taraxaci, Extr. Sarzce, 5a, 3v. M, Fiant Pilul. xlviij., quarum ca- piat tres quater in die. Form. 909. Pilule Scill* et Gai.bani Comp. R Pilul. Galbani Comp., 3j. ; Pilul. Scill® Comp., 3ij.; Ol. Juniperi, 01 v. M. Divide in Pilul. xxiv., quarum sumat binas ter quotidig. Form. 910. Pilul* Sod* cum Rheo et Hyoscyamo. R Soda; Carbon, exsic., 3ijss.; Pulv. Rhei, 3j.; Extr. Ily- oscyami, 3ij. M. Divide in Pilulas xxxvj., quarum, ter quotidid, bin® sumantur. Form. 911. Pilul* Stomachic*. R Pulveris Rhei, Pulveris Zingiberis, aa, 3ss. ; Extracti Anthemidis, 3j* 1 Olei Anisi, q. s. Fiat massa, in Pi- lulas sequales triginta dividends, quarum capiat tres ante prandium quotidie. (In Dyspepsia and Chloro- sis, &c.) Form. 912. Pilul* Sesquisulphureti Antimonii. R Antimonii Sesquisulphuret. Crud., Extract. Dulcamar®, partes aquales. Sint Pilul. gr. iij. Capiat iij. vel iv. ter die. Form. 913. Pilul* Thebaiac* Composit*. R Gummi Ammoniaci, 3j.; Camphor®, 3ss. ; Moschi Muse., gr. xx. ; Pulv. Opii, gr. x. ; Bals. Peruviani, q. s. M. Fiant Pil. gr. iij. Sumat aeger unam hord undecimft, iterum vespere hora quinta ; et cubitum petens sumat tres. Form. 914. Pilul* Tonic*. R Extracti Gentians;, Pulv. Rhei, 5a, 3ss.; Saponis Castil., 3j. M. Fiant Pilul. xviij., quarum sumantur bins ter quotidie. Form. 915. Pot us Aperiens. R Mann®, Jjss.; Potass® Bitart., Jss.; Seri Lactis, Oij. M. Capiat cyathum pro re nata. Form. 916. Potus Tamarindorum Comp. R Potass® Tartratis, Pulp. Tamarind., Gum. Arab., aa, J j. Solve in Aq. Font. Fervid., Ibij., et adde Oxymel. Simp., fij. M. Form. 917. Pulvis Ammoniaco- Camphoratus. R Ammon. Sesquicarbon., gr. iv. ; Camphor® pulveriz., gr. ij.; Sacch. Albi, gr. xxiv. M. pro dose ; vel fiant Pil. ij., cum Mucilag. Aoaciae, omisso Saccharo. Form. 918. Pulvis Anti-catarrhalis. R Kermis Mineral., gr. iij.; Florum Sulphuris, Pulv. Rad. Glycyrrh., 5a, gr. xij. Fiat Pulvis, ter die sumendus. (Quarin and Barthez.) Form. 919. Pulvis Aperiens, R Magnes. Carbon., 3ij.; Potass® Bitart., 3j.; Pulv. Rhei, Pulv. Rad. Glycyrrh., 55, gr. vj.-xij. Fiat Pulvis, omni nocte sumendus in theriaca communi ADDENDA TO APPENDIX.—Pulvis—Vinum. Form. 920. Pulvis Calumb* et Ferri. R Ferri Potassio-Tartrat., gr. x.-xv.; Pulv. Calumb®, gr. xij.-3j. Fiat Pulvis, ter quotidid capiendus. Form. 921. Pulvis Camphor* et Antimonii. R Camph. rasa;, gr. xvj.; Potass® Tartratis, 3j.; Antimon. Pot.-Tartrat., gr. j. M. Probe, et in chartulas viij. di- vide ; quarum sumatur una, t.ertifi quaque hord. Form. 922. Pulvis Diaphoreticus. R Kermis Mineralis, Campliorai, 55, gr. iij. ; Gum. Acacia;, Sacchar. Albi, 55, gr. viij.; Olei Fumiculi, ttlj. M. Form. 923. Pulvis Lientericus. R Ilydrarg. cum Cret5, gr. iij.; Pulv. Ipecac. Comp., gr. vj.; Pulv. Rhei, gr. v.; Pulv. Cinnamom., gr. vij. M. Fiat Pulvis, bis vel ter die sumendus. Form. 924. Pulvis Moschi Compositus. R Moschi, gr. vj.-xij. ; Pulv- Rad. Valerian., 3j.; Cam- phone, gr. vj. M. Fiat Pulvis. Form. 925. Pulvis Myrriije et Ipecacuanh*. R Pulv. Myrrh®, gr. xvj.; Pulv. Ipecac., gr. iv. ; Potass® Nitratis in pulv., 3ij.; Pulv. Opii, gr. j. Misce bene, et divide in doses ®qualesquatuor. Capiat unamquar- ta qullque hor&. Form. 926. Pulvis pro Torminibus. R Magnes., Sacchari Albi, 55, gr. viij.; Pulv. Canell® Cor- j ticis, gr. ij. M. Fiant Pulvis. Form. 927. Pulvis Resolvens. (Stahlii.) R Pulv. Antimonii Comp., Potassa; Nitrat., Ocul. Cancror. Pitcp., 55, 3j.; tere bene simul. Dosis 3j. Form. 928. Pulvis Salinus. R Potass® Chloratis, gr. v.-xij.; Sodii Chloridi, gr. viij.-xx. Sod® Sesquicarbonatis, gr. x.-xv.; Olei Pimentos, vel I Cajeputi, vel Sine, Ttlij.—v. M Fiat Pulvis pro re { nat5 sumendus in decocto Hordei vel jusculo Bovino. Form. 929. Pulvis Sod* Nitratis Compositus. R Sod® Nitratis, gr. v.-3j. ; Pulv. Cinnam., gr. vj. ; Pulv. j Ipecac., gr. ss.-j.; Olei Piment®, Ttlj. M. Fiat Pulvis, j ter quaterve in die sumendus. (For Diarrhoea, Dys- entery.) Form. 930. Pulvis Valerian* Compositus. R Pulv. Rad. Valerian., 3j.-3ij. ; Magnes., Ammon. Hy- I drochlor., 55, gr. v.; Olei Cajeputi, TIlij. M Form. 931. Solutio Belladonna Extracti. R Extracti Belladonna, 3j. ; Aq. Destillat., fj. M. Fiat Solutin. Form. 932. Solutio Cambogi* Alkalina. R Gum. Res. Cambogite, Jss. ; solve in Liquor. Carbon. Po- tass®, Jss. Hujus solutionis capiat 1ltxx.,quater in die, quovis invehiculo idoneo. (Both Diuretic and Cathar- tic. Hamburgh Dispensatory.) Form. 933. Solutio Hydro-Sulphatis Calcis. A Hydrosulphate of the Protoxide of Calcium. R Sulphur. Pulveriz., ftj.; Calcis Vivi, Ibij. ; Aq. Fontan®, Ibxv. Coque per partem hone quartam, et cola. (Pier- quin’s Antipsoric Milk. Hahnemann and Passing recommend it as a gargle in salivation ; and a dessert or table-spoonful of it is to be taken internally in some soup (mutton or veal broth), in cases of poisoning by mercurials.) Form. 934. Solutio Refrigerans. R Nitrat. Potass®, Jss.; Ammon. Hydrochlor., jiij.; Aq Pur., fviij. Solve leni cum calore, et adde Camphor® pulverizat., 3jss.; Alcoholis, q. s. Macera. Capiat 3j.-3iij., in Decocti Hordei cyatho. Form. 935. Sirupus Antimoniatus. R Kermis Miner., 3j.; Sirupi Scillse, Sirupi Althiese, aa, 5jss. M. Capiat coch. j.-iij. minima, ter quaterve in die. Form. 936. Tinctura Astringens. R Catechu, Myrrh®, 5a, fss.; Pulv. Cinchona;, 3ij.; Bal- sami Peruvian., 3jss.; Spirit. Armoraciae Comp., Spirit. Vini Rectificati, 55, fjss. Misce, et digere. (For Sponginess of the Gums.) Form. 937. Trochiscus Astringens. R Catechu, Jij. i Moschi, 3ij.; Sacchar. Albi, f iijss.; Mu- cilag. G. Tragacanth., q. s. Misce. Fiant Trochisci par- vuli. (For Relaxation of the Uvula, Hoarseness, y Dr. Gerhard, p. 314, 1842). We have heard of but few cases of the disease in the human subject in this country, although it is frequent- ly met with in horses ; and as little precaution against it is used, we infer that the susceptibility to it is not as great as has been represented.] * [Since this was written several cases have recovered nnder the use of creosote and turpentine.] GOUT. 37 the disease. The vapour bath, with the fumes of camphor diffused in it ; the warm bath, con- taining a sulphuret, or consisting of water in which aromatic and stimulating herbs are in- fused ; the nitro-hydrochloric acid, or chlorine baths, &c., are severally deserving of trial. Terebinthinate embrocations, as warm as they can be endured, may also be applied externally; or turpentine may be given internally in small and often-repeated doses, with aromatics, &c. The various means detailed in the article Fe- ver (§ 559, et seq.), with reference to the treat- ment of the typhoid varieties, may likewise be resorted to. 16. Dr. Elliotson mentions (Med. Gazette, vol. vii., p. 655) that the veterinary surgeon of the 13th light dragoons treated this disease in the horse by putting a quantity of scalded bran, mixed with Venice turpentine, into a horse- hair bag, and tying it over the horse’s head ; the whole body of the animal being wrapped at the same time in a large blanket wrung out of boil- ing water, and covered with several horse- cloths. This treatment procured a profuse sweat, and a free discharge from the frontal sinuses and nostrils, and promoted the healing of the ulcerations. Dr. Elliotson also states, in his last paper on this disease, that the sedu- lous injection of a solution of creasote up the nosttils removed the whole of the symptoms, in a case of chronic glanders in the human subject, after a very few weeks. Mr. Storry (Veteri- narian, vol. vii., p. 145) adduces cases in which fumigation with carbonic acid gas appeared beneficial in glanders occurring in the horse ; but other means, as calomel, aloes, &c., were also employed. [In one instance, Mr. Travers succeeded in effecting a cure by the frequent administration of emetics. Rayer recommends the imme- diate excision of the swollen glands in the ear- ly stages of the disease ; and also mercurial frictions. He also thinks highly of the acetate of ammonia in large doses, and repeated pur- gings. As to topical treatment, he advises the free incision and subsequent cauterization of the pustules and abscesses, w'hile the patient’s strength is supported by tonic drinks, wane, &c. The oil of turpentine has recently been given with success in a case of glanders in the horse (Lond. Lancet, No. 390, p. 689).] 17. In the chronic, as well as in the acute states of the malady, tonics or stimulants con- joined with purgatives, particularly cinchona, or the sulphate of quinine, capsicum, and cam- phor, with aloes, &c. ; antiseptics, as the chlo- rides, hydrochloric acid, or chloric aether, cre- asote, and pyroligneous acid; warm alterative diaphoretics, especially guaiacum, mezereon, senega, sassafras, sarsaparilla, variously com- bined ; the terebinthinates, balsams, &c., and fumigating or medicated warm baths, may sev- erally be prescribed and varied, appropriately to the characters of the case. The excessive thirst always attending the disease will be most beneficially quenched by a liberal use of soda water, spruce or ginger beer. Seltzer water, &c., which may be rendered still more cooling by the addition of small quantities of nitre, or of the carbonates of the alkalies ; or they may be made the vehicles of several internal medi- cines. Bibuoq. and Refer.—Rust's Magazin fur die Ge- sammte Heilkunde, 8vo, 1821 and 1824; and .Tourn. der Prakt. Heilk., March. 1822. — B. Travers, Inquiry con- cerning Constitutional Irritation, 8vo, p. 397. Lond., 1827, 2d edit.— A. Brown, Fatal Case of Acute Glanders in the Human Subject, Lond. Med. Gazette, vol. iv., p. 134.—H. S. Roots, Case treated by, in Ibid., vol iii., p. 590.— /. El- liotson, Qn the Glanders in the Human Subject, Med. Chir. Trans., vol. xvi., part i., p. 171 ; vol. xviii., part i., p. 201 (with a coloured plate); vol. xix., p. 237; in Lond. Med. Gazette, vol. vii., p. 300, 655 ; in Renshaw's Med. and Surg. Journ., vol. vii., p. 606 ; and in Lancet, No. 616, p. 398.— Wolff, Cases of Glanders in the Human Subject; and M. Vogeli, Cases of Farcy, Lancet, No. 605, p. 2, 3.—M. Vo- geli, Farcy in the Human Subject, Veterinarian, vol. viii., p. 214.—Alexander, in Hufeland u. Ossann, Journ., &c., b ii., 1835.—Rayer, On Cutaneous Diseases. English edi- tion, p. 1202.—The volumes of the Veterinarian contain several papers on this disease. I can recommend this peri- odical to the notice of the reader, on account of the excel- lant communications in it upon comparative pathology and therapeutics. Many of these communications reflect much light upon practical medicine generally. It is to be hoped that the able and scientific conductor will continue his very useful researches into these subjects, and that the growing spirit of investigation in this branch of the profession will advance still farther, and receive due encouragement and consideration. [Case of Glanders, Med. Chir. Review, vol. xxvi., 1837, p. 500, from Medicinisch Jahrbucher.—Brown, Case of Glan- ders, Ibid., July, 1837, p. 246, from Dublin Jour., May, 1837.—James Johnston, Case of Glanders in the Human Subject, Ibid., Oct., 1837, p. 359, from Provincial Trans.— Opinions on Contagion of Glanders, London Lancet, Aug. 5th, 1837, and Med. Chir. Rev., Oct., 1837, p. 500.—Dis- cussion at. the French Academy on the Nature and Treat- ment of Glanders in Man, Ibid., Oct., 1837, p. 518.—Cases of Glanders in Man, Ibid., July, 1838, from Medicinische Zeitung, Mai, 1837.—Andral, On Glanders in Human Sub- ject, Ibid., July, 1839, p. 233, from Memomires de l’Acade- mie.—MM. Norrat and Bouley, Report on the Work of l)e- ville on Glanders, in Ibid., Ap„ 1840, p. 513, from Revue Medicale.—/. B. Tytler, Cases of Glanders in Man, Med. Chir. Rev., July, 1841, p. 279, from Ed. Monthly Jour., June, 1841.—A. Graham, Ibid., p. tlSO.—Ddaharpe, Cases of Glanders, with Remarks, in Med. Chir. Rev., Jan., 1842, p. 188, from Revue Medicale.—M. Bcrard, On Transmis- sion of Glanders from one Human Subject to another, Ibid., Ap., 1842, p. 532.—H. M. Hughes, Cases of Glanders in the Human Subject, Med. Chir. Rev., July, 1843, p. 233.—M. Renaut, On Transmission of Glanders by the Blood, Ibid., Oct., 1843, p. 523.— Youatt and Percival, The Veterinari- an, or Monthly Journal of Veterinary Science, Lond., 1844. —John Field, Posthumous Extracts from his Veterinary Records, Lond., 8vo, p. 236, 1844.— Review of the above Works, in Med. Chir. Rev. for Jan., 1844.—MM. Rayer ajid Breschet, Review of their Work on Glanders, in Med. Chir. Rev. for July, 1840, and in Brit, and For. Med. Rev. for July, 1838 ; also, Gaz. Medicale, 1840.—It seems that, from 1837 to 1840, no fewer than 27 persons have died in Paris of the Glanders. See Med. Chir. Rev. for Oct., 1844.— Robley Dunglison, in Cyclop, of Tract. Medicine. Philad., 1845, art. Glanders. Dr. D. treats of the disease under the name of Equinia Glanduloca."—London Lancet, June 20th, 1833.] GLOSSITIS. See Tongue — Inflammation of. GOUT. — Syn. ApdpiTtq (and rov apOpov) ; ap- OpiTtKr/ vovooe, Hippocrates, Aretaeus. Ar- thritis, Auct. var. IIodaypy, Hippoc. et Aret. Tlodaypu (ruv notiuv uypa, Lucian). Podagra, Auct. var. % IlodaXyia, Gr. Morbus Articula- ris, Pliny. Chiragra ; Arthritis Podagra; Morbus Dominorum ; Gutta, Radulphus, Bar- tholin, &c. Febris Podagrica, Vogel. Poda- gra Arthritis, Parr. Arthrodynia jpodagrica, Swediaur. Cauma podagricum, Young. Ar- throsia podagra, Good. Goutte Arthrite, Fr. Gliedersucht, gichtschmcrzen, Fussgicht, Germ. Gotta, Ital. Gota, Span. Classif. — 1. Class, Febrile Diseases ; 2. Order, Inflammations (Cullen). 3 Class, Sanguineous Diseases ; 2. Order, Inflam- mations (Good). III. Class, IV. Order (Author in Preface). 1. Defin.—Constitutional disorder, giving rise to a specific form, of inflammation; often favoured by original or hereditary constitution ; appearing after puberty, chiefly in the male sex; returning after intervals ; generally preceded by, or alterna- 38 GOUT—Acute—History ting with, disorder of the digestive or other inter- nal organs; and characterized by affection of the first joint of the great toe, by nocturnal exacerba- tions and morning remissions, and by vascular plethora; various joints or parts becoming affected after repeated attacks, without passing into sup- puration. 2. I. Gout is one of the diseases, the nature and treatment of which were best known to the ancients. In modern times, however, the mor- bid relations and associations of the disease, and its various modifications have been more fully elucidated, and its treatment assigned, ac- cordingly, with greater precision. But attempts at distinguishing its various manifestations, lo- cally and constitutionally, and with relation to the numerous disorders arising in the gouty di- athesis, have induced modern writers to make so many divisions of it, and to arrange its forms and states so differently, as to render its study somewhat perplexing to the inexperienced. This is one of the greatest objections that can be urged to the works of Musgrave, Guilbert, and some others. The arrangements adopted by some of the best writers on the disease are, however, very similar; and I will not mate- rially depart from them. Those of Cullen and Good nearly agree, and that of Sir C. Scuda- more and of Dr. Mackintosh is quite the same. Differing, therefore, but little from these wri- ters, I shall consider, 1st. Acute gout; 2d. Chronic gout; and 3d. Irregular gout. The forms described by authors under the appella- tions of regular, acute, inflammatory, chronic, ir- regular, nervous, atonic, lurking atonic, primary asthenic, primary fixed, anomalous, wandering, in- ternal, visceral, retrocedent, misplaced, latent, masked, emphysematous, flatulent, disguised, aber- rant, &c., will be appropriately considered un- der one or other of the above heads. 3. i. History of Acute Gout. — A. Of the Symptoms premonitory of the Paroxysm.—Al- though the gouty paroxysm may attack sudden- ly a person apparently in good health, especial- ly on the first occasion of its appearance, it is more frequently preceded by-symptoms of dis- order referrible chiefly to the digestive organs. I believe that if the cases in which it is said to have appeared suddenly were investigated, it would be ascertained that more or less disor- der had existed for some days before the seiz- ure, although not so as to have excited any concern in the mind of the patient. The most common symptoms of premonition are, flatu- lence, oppression after a meal, irregular appe- tite ; heartburn, with acidity of stomach, some- times with acid or acrid eructations; costive- ness, irregularity, or, more rarely, an irritable state of the bowels ; scanty, deep-coloured urine, becoming turbid or thick on cooling, or sometimes copious or pale urine; a sense of soreness, or occasionally of coldness, at the epigastric region ; itching or irritation of the skin ; drowsiness, or frequent yawning, rest- less or unrefreshing sleep, more rarely night- mare ; general lassitude and depression of spir- its. In some persons, the symptoms of gastro- intestinal irritation are still more manifest, the tongue being loaded, red at its point and edges, the epigastrium tender, and the stomach op- pressed after a meal. In many cases, increase of corpulency ; scanty, thick urine ; drowsi- ness, especially after eating, and a sense of general fulness and oppression, have preceded the paroxysm for a longer or a shorter time, accompanied by several of the preceding symp- toms. The appetite is frequently craving ; and when indulged, is often followed by nausea, or vomiting of acrid matter, or by heartburn, flat- ulency, acrid eructations, &c. The premoni- tory symptoms vary in different persons, and depend much upon idiosyncrasy. Dr. Mackin- tosh justly remarks that persons subject to gout are warned of a fit by some sensation or symptom peculiar to themselves individually; one feeling heat, pain, and dryness of the eyes ; another, heat, redness, and swelling of the nose ; a third, an unusual craving for some particular kind of food, or some peculiar feel- ing at the stomach, &c. Palpitations or inter- nal fiutterings ; severe cough, with mucous ex- pectoration ; irritability of the bladder, the urine being loaded with mucus ; a discharge from the urethra, with scalding or difficulty in passing the water ; unusual lassitude, and inaptitude for mental exertion ; peevishness, irritability of temper; depression of spirits, more rarely an unusual hilarity; and various other symp- toms severally precede the paroxysm in differ- ent cases. 4. With more or less of these indications of constitutional disorder, the patient often expe- riences chills or rigours, followed by heat, flushings, headache, and the sensations refer- rible to the part about to be chiefly affected. These sensations, however, may have already appeared ; but they are now more evident, and are increased during the night. The patient complains of weakness, tenderness, achings, numbness, prickings, or shooting pains, with spasms, or a tingling sensation, in the limb; or of stiffness and weakness of the joints. A dark hue of the skin; fulness of the veins; swell- ings of the feet after exercise ; disappearance of an accustomed moisture from the soles, with remarkable dryness and heat; and frequent change of position of the legs and feet, espe- cially in bed, with general restlessness, are among the more constant precursors of the fit. One or both feet, particularly the soles, and the balls of the great toes, become burning hot : sometimes, however, they are cold, and are kept warm wflth difficulty ; frequently the chil- liness and coldness of the extremities alternate with feverishness, flushings, flying pains, and vertigo. Some of these symptoms, particular- ly the twitchings or cramps in the limbs, are felt chiefly when about to fall asleep, and are attended or followed by restlessness or watch- fulness. Local signs of premonition are most common in persons who have experienced pre- vious attacks. Where concretions have form- ed, severe pricking pains, with increased ten- derness, are generally present. In those of an inflammatory diathesis, or who are plethoric, exposure to cold, or other exciting causes, may induce internal disease, with all the characters of idiopathic inflammation, which may continue for a longer or shorter time, and suddenly sub- side, being quickly followed by a regular par- oxysm of gout; such instances, however, be- long to a form of the disease hereafter to be noticed. 5. B. History of the regular Gouty Paroxysm —a. The first fit of gout, although commonly preceded by more or less of the above symp- toms, sometimes occurs while the patient is in apparent health ; but, even in this case, there have been indications of an inflammatory diath- esis, or of vascular plethora, with slight dis- order of the digestive organs. Most frequently he is suddenly awakened about midnight, or at one, two, or three in the morning, with severe throbbing pain in the affected part—commonly the ball of the great toe of one foot, attended by heat, stiffness, and a sense of distention and weight. These sensations increase to burning, with an actual augmentation of the temperature of the part, and with occasional severe stound- ing, or darting pains up the limb. Restless- ness, watchfulness, and fever increase, or con- tinue till about six or seven in the morning; when a gentle perspiration breaks out, followed by abatement of the symptoms, and some sleep in the slighter cases. The integuments of the part affected are swollen, slightly red, some- times shining as if varnished ; and the veins proceeding from it are remarkably full. In se- vere cases, but slight remission of the symp- toms occurs for two or three days. More com- monly, however, the symptoms abate in the day, but return, often with increased violence, at night, or shortly before midnight, and last till about five or six in the morning ; the integ- uments have now become of a vivid or scarlet red, and admit of slight pitting on pressure. The pain is shooting, throbbing, intense, and gnawing, with an unpleasant sense of heat, burning, or weight. The least compression or touch of the joints cannot be endured. 6. b. The constitutional symptoms of the par- oxysm vary with the severity of the attack and the previous health of the patient. Fever is generally present, and commences as stated above. It is attended by restlessness, thirst, loss of appetite, oppression at the prascordia, flatulent distention of the stomach, with ab- dominal pain, costive or irregular bowels, mor- bid evacuations, and scanty high-coloured urine, depositing a pink or brickdust sediment after standing, and sometimes containing mucus. The pulse varies, but is generally full or hard, and quicker than natural. Pain, heat, and ten- derness of the epigastrium, with spasmodic sen- sations referrible to the stomach, are frequently complained of, and are attended by sour eruc- tations, or vomiting of acrid or acid matters, sometimes mixed with bile, and causing un- pleasant irritation of the pharynx and fauces. The tongue is furred or loaded, the papillae erect, and the edges and point red. The stools are offensive, mixed with mucus, sometimes pale or clayey, but more frequently foul, black- ish, or of an olive green. The symptoms alto- gether evince more or less irritation of the gas- trointestinal mucous surface, with obstruction or vitiation of the biliary and intestinal secre- tions. In old cases, and in persons far advan- ced in life, the attendant fever is much less inflammatory, and sometimes partakes more or less of the nervous character. In most instan- ces, the nervous system evinces disorder by irritability of temper, increased sensibility, rest- lessness, and darting pains in the course of the nerves, very generally attended by violent cramps or spasmodic contraction of the mus- cles of the affected limb, and sometimes follow- ed by the sudden transition of the disease from one limb to the other. Almost any change of GOUT—Acute—History. posture produces this spasmodic action, and the severe pain attending it. Sir C. Scudamore states, that of 120 cases, cramps occurred in 90, with more or less severity, either upon the accession of the paroxysm, or during its height, or at its close, or even during all these periods. 7. c. A first attack may continue from two or three days to ten or twelve. The cedema re- mains a short time after the inflammation, which disappears with desquamation of the cuticle of the part, and much itching. Some- times the disease appears in the other foot, giving rise to the same succession of disorder, often with greater severity and prolonged du- ration. Sir C. Scudamore thinks that the first attack is more frequently mild in men than in women ; and states that of 198 cases, the great toe of one foot only was affected in 130 ; the great toe of both feet in ten ; the great toe and instep in three ; the instep of one foot in five ; the instep of both feet in three; one ankle in ten ; both ankles in one ; the ankle and instep of one foot in four; the right knee and left hand in one ; the back of one hand in two ; and the wrist in one; various parts of the lower extremities, especially of the feet, being affect- ed in the rest. He farther remarks that, in hereditary gout, the great toe is mostly the part first affected ; and that the exceptions to this seat of a first attack are chiefly met with in persons who have acquired the disease. 8. d: The frequency of the returns of the. fit. depends upon the constitutional tendency, the treatment, and the regimen, and mode of life of the patient. Although the disease generally returns to the part previously affected, the other foot seldom escapes. Each succeeding seizure is usually more severe and of longer duration than its antecedent, and the attendant consti- tutional affection more serious. Exceptions, however, to this may occur when the disease has been treated with judgment, and the pa- tient has been careful of his health. The in- tervals also become shorter, and the parts af- fected more numerous ; but the fits are most apt to recur early in the spring or late in au- tumn, probably owing to the variability of the weather at these seasons ; but they may occur at any season. The malady generally acquires strength with each returning fit, both as to the number of parts affected, and as to the duration and degree of suffering caused by it; the sus- ceptibility to it increasing both locally and con- stitutionally with the repetition of the attacks. 9. e. In some persons the gout seizes only the feet; but, in more numerous instances, in its progress, several parts are attacked in the same paroxysm; the gouty inflammation af- fecting different places in succession, or at the same time, with equal or various degrees of severity. The feet, ankles, knees, and elbows are occasionally thus successively or simulta- neously attacked ; together with the ligaments, the bursas mucosae, sheaths of tendons or apo- neuroses. In the older cases, even the shoul- ders and hips are sometimes affected. The disease often suddenly leaves one part, and as instantly appears in another; but it occasion- ally commences in one situation before it de- parts altogether from the other. This rapid transfer of the morbid action from one part to another, either of the same or of a different : limb, is one of the most characteristic phenom- 39 40 GOUT—Chronic. ena of gout. When it thus passes to the oppo- site limb or extremity, some indications of the disease have often existed previously in that part. In a few instances, the chief suffering of the patient is in the day ; in others, both day and night are passed in equal pain ; but in most cases, particularly in the more recent attacks, the night is the period of greatest distress. The redness and cedematous swelling are most remarkable in the foot, hand, and elbow. In the ankle, knee, wrist, &c., there is little red- ness, excepting in small patches, and the swell- ing is caused by effusion into the sheaths of tendons, and into the bursae ; the latter often being greatly distended, painful, and exquisite- ly tender. In the more severe cases the veins of the limb are large and full, and unusually numerous near the affected part. The pain in gout is peculiar—is severe, burning, throbbing, shooting, or stounding, and otherwise modified in different cases, as stabbing, cutting, boring, or gnawing. 10. C. The Sequela of Acute Gout respect, 1st. The effects of the disease in aggravating previous derangement, or inducing disorder of internal organs ; and, 2d. The alterations pro- duced by it in the part affected.—a. Severe at- tacks of gout impair vital power in the digest- ive, biliary, and nervous organs ; or they may be said, with greater accuracy, to weaken still more the previously debilitated organic nervous influence. Hence occasionally result a numer- ous train of dyspeptic symptoms; hypochon- driasis, and torpid or otherwise deranged func- tion of the liver; inaction of the caecum and colon, causing a sluggish state of the bowels and morbid evacuations ; increased liability to apoplectic and paralytic seizures, or to cramps, wandering pains, &c. Sydenham supposed that gout disposed to the formation of urinary calculi; and numerous cases have been record- ed in which either they or gravel in the urine alternated with the gouty paroxysm. This connexion has received support from the ob- servations of Morgagni, Schdrig, Buechner, Shroeder, Mursinna, Heim, and Forbes ; but Sir C. Scudamore states that irritation of the urinary organs and gravel occur rather before and during the paroxysm than in the interval; and that calculus of the bladder is a very infre- quent complaint among gouty persons ; of 231 of whom five only were so afflicted. This, however, does not altogether disprove the con- nexion ; as renal calculi may have existed in some, if not in many of these. He, however, adds that the urine of gouty persons deposites, without any exception, at some period or other, either gravel or the pink or brickdust sediment. There can be no doubt that the gravel is form- ed either in the kidneys or in the urinary blad- der ; and if this be granted, a strong argument will be thereby furnished in favour of the occa- sional supervention of calculi. 11. b. The most frequent consequence of acute gout, as respects the local affection, is the passage of it into the chronic form ; but before this degeneration may have taken place, several lesions of the tissues composing the part affected may be produced by acute attacks. These are, weakness, stiffness, and lameness of the joint, with a snapping or grating sensa- tion upon motion, owing to imperfect secretion of the synovial fluid. The ligaments and mus- cular aponeurosis become thickened, stiff, or inelastic, and tender. The secretion from the sheaths of the tendons is thickened or other- wise vitiated, causing a knotty and thickened feel upon examination, sometimes with con- traction and rigidity. The bursae mucosae are enlarged, and either distended or soft and yield- ing to the touch. The contents of the small bursae are sometimes inspissated so as to form hard tumours ; and the deep-seated textures of the joints become thickened and apparently consolidated. The veins of the feet and legs are often either enlarged or varicose ; but these, as well as various other changes, as concre- tions, &c., are chiefly the result of the chronic disease. 12. ii. Chronic Gout.—a. This state of the disease is characterized by the inflammation and pain being more slight, irregular, and wander- ing than in the acute ; by the faint redness of surface, the permanent distention and oedema of the part; by impaired power of motion ; by its more continued duration, and association with disorder of the digestive organs ; by the languid or oppressed circulation; and by gen- eral irritation of the nervous system. It is generally a consequence of one or more acute attacks, either when the paroxysm has not passed off with a regular crisis or evacuation, or when repeated seizures have so enfeebled the constitution as to render it incapable of manifesting sthenic action. It may, howev- er, appear primarily, constituting the Primary Chronic Gout of J. P. Frank. In this case, in- stead of severe paroxysms occurring at distant intervals, the seizures are much milder, but much more frequent, prolonged, and irregular. Primary chronic gout is more common among women than men, and in them, especially, sel- dom affects the great toe ; sudden swelling and pain, with but little of the appearance of the gouty inflammation, affecting chiefly the instep or ankle, or the wrist, or hand. When chronic follows acute gout, the various parts which had been inflamed in the paroxysm of the latter continue affected, either alternately or in con- junction ; but the pains are more wandering, and have now and then a rheumatic or nervous character. 13. b. Whether primary or consecutive, chron- ic gout presents the following local symptoms: A sense of alternate heat and coldness is felt in the affected part, and is much increased at night. There are often numbness and an un- easy sense of fulness and weight. The mus- cles and joints feel weak, and cramps of the lower limbs occur chiefly at night, when falling asleep. Startings and restlessness are gener- ally also complained of. The surface of the part is either of a pale reddish colour, or of the natural hue, or of a purplish tint, the discolora- tion being sometimes transient. The parts are tender ; shooting pains pass along the nerves ; motion is difficult and painful; and the energy of the limb very much impaired. The bursae and the sheaths of tendons are more frequently affected in the chronic than in the acute gout, occasioning puffiness and distention. (Edema is generally present and permanent, attended by fulness of the veins. Even in the slightest cases, aching and a sense of heat are felt in the ankles after walking. 14. c. The constitutional symptoms are remark- ably diversified by the temperament and habits of the patients, the situation and degree of the local disease, and by the nature and extent of the internal associated disorder. Numerous dyspeptic symptoms and uneasy sensations re- ferable to the stomach, as craving for food, nausea, oppression after a meal, flatulency, heartburn, a sense of coldness at the stomach, transient pains or spasms of the muscles of the abdomen or chest; a costive or irregular state of the bowels, w'ith morbid or offensive stools ; a deficient or unhealthy biliary secretion ; and haemorrhoids, with evacuations of blood, are often present. Feverishness or irritation fol- low too full a diet, or stimulating food ; and a sallow or slightly yellow cast of countenance, with uneasiness or pain in the hypochondria, and deficiency of bile, are not infrequent. The urine is various, being sometimes scanty, high- coloured, or thick, or occasionally abundant and dilute ; it generally deposites a pink or lateritious sediment. Palpitations and flutter- ings of the heart are very common, particu- larly when there is much flatulence. Sleep is broken, disturbed by unpleasant dreams, and unrefreshing ; the temper is irritable, and the mind hypochondriacal, imaginary or trifling ills occupying the attention. In some cases a chronic dyspeptic cough, or an increased secre- tion of mucus in the trachea, is complained of. Many persons, especially females, are exqui- sitely sensitive, and have their ailments in- creased by vicissitudes of atmosphere, espe- cially by cold and humidity. In prolonged or severe cases the system often becomes cachec- tic ; the limbs weak, stiff, and wasted, and the abdomen large. Although the patient’s appe- tite may be natural, yet he is neither nourished nor strengthened by his food, which may even increase both the constitutional and local af- fection. 15. d. The concomitants or consequences of prolonged chronic gout are thickening and con- solidation of the tissues of the affected part. The veins of the limb often become varicose, and increase the achings and fulness of the part, or cause purplish blotches of the surface, and, although rarely, ulceration of the skin. Gouty concretions occur only in a few cases, and arise from the effusion of a whitish fluid, the watery portion being absorbed. Mr. Moore remarks that this effusion occurs not only during the fits, but also in the intervals ; that it is not en- closed in a cyst, but usually lies in the cellular membrane, in the bursae mucosae, or in the cav- ities of joints. In the sheaths of tendons these concretions are generally hard or stony ; in the bursae they are likewise hard, and in the cellu- lar tissue their consistence varies. They may also form between the cuticle and cutis, where they vary in consistence, or even occasion in- tractable deep ulcers, as in a case related by Mr. Herbert Barker. When they are situa- ted within the capsular ligaments, the cartilage is absorbed, and one or more phalanges dis- torted. Sir C. Scudamore mentions several such cases. When the concretions cause ul- cerations, the chalk-like matter is constantly secreted in a fluid or semifluid state, and ac- cumulates in the bottom of the ulcers.* The GOUT—Irregular. 41 surrounding surface is usually of a red colour, shining, and the seat of severe burning pain, symptoms occurring in paroxysms, with remis- sions or intervals of various duration. In such cases, erythema or erysipelas may be associa- ted with the local affection. Although the concretions generally appear in the joints ana surrounding tissues, they may occur in other situations, either simultaneously or otherwise. Morgagni mentions their formation in the breast of a patient suffering from hereditary gout. In the case detailed by Mr. Barker there was a gouty concretion, of the size of a horse-bean, deposited on the left side of the nose. Dr. Elliotson met with a case in which they formed in the ears. Their chemical con- stituents seem to be lithic acid combined with soda, potash, or ammonia, but mostly with soda, and with a little animal matter. They are of a light or whitish gray colour ; insoluble in cold, and partially insoluble in hoiling water. 16. iii. Irregular Gout.—Under this head may be arranged the various states of disorder either occurring in the gouty diathesis, or con- nected with the appearance of the gouty par- oxysm, or following its sudden cessation in an external part. In this extended acceptation of the term, irregular gout will comprise the brief consideration of those derangements to which the names anomalous, imperfect, internal, visce- ral, misplaced, displaced, retrocedent, transferred, metastatic, wandering, flying, disguised, masked, &c., have been applied. I shall therefore con- sider, 1st. Those specific or anomalous disor- ders appearing in the gouty diathesis, and fol- lowed by a complete or imperfect external gouty affection ; 2dly. The derangements con- sequent upon the sudden cessation of the gouty paroxysm ; and, 3dly. The various anomalous or disguised affections affecting persons of the gouty diathesis, without being followed or at- tendefl by any manifestation of external dis- ease. It has been urged by some modern au- thors, and even by the latest writer on gout, Dr. Barlow, that several of the forms just al- luded to are merely internal disorders occurring in gouty persons, and differing in their nature and treatment, in no respect, from those usu- ally observed; or, in other words, that these internal affections possess no specific gouty character. This is true in one point of view only, but not in others ; for it must be admitted that the gouty are even more liable to internal diseases than healthy persons, and that these diseases will often pursue the usual course in the former as well as in the latter. That the gouty are very liable to nervous and functional disorders, especially those implicating the di- gestive and excreting functions, and that those disorders often present nothing peculiar, are generally admitted; but that many of the af- fections which either precede or follow the external manifestation of gout, or that appear in the gouty diathesis, differ very materially from those observed in other persons, is shown by the following circumstances : 1st. Gouty inflammations of the eye are very different in their visible characters, their seats, and were removed from his hands, and he conld write on the table with the point of his finger. Ulcers had also formed on his feet, which usually discharged an ounce of fluid chalk in the 24 hours.”—(Catal. of Prepar., $c., in the Mu- seum of Fort Pitt, &c., p. 167.) * “ An officer of temperate habits, who had undergone much active service, was, for some years before his death, aetat. 45, much affected with gout; many balls of chalk 42 GOUT—Irregular. their consequences, from common ophthalmia ; and every one possessed of due powers of dis- crimination will admit that they require a dif- ferent mode of treatment. 2dly. The knowl- edge we possess, however imperfect it may be, as to the changes and appearances consequent upon fatal internal disease in gouty persons, is conclusive of a material difference between them and those following more common mala- dies ; and, 3dly. The juvantia. and ladentia in the former are often very different from those in the latter. 17. A. Specific or anomalous affections often precede the external manifestation in a complete or imperfect form of acute or chronic gout. They may be either in every respect similar to other affections of the same seat, or very dif- ferent and peculiar. In the former case, the external appearance of gout seems critical, and has been viewed as such by many writers ; in the latter, it appears as the external mani- festation of a constitutional disorder previously implicating the functions or sensibility of one or more internal organs. In perusing the older writers, numerous instances present them- selves of gout supervening upon, and appear- ing critical in inflammatory and severe inter- nal complaints. Morgaoni considered himself cured of an ophthalmia that had resisted treat- ment, by an attack of gout. Dr. Baillie men- tions a case of palpitation of the heart disap- pearing upon the occurrence of the gouty paroxysm, but these are not rare occurrences. Indeed, palpitations of the heart are frequently symptomatic of the disorder of the digestive organs ushering in the seizure. Affections of the urinary organs, erysipelas, asthma, and other diseases have likewise been removed by a regular fit of gout. One of the most inter- esting illustrations of the succession and criti- cal influence of gout upon dangerous irycrnal disease occurred to a medical gentleman whom I attended in 1824. He was seized in the evening with symptoms of complete congestive apoplexy, for which he was bled and purged, but without restoration of his consciousness. On the following morning gout suddenly appeared for the first time, with great intensity in the ball of the great toe of the right foot, and in- stantly removed all the apoplectic symptoms, the mental functions being perfectly clear and undisturbed on my seeing him very shortly af- terward. When gout assumes a regular char- acter, such antecedent affections appear merely as unusual precursors of the paroxysm, usher- ing in either the first seizure, or an attack in persons who had been previously affected by it. 18. B. Retrocedent or displaced Gout; rece- dent, or transferred, or metastatic Gout; Podagra retrocedens; P. retrograda, Cullen; P. compli- cata, Good.—a. During the gouty paroxysm in either its acute or chronic form, it sometimes happens that an internal organ becomes sud- denly and dangerously affected, the external disease being either much mitigated or having entirely disappeared. It has been disputed whether the internal disorder arises from the suppression or subsidence of the external af- fection, or whether the latter disappears in con- sequence of the occurrence of the former. Either may take place, as evinced by the suc- cession of morbid phenomena in different ca- ses ; the development of disorder in an internal organ deriving it from external parts in some instances ; and the suppression of external manifestation of a constitutional disease‘de- termining it to an internal predisposed viscus in others. When retrocession occurs in the height of an acute paroxysm, the superinduced malady is generally also acute, and rapid in its course ; but when it takes place in the chronic form, it is often less severe and more prolong- ed. The internal affections which thus arise are generally caused by the patient’s impru- dence by his habit of body and temperament, by previous disorder, or by injudicious treat- ment and management. The stomach is most liable to be affected, severe pain and spasm, with sickness, being complained of. The in- testines may be also attacked, either alone or in conjunction with the stomach, with all the symptoms of acute inflammation ; either form of disease often pursuing a violent or rapidly fatal course. Severe pain in the head, and symptoms of inflammation of the brain and its membranes, stupor, coma, apoplexy, epilepsy, or palsy supervene in some cases, especially in those who have previously evinced a tendency to these maladies. In other instances, affec- tions of the chest appear, particularly dyspnoea, sense of suffocation, oppression at the praecor- dia, with or without cough or expectoration. In some, pain or constriction in the region of the heart, violent palpitations, oppressed breath- ing, urgent anxiety, syncope, or leipothymia, &c., occur, indicating a serious affection of the heart or pericardium. In a case of this de- scription recorded by Mr. Brown, and which terminated fatally some months after the dis- appearance of gout, the pericardium was thick- ened, and contained six ounces of bloody se- rum ; the heart was greatly enlarged, and its substance was pale, soft, flaccid, and attenua- ted, its internal membrane being of a deep vio- let colour ; honeycombed ulcers were also observed at the root, and in the arch of the aorta. Other diseases of an inflammatory, spasmodic, or nervous character, or of these mixed, may follow the disappearance of the external gouty affection, more particularly dys- entery, hepatitis, peritonitis, and various affec- tions of the urinary or uterine organs. Dr. Cullen mentions strangury, catarrhus vesicae, and liaemorrlioidal affections among those not infrequently alternating with gout ; and in- stances have occurred to myself, as well as to Sir C. Scudamore, Mr. Howship, and many others, of the transference of the morbid action to the kidneys, causing suppression of urine, or inflammation with partial suppression ; or to the neck of the bladder with severe spasm, or even to the prostate gland. Mr. Howship mentions that when gout is transferred to the kidneys, the urine becomes albuminous as well as scanty. Dr. Home states that a gentleman who exposed himself to cold and wet, while affected by gout in the feet, was in a few hours afterward affected by enteritis, which proved fatal in twelve hours ; and Sir C. Scudamore mentions that Dr. Parry met with two instan- ces of extravasation in the brain in the same winter, after repelling gout from the extremi- ties by immersing them in cold water. * ' • [Gout is sometimes transferred to the spinal marrow, where it causes inflammation and softening of its substance, attended with a variety of anomalous symptoms, and termi- 19. b. The information we possess as to the lesions produced by the transference of the morbid action to an internal part is extremely imperfect; many who have the opportunity not giving themselves the trouble to inquire respecting them, or supposing that little or no alteration may be expected in such cases. Others, again, believe that the changes consist chiefly of those produced by inflammatory ac- tion. Without disputing that the consecutive affection is frequently inflammatory, I have seen it, in several instances, possessed of a distinctly nervous and spasmodic character, or consisting chiefly of remarkable depression of power, with the abolition of the function of the organ principally affected, and most intense suffering. A medical friend some years ago, whom I attended in the disease, took, contrary to my wish, and previously to removing biliary accumulations and morbid excretions, a large dose of colchicum, and was very shortly after- ward seized with violent pain in the stomach, a sense of sinking, and languid, small pulse, the gout having instantly disappeared from the foot. I soon afterward found him in the ut- GOUT—Irregular. 43 most agony, and prescribed large doses of camphor, with other diffusible stimuli, and mustard cataplasms to the feet. The gout as instantly returned to the extremities, and the affection of the stomach disappeared. A med- ical man, lately resident in Crawford-street, experienced, in 1830, an imperfect attack of gout in the feet. When I saw him, it had just forsaken this situation, and in twenty-four hours it successively had attacked the bowels, in the form of most violent colic, the diaphragm, and lungs, causing the most urgent dyspnoea ; and, lastly, the head, in a slight degree. The disease then appeared in one foot, and after- ward transferred itself to the other. In these cases the phenomena of internal disorder were those of severe nervous affection, probably also connected with congestion, or irregular determination of blood ; and the treatment founded on these views procured relief in them all. 20. Formerly the internal affections thus con- nected with the disappearance of gout were too exclusively viewed as nervous, and treated as such, notwithstanding the indications of in- flamm'htory action sometimes attending them. More recently, and even at the present day, a very opposite opinion has been promulgated. Dr. Gregory, of Edinburgh, supported this lat- ter opinion, and was followed in it by Dr. Bate- man and Dr. Barlow. Fully admitting the in- flammatory character of these consecutive af- fections in some cases, I must strenuously con- tend that it does not constitute the principal feature of them in others. In several instan- ces, three of which occurred in medical men in this city, any inflammatory state could not be inferred either from the sensations of the pa- tients, or from any symptom that I observed; and as the treatment founded upon the gouty and nervous characters of the disease was suc- cessful, there is no reason to infer that a latent inflammation had existed in these cases. That inflammatory and congestive affections of va- rious internal viscera often occur in such cir- cumstances cannot be disputed ; but the prac- titioner should be prepared to meet also with very different and often anomalous disorders— to find some attended by the most intense suf- fering and distress ; others by a feeling of sink- ing or dissolution; others by distressing anx- iety, terror, and irritation; others by spasmo- dic action and morbid sensibility; and, lastly, others by constant pain, internal heat, disten- tion, tenderness, and other indications of in- flammatory action. In some, the pulse is weak, irregular, fluttering, small, or intermittent; in others, excited, frequent, irritable, but regular, or full, strong, and energetic. I have even seen it all these in succession in the same ret- rocedent affection, and within a few hours. Some cases, even where the same organ is implicated, are attended by constant pain, a sense of increased heat or of burning, remark- able tenderness, and excited pulse ; and oth- ers by remarkable depression, great langour, a sense of coldness or of weight, or oppression, a weak and languid pulse, and a feeling of vital exhaustion and of impending dissolution. Of the pathological relations of these different morbid conditions more particular notice will be taken hereafter (§ 40-42). 21. C. Disguised or lurking Gout—anomalous, Dating often in hemiplegia. Such a case lately occurred under our treatment, in an old gentleman of seventy, who had all his life been subject to frequent and painful gouty attacks, but which had, in consequence of a more temper- ate mode of living, nearly disappeared. The disease came on gradually, with a painful sensation through the upper dorsal vertebra;, shooting through the chest, and causing embarrassed respiration, disturbed sleep, sediment in the urine, &c. These symptoms gradually increased till com- plete paraplegia ensued ; and after lingering about a year and a half from the commencement of the spinal affection, he sank under the disease. Dissection revealed softening of the spinal marrow opposite the lower cervical and upper dorsal vertebrae, and other appearances indicating an in- flammatory condition. Dr. Graves has also described cases of disease of the spinal cord connected with, and apparently caused by, gout, in some of which the symptoms were very similar to those above described. In one instance the patient was subject to attacks of severe colic, preceded or followed by a gouty affection of the feet. After several of these attacks, he became affected with great weakness of his wrists, with pains in his fingers, particularly in the last joints. As the disease progressed these pains became, more intense and extensive, till at length paralysis of the upper extremities came on, which was soon followed by that of the lower. Shortly after the paralytic affection had thus decidedly shown itself, he had an attack of gout in his feet (a circum- stance which also occurred in our own case), and this was followed by several others in succession. After each at- tack of pain in the feet, the paralytic state of all the limbs increased, and if he gained a little strength in the intervals between these attacks, a recurrence of the paroxysms al- ways made him worse than before. On examination after death, the spinal cord was found to be softened to the con- sistence of thick cream, opposite to the last cervical and first dorsal vertebra. The eye, also, according to Dr. Todd (On Gout, Rheu- matic Fever, &c., Lond., 1843), is liable to be secondarily affected in gout, but only after severe attacks of the disease in other parts where the diathesis is thoroughly establish- ed. It attacks most of the various textures of the eye in succession, and ultimately destroys vision. The conjunc- tiva and the sclerotic are first affected, then the choroid and iris, the latter of which forms adhesions to the neigh- bouring parts, and these intercept the rays of light. It is probable that the retina also suffers. Mr. Wardrop thinks that the eye may be primarily attacked in gout, and gives a case in illustration of a gentleman who suffered from ar- thritic inflammation of the eye, accompanied by severe pain in the head, which was relieved by sinapisms to the feet so powerful as to cause ulceration. A connexion between apoplexy and gout has long been known ; the urethra and bladder are also peculiarly obnoxious to the disease ; but the affection of these parts generally precedes the develop- ment of the gout in the joints, and is relieved when it ap- pears externally. The bronchitis which occurs in gouty subjects seems to be of the same kind. These diseases, un- der such circumstances, are most readily relieved by bring- ing back the gout, by stimulating epithems to its original seat.] GOUT—Diagnosis. 44 imperfcct, internal, visceral, nervous, masked, or misplaced Gout—Podagra atonica, Cullen ; Po- dagra larvata, Good. The gouty diathesis may be generated in a constitution too weak to de- velop the local affection in the extremities. When this is the case, various disorders affect- ing internal organs, most frequently those of digestion and excretion, arise, and often as- sume anomalous or Protean forms, with func- tional or nervous characters, and even congest- ive or inflammatory states, as in retrocedent gout. In that variety, the internal disease is preceded by, and is rapidly consecutive of the disappearance of an external gouty affection ; but this variety is frequently unattended by any such affection, however slight or fugitive, al- though it may occur. It has been too generally inculcated that the disorders appearing in the gouty diathesis have nothing peculiar in their character, or different from those observed in other circumstances. This subject has been already sufficiently adverted to with reference to retrocedent gout; and the observations there made are equally applicable to those affections which appear in the lurking or man- ner now being considered. When, in connex- ion with the generation of the gouty diathesis, the constitutional powers have been greatly im- paired, and the functions of excretion weaken- ed, numerous internal disorders result, wheth- er the patient may have experienced a fully formed fit of this disease or not. A fastidious or impaired appetite ; a sense of distention and flatulence; acid or acrid eructations, or nau- sea or vomiting; spasmodic constriction, or most painful oppression at the epigastrium; costiveness and violent colic; mental depres- sion, anxiety, or hypochondriasis ; palpitations or other irregularities of the heart’s action; hemicrania, vertigo, and various affections re- ferred to the head, or even palsy, epilepsy, or apoplexy ; nervous excitement and irritability, with a sense of depression, and several other affections, sometimes present themselves, ei- ther with or without slight manifestations of gout in one or other of the external situations above enumerated. That those complaints are favoured by, and very often occur in the gouty constitution, cannot be, and, indeed, is not doubted. The question only is, whether these be of an inflammatory, or of a nervous, or of a mixed, or of a specific or peculiar character. That they are functional, chiefly, cannot be dis- puted ; but that others of a more decidedly in- flammatory or congestive kind may occur, as in cases of retrocedent gout, seems to be most consonant with the phenomena observed in dif- ferent cases, and with the pathology of the dis- ease, according to the view of it hereafter to be exhibited. Dr. Havgaeth has recorded two most interesting instances of misplaced gout, causing arthritic carditis in the one case, and enteritis in the other ; and, although an attack of gout had not been experienced for many years, moderate depletions, and sinapisms ap- plied to the extremities, were followed by the external gouty disease. 22. it is not unusual to hear persons who are advanced in life, and who have ceased to have their usual attacks of gout, complain of various nervous or functional disorders of so remarkable and peculiar a kind, as to convince them that gout is affecting or wandering through the system without developing its usual effects. Sir C. Scudamore very justly observes that some gouty persons are affected with severe colic upon accidental exposure to wret and cold, or from acid or indigestible articles of diet, and that almost invariably these attacks are spasmodic, and not inflammatory; hot brandy and water, or compound spirit of ammonia, giving relief. It should, however, be recol- lected that the continuance of pain may cause congestion of, or inflammatory determination to the affected part. The internal complaints occurring in the gouty diathesis are generally attended by sensations so distressing, and oft- en so peculiar, as to excite suspicions of their nature in the mind of the patient, and to cause him to desire an attack of gout, however se- vere, in the extremities, believing that it will remove the internal and more dangerous suf- ferings. Sir C. Scudamore defines these af- fections “ to be disordered functions of internal organs in a gouty constitution, and thereby modified in their characterand in this opin- ion he has been followed by Dr. Barlow and others. Dr. Cullen, and those who preceded him, distinguished these complaints by the term “ misplaced goutand, as it will appear in the sequel, the difference between the ideas intend- ed to be conveyed by these terms is more ap- parent than real; for the one, in admitting that such complaints are modified by the gouty di- athesis, concedes all that is contended for by those who distinguish them by applying to them, without circumlocution, a term indicating at once their most important features and rela- tions. 23. II. Diagnosis.—A. Acute Gout may be mistaken for acute rheumatism, which it may ap- proach more or less near, when the latter af- fects the joints, or for common inflammation of these parts. It seldom happens that more than one part is affected, and still more rarely that more than one is attacked at the same moment in the first fit of gout. This character, however, cannot be extended to acute rheumatism. In the former there is much more disorder of the digestive organs, precursory of the attack, than in the latter, and the remission from pain and fever during the day is much more distinct. In gout, serous effusion into the cellular tissue is early in the fit, and to the extent of admit- ting of slight pitting on pressure; the veins are turgescent in the vicinity of the affected part; the pain is pungent, severe, burning, stounding, lancinating, or peculiar; the surface is inflamed, deeply red, shining as if varnished, turgid, and exquisitely tender; the temperature of the part is very much increased ; and the urinary secretion is remarkably disordered, gen- erally depositing a quantity of the pink or lat- eritious sediment, consisting of the lithate of soda, the tinging substance being the purpurate of soda. These symptoms are either absent or slightly marked in acute rheumatism. 24. The hereditary character of gout; the frequency of it in the plethoric, sanguine, and irritable constitutions, and at an advanced age ; the sudden incursions of the fit; and the com- mencement of it. in the small joints, farther serve to distinguish it from rheumatism. Al- though gout may affect the knees, shoulders, elbows, &c., after repeated attacks, or in its chronic form, it rarely commences in these sit- uations, whereas rheumatism generally begins in the shoulders and larger joints. It is some- times, however, observed that the patient, on recovering from the one disease, may be attack- ed by the other, upon exposure to its exciting causes ; and a person who early in life has liv- ed frugally and laboriously, and been subject to attacks of rheumatism, has, at a more advan- ced age, lived fully and indolently, and been at- tacked by gout. In either case, the patient himself has no difficulty in distinguishing be- tween them, and the experienced practitioner will have as little, however much he may be at a loss to convey his ideas respecting their di- agnosis to others. It is not so much by any one mark as by the concurrence of several cir- cumstances, connected with the causes, the constitutional disturbance, antecedent and ex- isting, and with the local characters, that a cor- rect diagnosis can be formed. Common inflam- mation of the joints cannot be mistaken for acute gout, if the character of the pain, the state of constitutional disorder, and the urinary secre- tion receive attention. The continued or un- remitting state of the symptoms, and the course, progress, and termination of the disease, will also serve to distinguish them. 25. B. Chronic Gout may be distinguished from chronic rheumatism by several of the cir- cumstances already adverted to. The former is much more frequently preceded by the acute disease, and by disorder of the digestive and excreting functions, and is very much oftener attended by swelling, thickening, or nodosity of the affected parts than the latter. However, cases not infrequently occur in which gout, in its more chronic form, very nearly resembles chronic rheumatism, there being but little dis- order of the above functions attending them. In forming a diagnosis, the temperament, hab- it of body, age, and mode of living should be taken into consideration. Dr. Haygarth ob- served that only 14 patients out of 300, ill of chronic rheumatism, had swelling in the seat of disorder. It should, however, be recollect- ed that when chronic rheumatism affects the bursai mucosaj and thecae of tendons, particu- larly those of the knee joint, considerable tu- mefaction takes place. Although the gout, in its chronic form, is still more fugitive than when acute, and thus approaches nearer to the na- ture of rheumatism, yet it is much more dis- posed to seize the hands and feet than that dis- ease, as wyell as to be more solitary in its situ- ation. The parts which have been often affect- ed with gout become very susceptible of chan- ges of temperature, and, in this respect, partake of the rheumatic character. Sir C. Scudamore thinks that it is only in this wray that any pro- priety can be attached to the expression rheu- matic gout, and conceives that gouty and rheu- matic inflammations cannot both exist in the same part at the same time, although they may occasionally co-exist in different parts; as when a patient suffering gout in the usual sit- uations is seized with rheumatism in the mus- cles oi the neck, or in the shoulder, or other parts, in consequence of exposure to currents of cold air, &c. When gouty concretions form, the nature of the complaint will be sufficiently evident. 26. C. It is a matter of great difficulty to discriminate between the internal affections GOUT—Prognosis characterizing irregular gout, and similar af- fections unconnected with this disease, as may be inferred from what has been already ad- vanced on the subject. It is only by applying sound principles of pathology to the investiga- tion, guided by much acumen and experience, that we can expect to distinguish between them. When called to a patient advanced in life, of the irritable and nervous temperament, complaining of violent sufferings, or of various nervous and functional disorders, or of severe spasmodic affection, we should endeavour to ascertain, from the state of the pulse and the temperature of the surface, from the sensations produced by a minute examination, from the appearances of the excretions, and from the history of the case, especially with reference to its causes and to previous attacks of gout, and to any hereditary predisposition to it, the ex- act pathological condition upon which the symptoms depend. The existence or non-ex- istence of inflammatory action, or the degree in which either may be mixed up with spasm or morbid sensibility, should be ascertained. Many writers, both previous to, and contempo- rary with Dr. Cullen', considered debility and spasm, with altered sensibility, to he more characteristic of retrocedent and misplaced gout than inflammatory action ; and this opin- ion seems to have been too generally, and often injuriously adopted. But I am convinced that, in more recent times, the opposite doctrine has been too exclusively confided in, and with lit- tle less injury as to the results. The practi- tioner, in all such cases, should be guided by pathological inferences derived from the phe- nomena characterizing individual cases ; and if he find the pain fixed, the pulse excited, or hard, or oppressed, the skin hot, and the parts tender or painful on pressure, he will deduce the existence of inflammatory action ; where- as, if the pulse be weak, small, irregular, or in- distinct, and compressible ; if the skin be cool, the countenance collapsed or anxious ; the surface relaxed and perspirable, the parts tol- erant of pressure, and if no unnatural sound be detected on auscultation and percussion, he will infer the presence of functional disorder merely or chiefly, or of spasm, or of depression of nervous power, with altered sensibility. 27. III. Prognosis.—The prognosis should vary with the form which gout assumes.—A. In the regular acute disease a favourable opin- ion may generally be given, if the internal or- gans betray no serious lesion of function or of structure. The subsidence of sympathetic fe- ver, improvement in the excretions, the urine ceasing to deposite a sediment, or losing its high specific gravity; a return of the appetite, and of the spirits; desquamation of the inflamed cuticle, with disappearance of the swelling, are indications of recovery. The sudden transfer- ence of severe affection from one part to an- other, especially if accompanied with painful sympathy of the digestive organs, or with ner- vous symptoms and exquisite susceptibility, or with irregular fever, and with persistent disor- der of the excretions, are signs of a difficult and intractable disease. In this form of gout especially, the prognosis should be influenced chiefly by the state of the excretions; for as long as the stools and urine continue morbid, other signs of amendment will prove delusive 45 46 GOUT—Causes. 28. B. The prognosis in chronic gout is more unfavourable than in the acute, as respects subsequent immunity from the disease. As to recovery from the seizure, the circumstances just stated will influence the opinion of the practitioner, as in the acute variety. In every case, however, the state of constitution and of internal organs, and the effects produced by treatment, should be taken into account in de- ciding respecting the duration or the event of the disease.—C. Internal affections, occurring either in the gouty diathesis or upon the sud- den disappearance of the external disorder, are always unfavourable in proportion to their se- verity, and the vital importance of the parts in which they are seated. When the heart, the brain, or the stomach and intestines are the seats of retrocedent or misplaced gout, the patient should be always considered in the utmost dan- ger, especially if he be far advanced in life, if nervous energy be much impaired, and if judi- cious treatment has not immediately produced the desired effect. Cases of this description, however, not infrequently recover when ap- propriate and decided means have been prompt- ly resorted to, and when the constitution of the patient has not been remarkably injured. 29. IV. Causes of Gout.—i. Predisposing Causes.—These may, as in other diseases, be- come exciting causes, owing to continued or energetic action.—a. Hereditary disposition has always been viewed as most influential in the production of gout. Cadogan, however, at- tached too little importance to it, and Cullen too much. It is very probable that it will evince various grades of influence in different classes or states of society—that it will seem of greater importance in those who live regu- larly, soberly, and laboriously; and of much less in those who are indolent, luxurious, or dissipated. Sir C. Scudamore states that of 213 persons afflicted by gout, 84 could not trace it either to the father’s or mother’s side. But it is probable, conformably with what has been just stated, that an unusually large pro- portion of non-hereditary cases will be met with among the indolent and luxurious inhab- itants of a large metropolis. Of the hereditary cases, 62 were derived from the father, 29 from the mother, 14 from both father and mother, 14 from the grandfather, &c. When both pa- rents have had the disease, a greater number of the children will experience it. Where one parent only has had it, the child or children having the greatest resemblance to that parent will be most liable to it. 30. b. Adult age, particularly from 25 to 50, is the period at which gout most frequently first appears. Sir G. Scudamore states that of 209 cases, 25 had the first attack between 20 and 25 years of age ; 38 between 25 and 30 ; 41 between 30 and 35 ; 37 from 35 to 40 ; 18 from 40 to 45; 25 from 45 to 50, and 11 be- tween 50 and 55. Gout is rarely met with be- fore puberty. Hippocrates first stated this fact, and it has been confirmed by Sydenham and many other writers. Heberden never saw an instance of it. Dr. Scudamore men- tions a case at 8 years of age. I treated one, many years ago, at 11, and am at present at- tending a boy of 9, recovering from a severe attack in the foot. Very early seizures have generally been observed where the hereditary predisposition has been strong. In the two cases just alluded to it existed in both pa- rents, and in one of them there was great precocity of intellect. In some cases, where the disease appeared very soon after puberty, premature or excessive venereal indulgences seemed to me to have aided in its production. 31. c. The male sex is much more disposed to gout than the fdmale. Hippocrates men- tions the non-liability of females until the ces- sation of the menses This, however, is not correct; for cases occur at an early age in the plethoric through indolence and high feeding, and in those who have not had children. I met with an instance of it in a female of 27 years of age, who was thus predisposed. Dr. Greg- ory observed, in his lectures, that females sub- ject to gout had experienced menorrhagia, or had become plethoric from ingurgitation ; and Dr. Cullen has remarked that robust and mas- culine females, before the menses have ceased, or those in whom they have been very abun- dant, are not infrequently attacked. The in- stances of gout which I have seen in this sex, previously to the change of life, have been chiefly in those who had suffered frequent or excessive menstrual evacuations, who had lived very fully and indolently, and who had not been pregnant. The relative immunity of females is evidently owing to their temperance, to their periodical evacuations, and to the dis- charges and secretions connected with child- bearing. 32. d. Habit of body and temperament.—Gouty persons are said to have capacious and circu- lar chests, with large full veins, and loose sol- ids ; but to this rule there must evidently be numerous exceptions. Sydenham remarks that the gross and corpulent, and those with large heads, are most frequently affected. J. P. Frank states that the gouty conformation consists of a large and full body, voluminous head, large bone, and thick skin. Sir C. Scu- damore found that of 226 males, 64 were tall and corpulent, 41 middle height and corpulent, 25 short and corpulent, 28 middle stature and bulk, 14 tall and middle bulk, 21 short and mid- dle bulk, &c. ; and that of 28 females, 9 were tall and corpulent, 8 short and corpulent, 4 middle height and corpulent, and 4 short and slight. Corpulence usually precedes the dis- ease, and often increases with the progress of it. The gouty generally possess good consti- tutions, abused by indulgence. The sanguineo- nervous and irritable temperaments are the most liable to be attacked by gout, although other diatheses may be also affected. Cadogan as- cribed gout to three causes, which generally act conjointly, namely, indolence, intemperance, and vexation. Taking these in their wide sig- nification, their importance cannot be contro- verted. In whatever station of life they pre- vail, particularly indolence and intemperance, gout will appear as one of the most frequent re- sults ; hence it is not infrequent in butchers, innkeepers, and publicans ; and in butlers, coachmen, and porters in wealthy families, as well as in the more easy classes of society. It is, in short, met with in all occupations which conduce to inactivity and repletion. 33. e. Venereal excesses are among the most unequivocally predisposing causes, especially if associated with the intemperate use of animal food and of wine ; for while the former species t of excess exhausts the nervous power, the lat- 1 Ler occasions plethora, and both combine to im- s pair the functions of digestion, assimilation, 1 and excretion; hence the ancients said that ( j gout was the daughter of Bacchus and Venus. | t The wines which favour most the production 1 of gout are Champagne, new port, and the clar- 1 ets ; but other wines have more or less influ- < ence, and are more productive of the disease 1 than malt or spirituous liquors.* Strong malt i liquor disposes to it even more than spirits. 1 Dr. Cullen justly remarks that gout never at- i tacks those following laborious occupations, or i who live chiefly on vegetable food, or use i neither wine nor other fermented liquors. Schenck, Van Swieten, and other authors have adduced numerous instances of persons who, during a life of luxury and indolence, had been subject to this disease, but had never af- terward suffered from it when their circum- stances required them to live abstemiously and laboriously. In countries where animal food and vinous or intoxicating liquors are little used, gout is almost unknown. The habit of partaking of a great quantity or variety of an- imal food is not less influential than other kinds of intemperance in causing the disease. Se- vere study has been considered to predispose to it; but this cause is merely apparent or in- direct, others of a less doubtful kind also ex- isting. The depressing passions are not with- out influence, inasmuch as they weaken ner- vous energy and the functions of digestion and excretion. A cold and variable climate favours also, in some degree, the formation of the gouty diathesis; and the changeable weather in spring and autumn, and the cold winds and humid atmosphere of these seasons have a sim- ilar effect. The disease is comparatively rare within the tropics, unless among those who have indulged in those habits which are most influential in predisposing to it; and yet two of the severest cases I ever saw occurred near- ly under the equator in Africa. 34. /. Functional disorder of the digestive organs is one of the most universal causes of gout. Many of the causes already noticed, and of those about to be mentioned, act partly by weakening these organs and favouring con- gestion of, or inflammatory determination to the mucous surface. It is not, however, a state of inflammation of this surface, but rath- er of vascular erethism, that is thereby genera- ted. Hence the appetite, instead of being im- paired, is often increased: and the patient is prompted to take more food than the stomach and collatitious viscera can digest and assimi- late. When the appetite is impaired, owing to the digestive mucous surface having assumed a more inflammatory state, frequent attempts are but too often made to excite it by stimula- ting and savory articles of diet; and the mis- chief is thereby augmented. Even where func- GOUT—Causes. tional disorder only exists, inflammatory irri- tation is superadded, attended by the severer symptoms of indigestion ; by acrid eructations; by painful distention and soreness of the epi- gastrium ; by congestion and impaired action of the liver ; by interruptions of the passage of bile into the duodenum, accumulations of it in the gall-bladder and ducts, and a redundancy of its constituents in the blood ; by acidity of the prima via, and an imperfect elaborated or unhealthy chyle ; and ultimately, as will be hereafter shown, by a morbid state of the cir- culating fluids. But these are merely acces- sories to the formation of the gouty diathesis ; other conditions, particularly vascular pleth- ora, being also required; and this state, with the various other elements of the gouty con- stitution, is that which is generated, in a great- er or less degree, by the causes now passed in review. 35. ii. Exciting Causes.—While the forego- ing causes act chiefly in generating the gouty constitution or predisposition, those about to be mentioned are mainly concerned in exciting or developing the paroxysm. The sudden re- pletion and inflammatory excitement of the vascular system, in connexion with irritation of the digestive mucous surface, produced by excessive indulgences at the dinner-table, fre- quently occasions a fit in a few hours, when the morbid diathesis is already formed ; and when the excess is repeated, particularly in quick succession, the morbid effect rarely fails to take place. Champagne excites an attack more certainly than any other wine. A lady under my care, and who had not passed her thirtieth year, always suffered more or less on the following day, after taking a single glass of Champagne ; but the excessive use of any wine, especially if new or of inferior quality, will pro- duce a seizure. The use of malt liquor during dinner, and of port wine afterward, will excite it, if active and regular exercise be not taken. Strong malt liquors and spirits will ofteu have a similar effect, especially if much animal food be habitually eaten. It is not only indulgence in wine or other exciting liquors, or the admix- ture of them, that is injurious; for a great quantity and variety of animal food, and of highly-seasoned dishes, which they excite the stomach to receive until it is overloaded, are equally prejudicial. Acidity of the prvma via, from the imperfect digestion of the mass of dif- ferent substances partaken of, inflammatory ir- ritation of the digestive mucous surface, disor- der of the biliary secretion and excretion, vas- cular plethora excessively or suddenly increas- ed on each of such occasions, and the accumu- lation of excrementitious and irritating matters in the blood, are the common consequences of these indulgences. In many cases, not merely acid, but acrid or acro-rancid combinations are formed by the imperfectly digested substances and the disordered secretions poured into the alimentary canal; and these increase or per- petuate the irritation of the mucous surface, while they exert upon the organic nerves a noxious influence, which is more or less mani- fested throughout the digestive circle, as well j as the extreme parts of the frame. 36. Neglected or constipated bowels, and in- terruption of any of the excreting functions, ; will occasionally be followed by an attack, with- 47 * [Dr. Alison remarks (Outlines of Pathology and Prac- tice of Medicine, Am. Ed., 1‘hil., 1844, p. 219; that those who drink fermented liqoors to excess, as the London coal- heavers, although in other respects, particularly as regards exercise, in circumstances generally favourable to avoiding the disease, are frequently affected by itand Ur. W. IIHDD (Tweedie’s Lib. of Med.. 2d Am. Ed., iii , 587, Philad., j 18i2l slates that “ malt liquors tend, even more than wine, ! to produce a gouty diathesis,” a remark which is confirmed bv the experience of other accurate observers.] 48 GOUT—Pathological Conditions. out any cause having occurred that could have acted in any other way than this. Cold seems to operate, partly by suppressing the excretions, and partly by depressing nervous power. Its effects in exciting a paroxysm, whether applied to the general surface, or to the extremities, or to any part, are well known. Fatigue and exter- nal injury not infrequently produce an attack; and the injured part is usually the seat, espe- cially in cases of sprains, contusions, or con- cussions. The passions of the mind, also, have no mean influence. All powerful mental emo- tions, whether exciting or depressing, will ex- cite a paroxysm ; but anger or vexation has this effect in a very remarkable manner. The an- cients made Anger to be the midwife of Gout; and Cadogan considered vexation, in its wide signification, as one of his three great causes of the disease. The depressing passions, par- ticularly fright, severe grief, anxiety, &c., may either occasion an attack, or cause its retroces- si m, or give rise to a misplaced affection, or to some one of the irregular states of the dis- ease noticed above, particularly in persons who have been formerly affected. Besides these, mental and bodily labour, especially when they abridge the requisite duration of sleep; the sudden cessation of habitual evacuations and excretions, as of the catamenia, haemorrhoids, the sudor •pedum, &c.; cold, flatulent fruits or vegetables, and acidulous liquors or beverages ; sudden changes of diet or regimen ; and what- ever disorders the digestive and excreting or- gans, or suddenly impresses the nervous sys- tem, may excite the gouty paroxysm, either when the predisposition has been fully formed, or when an attack has been experienced. It is from a combination of two, or several, or even of many causes, that the disease is occasioned, especially if it appear independently of any he- reditary taint. In a few instances, this taint seems almost sufficient to produce it, without the aid of any manifest intemperance. This remark was made by Galen, and Haller and others have confirmed it. Cases sometimes, also, occur of persons entitled by both parents to be subject to the disease, who have es- caped it,, although they lived intemperately. Quarin states that he knew two brothers, sons of gouty parents; one of them lived so- berly and laboriously, yet was horribly affect- ed with gout; the other exposed himself to its common causes, and altogether escaped it: but these are rare exceptions from the general course of events. It appears that females fre- quently acquired gout in ancient times, inas- much as Seneca (Epist. 95) mentions the cir- cumstance as a proof of the depravity and lux- ury of his age. 37. V. The Pathological Conditions on which gout depends may be inferred from what has been already advanced as to its causes and phenomena.—a. The older writers imputed it to a peculiar morbid humour existing in the blood. This matcries morbi has been somewhat differently explained. Galen considered that it may be phlegm, or a mixture of phlegm and bile, or even blood, or all these, or simply a crudity of the circulating fluids; and that the gouty concretions arise from the crude hu- mours. Psellus believed that it is a thick humour generated and collected by an atony of the nutritive faculty. Alexander Tralli- | anus contended that the defluxion of humours j occasioning gout is various, according to the local changes and symptoms existing in differ- ent cases—that they are bilious, phlegmatic, melancholic, or even sanguineous ; and that these occasion pain by getting between the ten- dons and ligaments, and distending and irrita- ting them. Aetius maintained the disease to arise from a redundancy of humours caused by weakness of the part affected. C.*lius Aure- lianus assigned the remote cause of gout with great accuracy, and explained its nature in a nearly similar manner to the preceding writers. Paulus considered that a preternat- ural humour and a weakness of the parts com- bine in producing the disease ; and that the re- mote causes, which he enumerates very cor- rectly, generate indigestion and a cacochymy, whence proceed various morbid humours, which are bilious, melancholic, or sanguineous, but. for the most part, pituitous and crude, owing to excess of food and want of exercise. He attributed tophi, or chalk-stones, to thickness and viscidity of the humours, and the chronic or protracted forms of the disease to the admix- ture of several of these humours. 38. The doctrine of the humours, and the manner they give rise to arthritic complaints, have been fully explained by Macrobius (Satur-1 nalia, vii., 4). Mr. Adams, in the learned notes to his translation of Paulus HSgineta, remarks that the theory of the humours, notwithstand- ing its being at present in little repute, accords better with the phenomena of the disease, and is a more successful guide to practice than any hypothesis recently advanced. A similar pref- erence to it has been given by Sprengel. It should also be mentioned that the ancients, par- ticularly those just noticed, recognised the he- reditary character of the disease, and peculiar diathesis of gouty persons. The opinions of the Arabian writers are not materially different from those just stated. The most interesting production on the disease that has appeared was written by Demetrius Pepagomenos, about the middle of the 13th century, and was pub- lished at Paris in 1558. He states the remote causes of gout to be long-continued indigestion, repletion with food, drinking too much wine, venereal excesses, indolence or unaccustomed exertion, and retention of the natural secre- tions ; the venereal excesses, especially, weak- ening the tone of nervous parts. These caus- es give rise to imperfect digestion, and the ac- cumulation of excrementitious superfluities re- quiring to be evacuated from the system. When these excrementitious matters are retained, morbid humours are produced and collected in the affected joints. This very ingenious wri- ter farther remarks that, when crudities or morbid humours are formed in the system, those parts which are vigorous cast them off; but that those that are weak are unable to ac- complish this; and hence collections of such humours take place in them. 39. b. Many of the writers of the 16th, 17th, and 18th centuries were induced, by the ap- pearance of the urine, and the concretions formed in the joints, to account for the phe- nomena of the disease upon chemical princi- ples. Paracelsus first, and Hoffmann and others long afterward, ascribed the local and constitutional affections to the presence of tar- GOUT—Pathological Conditions. 49 taric salts in the blood : an opinion very gen- erally adopted until the middle of the last cen- tury. More recently, Forbes, Parkinson, Wollaston, Home, Brandk, and others have endeavoured to show that there is always a redundance of uric acid in gouty persons ; and, as will be shown hereafter, there can be no doubt that the constituents of this acid exist in them in excess. But this species of change is merely one of the elements of the gouty con- dition. The connexion of the disease with plethora was very justly insisted on by Dr. Cullen ; and Dr. Parry conceived that the paroxysm had a salutary influence in reducing a plethora relatively great, in restoring the balance of the circulation, and in determining the blood from internal and vital parts to the extremities. Here, again, is a part adduced for the whole of the mischief. Dr. Sutton supposed that the cause of disorder is seated in the alimentary canal; but he attempted no- thing beyond this very indefinite explanation. Broussais is more precise, if he be not more correct, in stating gout to be one of the several morbid manifestations depending upon inflam- matory action in the gastro-intestinal mucous surface. In this opinion he has been pretty closely followed by Armstrong, Mackintosh, and several writers of his own country. Dr. Bateman, Sir C. Scudamore, and Dr. Barlow have ascribed the disease to vascular plethora. Dr. Barlow, especially, insists upon its inflam- matory and plethoric nature, but pushes his doctrine too far ; while he overlooks the con- nexion of plethora with other morbid condi- tions. 40. c. It is indispensable to a correct view of the subject, to comprise all the elements forming the constitutional and local affections to which the term gout has been applied. If we analyze the numerous phenomena prece- ding, constituting, and following the disease ; if we connect these with the causes most es- sential to their production, and if we refer to those agents which increase or diminish the severity of the symptoms, we must necessarily arrive at the conclusion that gout does not depend upon one morbid condition only, but upon several; that neither the superabundance of excrementitious matters in the blood, ari- sing from imperfect or effete assimilation— from the ultimate results of animalization ; nor vascular plethora, absolute or relative; nor gastro-intestinal irritation ; nor gastro-hepatic disorder, is individually sufficient to explain all the changes constituting the disease ; al- though they may be sufficient, when viewed in connexion. But, even when thus considered —especially if we push the analysis sufficient- ly far—some antecedent and concomitant le- sions must be inferred. If we view the sev- eral causes in the connexion and succession in which they usually give rise to gout, we must necessarily conclude that the organic nervous energy is impaired or exhausted by them ; and that, as the organic class of nerves bestows its influence on the digestive, the secreting, and excreting functions, exhaustion of its powers will impair the functions of the organs which it supplies. The necessary consequences of such impairment will be imperfect digestion and assimilation, torpor of the liver and bow- els, impeded and disordered secretion and ex- cretion, redundancy of excrementitious matters in the circulation, and vascular plethora, arising from deficient excretion, and from a continued supply of nourishment, aided by a stimulated appetite. These may be viewed as the ele- ments of the gouty constitution or diathesis ; and, when it is formed, the local action will be excited by either, or by several, of the causes mentioned above (<) 35, 36). That most of these causes affect the organic nervous influ- ence more or less directly, is shown by the im- paired or otherwise disordered functions of the organs more especially endowed by this sys- tem. To functional disorder and morbid sen- sibility succeed the accumulation of effete and irritating matters in the blood, and excited vas- cular action, either local or general, or both. These matters aggravate the morbid sensibility and irritation, particularly in situations most prone, by previous disorder or debility, to ex- perience either or both. 41. It is, however, not easy to explain satis- factorily wherefore the morbid action should manifest itself in the extremities, and assume peculiar characters, otherwise than by referring both circumstances to the previous change pro- duced in the system—to the antecedent diathe- sis, either original or acquired ; and to the morbid condition of the nerves, and of the ex- halations and secretions of parts most remote from the centres of nervous power and of cir- culation. Weakness of the remote nervous ramifications will necessarily influence the cir- culation and secretions of the parts which they supply; and when the blood abounds with ex- crementitious matters, the exhaled and secre- ted fluids-will necessarily possess preternatural or morbid properties, which will affect the sen- sibility of the extreme nerves, and irritate the tissues in which they are deposited. There are various phenomena, especially the sudden transition of the affection — which is some- times as quick as electricity—from one part to another, that cannot be explained otherwise than by referring them to the organic nervous system. If we consider the intimate connex- ion that exists between this system and the rest of the economy, and particularly the influ- ence which it exerts upon the vascular system, which it supplies throughout, and view both in their intimate relations with one another and with the rest of the frame—if we contemplate them as intimately interwoven together—as possessing numerous and diversified commu- nications with all the viscera and compound structures—we shall easily conceive that the altered sensibility existing in one part of this nervous circle may readily be transferred to other and distant parts, with the varying state of nervous influence, and with the several caus- es which may suppress it in its existing seat, or drive it to other organs; that a change jn the state of the organic nervous influence, when preternatural or intense,, may very obviously af feet the capillary circulation and vascular ac- tion ; and that, both nerves and capillaries be- ing thus affected, the exhalations and secre- tions of the part will be also changed, particu- larly when the fluids circulating to it are in ex- cess, or abound with excrementitious matters; the- alteration of the fluids, both circulating and secreted, exalting the morbid sensibility and vascular irritability, and perpetuating the suf- 50 fering until the cause is removed or both con- ditions are exhausted. 42. If this view he correct, several disputed matters connected with the disease will be more readily explained. For when the predisposition or diathesis is formed, and the organic nervous influence is morbidly affected in one or several parts, and the vascular system is inordinately repleted, causes affecting either the one or the other will not infrequently transfer the morbid action from one seat to another. The local af- fection of gout being the external manifesta- tion of a constitutional disease, the suppression of it in one part will often be followed by its appearance in another ; and its spontaneous extension to a new situation will as frequently derive it from its former seat; for as long as the constitution continues in fault, nervous power being impaired, the vascular system overloaded, and the blood abounding in excre- mentitious matters, some organ must experi- ence more or less prominent disorder. This view of the nature of gout farther enables us to account for the primary seizure of an internal part or viscus; for, in proportion to the defi- ciency of nervous power, or to the abundance or vitiation of the circulating fluids, or to the weakened or congested state of some viscus, will the disposition to a misplaced or lurking form of gout exist; the vital manifestations being incapable of developing the disorder in the extremities, owing either to their impair- ment, or to the extent of the derangements just mentioned, or to both circumstances conjoined. [Dr. Prout has made it appear in the high- est degree probable that urea and lactic acid are chiefly derived from the decomposition of the gelatinous textures of the body, and lithic acid and its compounds from the albuminous princi- ples, not only of the chyle and blood, but also of the albuminous textures. He supposes, also, that when, on account of the imperfect assimi- lation of alimentary matters by the stomach and primary assimilating processes, the chylous principles are not raised to that standard of per- fection by which they are fitted to become com- ponent parts of the blood, the healthy kidney possesses the power of selecting and disorgan- izing such imperfectly developed chylous mat- ters, and of converting them into the lithate of ammonia, which he thinks is the origin of most of the common yellow amorphous sediments oc- curring to healthy individuals from slight er- rois in diet, &c. JNow, as lactic acid is believ- ed by Dr. Prout to be the characteristic fea- ture in rheumatism, so also he supposes the lithic acid, developed principally during the mal- assimilation of the albuminous textures, to be the characteristic feature in gout; and that when the lactic and lithic acids are developed together, as they often are, showing that the mal-assimilation involves both the gelatinous and albuminous textures, the accompanying dis- ease partakes of a mixed character, constituting what may be properly called rheumatic gout, a form of disease which is more deep-seated and obstinate than either gout or rheumatism alone. According to these views, as he has remarked, the lactic and lithic acids, considered with ref- erence to rheumatism and gout, may be regard- ed somewhat in the light of materies morborum; or, strictly speaking, the undue presence of these acids in the urine or elsewhere, under GOUT—Pai hological Conditions. certain circumstances, may be viewed as indi- ces of the existence of certain diseased actions going on in the primary tissues of the body, and which are known by the names of rheuma- tism and gout. If we compare the symptoms of these disea- ses with those described under the article Glan- ders, which are acknowledged to be produced by the introduction of a morbid poison into the blood, the above views of Dr. Prout will not appear altogether groundless or improbable. The early phenomena of that disease (glan- ders) closely resemble those of rheumatic gout; the pains and swellings of the large joints, with copious perspirations of offensive odour, are among the first symptoms ; and Dr. Williams records a case, admitted into St. Thomas’s Hospital, of London, which was actually mis- taken for rheumatism (On Morbid Poisons). “ Acute glanders in the human subject,” says this writer, “ is ushered in by an attack of pri- mary fever, with or without rigours. This is followed by pains in the limbs, so severe as often to be mistaken for an attack of acute rheumatism.” A consideration of these and other facts has inclined us to believe that, both in gout and rheumatism, general nutrition is disturbed, not by mere local disease, nor by an impression on the nervous system, but by the development of a morbid matter in the blood, which visits every part to which that fluid is distributed, but which is attracted by some tex- tures much more than by others, but is, from unknown causes, subject to be suddenly repel- led upon other tissues, and those, too, of a more vital nature. It is also the opinion of Dr. Williams (Princi- ples of Medicine, Philad., 1844) that gout depends on the production in the system of an excess of lithic acid, which, being a highly azotized compound, is abundantly generated in those who take a large proportion of animal food, and in whom the digestive and assimilative pro- cesses are impaired. Hence it is produced by high living and sedentary habits. As it is one of the lower forms of animal matter into which the higher principles, fibrin, albumen, gelatin, &c., tend to pass in their progress towards dissolution, hence it is produced in excess where there is more azotized matter than is wanted for the reparation of the textures, or than the vital assimilating powers can appro- priate for this purpose ; but as Prout remarks, it results also from the decay of the textures, especially during febrile or inflammatory irrita- tions, during and after which copious deposites of the lithates are seen in the urine. Accord- ing to this able pathologist, the morbid effects of an excess of lithic acid will vary considera- bly, according to its amount and other circum- stances. The kidneys being the proper emunc- tories by which it is eliminated from the blood, these organs sometimes suffer from the irrita- tion which it causes ; hence nephralgia and ne- phritis may occur; or the water and alkali se- creted with it in the urine may be insufficient to hold it in solution, and it may be deposited in the form of sand or gravel, or calculus in the kidneys or bladder, and various irritations and obstructions in the urinary apparatus may be the result. “ But sometimes,” Dr. W remarks, “ the kidneys may fail in their power of elimi- nation ; the lithic acid and its compounds thus GOUT—Pathological Conditions. 51 accumulate in the blood, and may cause va- 1 rious irritations and functional derangements (irregular gout), until at length some circum- stance fixes the irritation on a limb, and a fit of regular gout is the consequence. In this fit, if perfect, inflammation is exerted with more or less febrile disturbance, which subsides as a copious deposite takes place in the urine, show- ing the removal of the morbid matter. The more acute and fixed the inflammation, and the smarter the fever, the more abundant is the de- posite, and the more free is the patient from disease afterward. On the other hand, when the inflammation is low, changing its place, and with little fever, it generally tarries long, and the system is not relieved. It is when gout thus lasts long, or frequently recurs, that often its material so accumulates in the joints as to be deposited in the form of a plastery or calculous matter, consisting of lithate of soda (chalk-stones of gout). This chronic form of gout is connect- ed with a more or less permanent disorder of the digestive or assimilative functions, which renders its treatment more difficult or less successful than that of the more acute forms of gout. In such cases (chronic) lithic acid seems to be engendered in great abundance, being often thrown off in large quantities in the urine for an indefinite period, yet never leaving the body free. Such cases are commonly ei- ther hereditary, or those which have been ren- dered inveterate by intemperate habits or neg- lect of proper treatment.”*—(Loc. cit.) The hypothesis that gout is caused by the presence of lithic acid in the blood, was pro- posed near the end of the last century by Mr. Murray Forbes, who supposed that this agent was prone to become deposited in the small vessels of tendons, ligaments, &c., under the influence of some stronger acid, either taken into the stomach or formed in the process of digestion. Dr. Todd, however, who admits that the same causes which favour the devel- opment of the lithic acid diathesis will promote the gouty one—that indolence, good living, want of exercise, deficient cutaneous action, are equally favourable to the production of both states of constitution ; and that the lithic acid diathesis is that which passes most readily into the gouty—nevertheless is of opinion that the presence of an undue quantity of lithic acid in the system, even although accompanied with the formation of a free acid, is not sufficient to account for the formation of gout, as we meet with many instances in which these conditions are present, even for a considerable period, without giving rise to any of the symptoms of gout. Brickdust sediments, he remarks, are among the most common of those that are found in the urine : “ a slight disturbance of the di- gestive process, or a febrile cold, will increase the quantity of lithic acid; in young persons such sediments are very common ; in fevers they appear, at first, in the urine, then disappear, and their reappearance sometimes seems criti- cal. In none of these cases do symptoms of gout occur, even when the disposition to the deposite is of long duration. I have known these deposites to show themselves for weeks and months without producing any symptom of gout. In hysterical women, the lithates and lithic acid are deposited in large quantity; and in diseases of the liver, chronic as well as acute, the proportion of this acid is very much augmented.” According to this writer, an ad- equate theory of gout should explain, 1. The frequent accompaniment of a large quantity of lithic acid with the disease ; 2. The occasional occurrence of gout, when this acid cannot be formed in undue quantity, as in the cases of gout appearing in low states of the system ; 3. It must account for the formation of a large quan- tity of free acid in the system, as appears from the undue acidity of the digestive organs and the sweat; and, lastly, it must explain the pa- thognomonic character of the disease, namely, the formation of lithate of soda in various parts of the body. In the present state of our knowl- edge, Dr. T. thinks it impossible to determine the correct theory of gout; but that it appears highly probable that the gouty matter is, in the first instance, derived from the stomach or du- odenum, inasmuch as a disturbance of the func- tions of those parts is an invariable antecedent or accompaniment of the fit; and as such de- rangements are generally accompanied with an undue development of Lactic acid, he deems it fair to conclude that it may be the primary dis- turbing agent. If the views of this writer are to be received, we are then to believe that the matter of gout is a compound, derived from a product of unhealthy action of the stomach and duodenum, which being absorbed into the blood, unites there with some element of the bile which has been suffered to accumulate through the defective secretory action of the liver. “ As the same causes which induce these two states will give rise to a lithic acid diathesis, we find it usually associated with them. But the former may exist without the latter ; and therefore gout may show itself without the oc- currence, at the same time, of a preternatural quantity of lithic acid.” Such an organic com- pound, he believes, may exist in the blood in variable quantity, and for an indefinite period, contaminating the whole frame, as well as the offspring, and thus give rise to the gouty diath- esis ; or this matter, ever present in the sys- tem, may be liable to periodical accumulations, which can only be got rid of by periodical par- oxysms. Our countryman. Dr Rush, has furnished * [According to Liebig, whose theory is advocated by Dr. Bence Jones, the presence of lithic acid in the sys- tem is due to the deficiency of oxygen ; and in the natural state, under the influence of a due supply of oxygen, this substance nearly or altogether disappears, being decompo- sed by oxygen into urea and carbonic acid ; so that in healthy urine its quantity is very small, and in the carniv- orous animals, which are largely supplied with oxygen, it disappears altogether. He supposes the free acid, which exists in the system, to be lactic acid derived from the stomach, and that this and other non-nitrogenous compounds present in the blood attract the oxygen, and hinder its ac- tion upon the lithic acid. (Lithic acid, Liebig believes, is formed from blood or muscular fibre by the action of ox- ygen and water; for, he says, the elements of lithate of ammonia and of choleic acid, with one equivalent of water and one of oxygen, make up the formula of blood.) For objections to this theory, the reader may consult Todd, •“ On Gout and Rheumatic Fever," p. 69. The British and For. Med. Review (vol. xvi.) suggests that lithate of soda is the morbific agent, because this sub- stance is separated from the blood in gouty deposites, from the known connexion of gout with biliary as well as urina- ry derangements, and from the beneficial results of treat- ment directed to both these secretions. “ Under the influ- ence of particular substances,” it remarks, “ lithic acid has a tendency to accumulate in the blood ; and it seems to us quite possible that, so long as it retains its uncombined form, gout may not result; but if, by a deficiency in the se- cretion of bile, soda also be allowed to accumulate, the two will combine, and lithate of soda will be formed.”! 52 GOUT—Treatment. some able observations on this disease, char- acterized by the same boldness and originality of views as distinguish all his medical essays (Med. Inq., vol. ii., p. 247). Defining it to be a disease of the whole system, affecting the ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, muscles, car- tilages, bones, and skin, he, nevertheless, held that it was a primary disease only of the solids ; chalk-stones, dropsical effusions, &c., being only the effects of a morbid action in the blood- vessels, as maintained by Cullen. The re- mote and exciting causes of the disease, which are pointed out with great minuteness by him, do not differ essentially from those given by Copland ; he, however, supposes that females are quite as subject to gout, though not in the extremities, as males, and that tea. is a power- ful predisposing cause. He speaks of having treated it in the native American Indian, and of its occurring occasionally among those who make no use of fermented or distilled liquors. Its hereditary character he held to depend upon the propagation of a similar temperament from father to son, which sometimes passes over one generation to appear in the next. In ev- ery instance he believed it to be induced by general predisposing debility, which may have been occasioned by indolence, great bodily la- bour, intemperance in eating, excessive venery, acid aliments and drinks, strong tea and coffee, fermented and distilled liquors, grief, anxiety, and other depressing mental emotions, &c. That form of gout which appears in the liga- ments and muscles, he supposed is always brought on by the use of spirituous drinks ; and whatever form the disease assumed, he be- lieved it to consist simply in morbid excitement accompanied with irregular action, or the ab- sence of all action, from the force of stimulus, precisely as occurs in fevers. The doctrine of a specific acrimony, or morbid poison, he re- jected as unphilosophical and improbable. This was in accordance with his general theory of disease, namely, that however varied morbid actions may be by their causes, seats, and ef- fects, they are all of precisely the same nature. According to this writer, there is not a disease in the whole catalogue of nosology but what is mimicked by the gout, its symptoms being man- ifested in the ligaments, the blood-vessels, the viscera, the nervous system, the alimentary canal, the lymphatics, the skin, and the bones ; in short, “ it is an epitome of all diseases.” Instead, therefore, of being a primary affection of the joints, Dr. Rush understood by the name, gout, a disease consisting simply in'morbid ex- citement, invited by debility, and disposed to invade every organ and tissue of the body.— (See Loc. 43. iVI. Treatment. — i. The opinions of the ancients, as to the treatment of gout, are in many respects as deserving of notice as those of modern writers; indeed, there is little dif- ference between the views of some of the former on this subject and those of the latter. As at the present day, so in ancient times were cold applications to the part, and colchi- cum internally, advised by some and condemn- ed by others; so also, as may be seen from the Tragopodagra ascribed to Lucian, were nu- merous nostrums lauded for the complaint, as well as a rational treatment pursued by the regular practitioners of physic ; and uo also, as at the present day, the habits and irregularities of the patient brought discredit on the science of the physician, and led to the too general adoption of the opinion of Ovid, that “ Tollere nodosam nescit medicina podagra in.” 44. Hippocrates recommended purgatives by the mouth and by injection, and cooling ap- plications to the part. In the more chronic cases, he advised means similar to the moxa of the Japanese. Celsus also prescribed re- frigerant applications to the affected part; but he likewise had recourse to warm fomentations conjoined with anodynes, and to depletions. Aretteus seems to have trusted chiefly to hel- lebore, and to applications of wool moistened with various substances, as oil, oxycrate, &c. Galen commenced the treatment of gout by evacuating offending matters by bleeding and purging; he afterward had recourse to discu- tient applications. Aukelianus direct- ed blood to be abstracted from the part by scarifications, and sponges squeezed out of hot water, or oil and water, or a decoction of fenu- greek, to be afterward applied. He also pre- scribed gentle emetics and aperient clysters. He disapproved of burning the parts, and of the indiscriminate use of narcotics; but advised warm bathing, spare diet, emollient ointments, and afterward gentle exercise. He enjoined complete abstinence from the commencement of the attack ; and at its decline he prescribed a medicine nearly the same as the Portland powder. Oribasius confided chiefly in bleed- ing and purging, especially in plethoric persons, and in the spring. Aeticis evacuated redun- dant humours by these means, and afterward endeavoured to strengthen the parts. 45. Alexander Trallianus adopted a treat- ment which he viewed as appropriate to his pathology of the disease. In cases proceeding from a bilious humour, as indicated by burning heat and the absence of swelling, he prescribed chologogue purgatives, consisting chiefly of cathartics and bitters conjoined, and cooling anodyne applications to the affected parts, with spare diet. When occasioned by a phlegmatic humour, indicated by the absence of heat and redness, he considered calefacients to be bene- ficial, and refrigerants injurious, and recom- mended a combination of purgatives and atten- uants, as hellebore, thyme, cumin, &e. Af- ter purging, he directed warm attenuants in- ternally, and calefacient anodyne cataplasms to the external affection. When there was gen- eral fulness of blood, or determination to the affected joint, he advised blood-letting, and ab- stinence from wine and animal food, and dis- cutients to the part. He has remarked that some insist upon taking medicines to allay at once the violence of their pains, not choosing to submit to a methodical treatment, but that he does not approve of this practice. For this purpose, he adds, the hermodactylus is particu- larly trusted to ; and he admits that it seldom fails to remove a paroxysm ; but he also affirms that it occasions more frequent returns of it I he identity of hermodactylus and colchicum is highly probable, as maintained by Prosper Alpinus, Sir II. Halford, and others. Alex- ander has farther stated that some endeavour to correct the prejudicial effects of this medi- cine by adding to it cumin, mastic, or ginger, GOUT—Treatment. 53 thinking that its action is narcotic ; but this he j affirms t o be a mistake, for in that case it could ; not prove cathartic. He admits, however, that | these things may correct its bad effects upon the stomach; and he therefore prescribes a combination of the hermodactylus with aniseed, pepper, and myrrh, or with aloes, scammony, j elaterium, colocynth, &e. He preferred, how- j ever, the coronopodium (which Mr. Adams, in his learned commentaries on Paulus, believes to be the buckthorn plantain, or plantago coronopus), as it procures evacuations and relief from pain without injuring the stomach. 46. Paulus HSgineta advised a nearly simi- lar method to that adopted by Alexander. He employed chologogue purgatives for the evacu- ation of bilious humours, when he inferred gout fo arise from this cause ; and numerous cooi- ng and anodyne cataplasms to the affected part, with a refrigerant and diluent diet, avoid- ing repletion and the use of heating dishes or liquors, as well as mental emotions and vene- real indulgences. In the sanguineous form of the disease, and in the first attacks, he en- joined blood-letting and purgatives ; the latter consisting chiefly of a combination of colocynth, aloes, black hellebore, and scammony. Some, he has remarked, have recourse to purging with hermodactylus ; but it is bad for the stomach, producing nausea and anorexia, although it re- moves the disease very speedily. In gout from a mixture of humours, he also had recourse to depletions in early attacks ; but, after frequent seizures, he considered the loss of blood inju- rious. Besides these, he directed a variety of both internal and external means, many of which deserve adoption, and are similar to those hereafter to be noticed. With respect to prophylaxis, he advised a moderate use of wine, exercise, and frictions of the joints, morning and evening, with oil triturated with salt. 47. The opinions of the Arabian physicians differ not materially from those of the Greeks. Serapion, Avicenna, and Phases recommend- ed evacuations and the hermodactylus. Haly Abbas directed blood-letting in cases proceed- ing from sanguineous plethora, and used cool- ing applications to the joints. For the bilious defluxion, he prescribed emetics and drastic purgatives, consisting of scammony, aloes, col- ocynth, and hermodactylus; and, for the serous or phlegmatic defluxion, very nearly the same means, the local applications being varied. The treatment adopted by Alsaharavius was almost identical with that pursued by Alexan- der, Paulus, and Haly Abbas. 48. Demetrius Pepagomenos has justly re- marked that the prophylaxis of gout is easily prescribed, but followed with great difficulty. It consists in great moderation in eating and drinking, and in avoiding indigestion. Viewing the disease as one of repletion, he ordered evacuations for its cure, consisting of emetics, blood-letting, and purgatives, and with a very judicious reference to the form and stage of the disease. He forbade the use of strong emetics ; but vomiting by gentle means he had recourse to at the commencement. In early attacks, and at their beginning, when there was evidence of plethora, he prescribed blood letting; but he considered it prejudicial in other circumstances, or much inferior to active pur- ging. He was favourable to the use of hermo- dactylus as a purgative, and combined it with aromatics. In other respects his treatment was similar to that of Alexander. 49. The reader will observe, from what has been just stated, how little has been added to our knowledge of this subject by the numerous productions that have appeared since the revi- val of learning in Europe ; and that, although there is much that is trifling, a little that is ab- surd, and something that is questionable in the doctrines and treatment of gout adopted by the ancients, there is also much deserving of com- mendation and adoption. 50. ii. Treatment of Acute Gout. — The indi- cations are, 1st. To avert a threatened attack ; 2d. To alleviate the symptoms during the par- oxysm ; and, 3d. To prevent the return of the disease, by suitable regimen and medical treat- ment, after the paroxysm has ceased. —A. In order to avert, or to render more mild a threat- ened attack, the premonitory symptoms should be treated promptly and judiciously. Much suffering and injury to the constitution have arisen from the idea that the paroxysm is a salutary effort of nature, and that the preven- tion of it may be followed by serious conse- quences. There is, however, some truth in the opinion, for, as I have shown, the external af- fection being the outward manifestation of con- stitutional disease, the suppression or preven- tion of it in an external part may lead to results still more severe than the impending attack. But it is the suppression of the paroxysm by means which leave the constitutional disorders untouched, or which increase them, that is in- jurious, and not the prevention of it by reme- dies directed to the removal of these internal disorders themselves in which the attack ori- ginates. A large dose of an acro-narcotic, as of colchicum, veratrum, or veratria, aconitum, &c., has often the effect of suppressing the morbid sensibility, and with it the irritative vascular action of the seizure ; and thus frees the patient from the impending suffering for a time. But it leaves the internal disorders, of which the external is merely a part, in the same state as before, or even increases them ; inasmuch as it tends to weaken organic ner- vous power, to irritate the digestive mucous surface, and to impair the functions of excre- tion ; and the consequence is, either a more frequent return of the precursory symptoms ol the attack, or the supervention of some serious visceral disease. The means, therefore, to be had recourse to, in order to avert the paroxysm, should be those only which are calculated to remove the internal derangements, in which it originates. These derangements we have seen to he, weakened organic nervous power; a torpid state of the functions of the liver, with accumulations of bile in the biliary passages and liver; congestion of this viseus ; feecal ac- cumulations in the large bowels ; collections of mucous sordes on the digestive mucous sur- face ; vascular erethism, or inflammatory irri- tation of the surface ; and the superabundance of excrementitious matters in the circulation. Means, therefore, which will remove these conditions, and prevent their recurrence, will the most effectually avert both a threatened paroxysm and a return of the disease. 51. Guided by those views, general blood-let- 54 GOUT—Treatment of Acute. ting may be employed in robust and plethoric persons. If signs of congestion of the head or of the liver be present, or of inflammatory ir- ritation of the digestive mucous surface, local depletions may be substituted, or used in addi- tion to the general evacuation. The quantity of blood taken away should depend upon the age and strength of the patient, and other cir- cumstances of the case. Haemorrhoidal or other spontaneous evacuations ought to be en- couraged by aloetic purgatives, &c. If the tongue be much loaded, and if heartburn, acrid eructations, or nausea be complained of, nei- ther pain nor tenderness of the epigastrium be- ing present, an emetic will generally be of ser- vice. But if vascular depletion be indicated, it should be premised. Emetics have been rec- ommended by Celsus, Fabricius, Hildanus, Gesner, Stoll, Scudamore, and others; they will be found most serviceable as here advised; in other circumstances they are doubtful means, and require much discrimination. If indigesti- ble matters remain in the stomach, emetics should not be withheld; but when there are pain and tenderness at the epigastrium, with determination to the head, they may be inju- rious. In almost every case, purgatives should be prescribed, although the bowels may have been said to be regular or open ; for collections of morbid secretions in the biliary organs, and of faecal matters in the cells of the colon, may nevertheless exist. Therefore a full dose of calomel, with camphor or with James’s powder, or with both, may be given at bedtime, and a stomachic purgative the following morning. The draught here prescribed I have found most efficient, especially when the bowels are very sluggish; and the frequent repetition of it is attended by no disadvantage : No. 233. B; Infus. Gentianse Comp., Infus. Senna: Comp., 4a fj.; Magnes. Sulphatis 3jss. (vet Sodse carbon. 3j.); Tinct. Cardamom. Co. et Tinct. Seimae Comp. 5a 3jss. M. Fiat Haustus, quamprimum mane sumendus. 52. If the excretions continue to present or assume morbid appearances, a small dose of blue pill, or of hydrargyrum cum creta with soap, or a full dose of calcined magnesia, should be taken at bedtime, and the above draught in the morning, until they assume a natural char- acter. If the precursory symptoms continue nevertheless, I agree with Sir C. Scudamore in considering that the constitution is labouring under the causes of the paroxysm, almost as much as if the attack had been developed, and that the treatment required during the parox- ysm should be resorted to. If the means here recommended restore the functions to a healthy state, abstinence or moderation in diet, regular exercise, especially on horseback, mental quie- tude, and early hours, should be strictly ob- served. 53. B. The Treatment of the ParSxysm should be varied according to the age, strength, and habit of body of the patient, to the predisposing and exciting causes, to the duration and char- acters of the paroxysm, and to the frequency and severity of the previous seizures.—a. Blood- letting is required in the plethoric and robust, and in early attacks, when the constitution is unbroken, and the inflammatory diathesis evi- dently exists. In these circumstances, it has been advised by Celsus, Galen, Alexander, Horstius, Riverius, Jumelin, Le Teluer, Sydenham, Patten, Huxham, Cullen, Hosack, Musgrave, Maobride, De Vernevil, Heber- den, Scudamore, &c. It has been too strong- ly insisted upon by Hamilton, Rush, and Bar- low, while it has been considered injurious by Trampel, Barthez, Halle, and Guilbert, un- less when the inflammatory action is very manifestly developed in some internal organ; or in strong plethoric persons, when the gen- eral vascular excitement is very great. The practitioner should be guided as to the extent of the depletion by the circumstances above alluded to ; keeping in view the fact that the disease is one more of irritation than of inflam- mation ; that the vascular excitement is, in great measure, the consequence of the morbid sensibility, and will subside as it is subdued. Local depletions are often preferable to general blood-letting, particularly when tenderness or fulness of the epigastrium or hypochondria is present, and will generally be sufficient to re- move hepatic congestion and vascular excite- ment of the gastro-enteric mucous surface. When blood-letting is clearly indicated, it should not be delayed, as the benefit it is cal- culated to afford will be diminished very mate- rially by delay, the debility consequent upon unmitigated irritation rendering the deferred depletion of little or no avail.* 54. b. Alvine evacuations are of less doubtful efficacy even than vascular depletion. Emetics are sometimes of service at the commence- ment of the paroxysm, when the symptoms in- dicating ($ 51) the propriety of resorting to them are present. In some cases they miti- gate the attack, while in others they have little or no effect upon it. They ought to be em- ployed with caution. When the case requires both vascular depletions and an emetic, the latter ought not to be exhibited until the for- mer has been carried into effect. Purgatives are of the most unequivocal benefit. Many of the empirical remedies employed against the disease are serviceable only in as far as they increase the alvine excretions. As vascular congestion of the liver and accumulations of [We have found mild antiphlogistic measures general- ly sufficient to relieve gouty attacks, and blood-letting rare- ly required unless in a very plethoric state of the system, and when the fever is high : we should bear in mind that there is danger in carrying this remedy too far, from its tendency to prevent a crisis. Local blood-letting will rare- ly be called for, as the inflammation will, m a large major- lty of cases, speedily subside, by keeping * ho part warm and still; by covering it with cotton, wool, or oiled silk ; or by the application of soothing lotions. As a general rule, we are satisfied, from considerable experience, that the an- tiphlogistic treatment of gout should be of the mild kind, as purgatives, calomel, or blue pill, combined with antimony or saline medicines ; but no permanent relief will take place until the urinary deposites commence. Vemesection we hold to be admissible but in certain cases, and under the circum- stancespointed out by our author. Dr. Barlow, of Bath, LnglamL referring to the states of the system under which gout is developed, maintains the existence of three kinds of plethora, one in which the nutritious function is redun- dant without much affecting the self-adjusting powers of the system, or without much diminution of the excreting functions: the second, with some diminution of the excre- ting functions taking place, chiefly in constitutions deficient in natural vigour, or impaired by predisposition to disease ; and the third, with impaired action of the excreting func- tions, indicated by sallow, dingy complexion, harsh, dry skin, slow, inert, and constipated bowels, and high-colour- ed, foetid urine. According to Dr. B., acute or regular gout occurs in connexion with one or other of the first two forms of plethora, and these cannot be satisfactorily or ef- fectually removed without the employment of blood letting ; he, accordingly, recommends that evacuation, both general and local, especially in young persons or those of middle age, and of average vigour of constitution.] GOUT—Treatment op Acute. 55 bile in the biliary passages are often connected with the production of the fit, such purgatives as promote the circulation in this organ, and increase its excreting function, should be se- lected. With this view, from five to ten grains of calomel, with four or five of James’s powder, < may he given at bedtime, and the draught pre- | scribed above () or the disease may commence in its usual manner, suddenly disappear, and affect some internal viscus ; (c) or it may seize at once upon some internal organ, and either exhaust itself or be remedied by treatment, without any external affection appearing in its course, or it may de- stroy the patient. The first and third of these varieties require the same treatment, modified according to the character and seat of the in- ternal affection. I shall therefore consider, in the first place, the means most appropriate to the disorders connected with the retrocession or suppression of the external affection. 83. A. Retrocedent Gout. — In no disease is discrimination, on the part of the physician, more necessary than in this ; for upon the in- ference that is formed as to the existence of inflammation or of spasm, and as to the degree in which either is present, the life of the patient depends —a. In nervous and weak constitu- tions a spasmodic or nervous character is gener- ally predominant, as indicated by the weak, or irregular, or unaccelerated pulse, and by the ease derived from pressure, &c. In these, en- ergetic stimulants or antispasmodics, with an- odynes or narcotics, or even warm brandy and water, are required. In other cases, a mixed affection, or a state of congestion may be in- ferred ; and in them the remedies just men- tioned may not be injurious, but additional means are required, especially alvine evacua- tions, external derivatives, or even local deple- tions. When the retrocession appears to have been caused by indigestible matters, an emetic should be exhibited, conjoined with a warm cardiac, as capsicum, ammonia, or camphor; and, if nausea and vomiting be present, a full operation should be procured by warm water, or by the infusion of chamomile flowers. If the stomach or bowels are principally affected, a full dose of calomel, with camphor, hyoscya- mus, or opium, should be given, and, two or three hours afterward, one of the purgative draughts already prescribed, which should be aided in its operation by a cathartic enema containing turpentine, asafcetida, or camphor. I have found I)r. Warner’s arthritic tincture to be excellent in this state of disorder. If suf- fering still continue, the calomel, camphor, and opium may be repeated, after an interval short in proportion to the severity of the case ; the feet should be plunged in hot water to which a large quantity of mustard flour and salt are added, or be enveloped in sinapisms ; and flan- nels wrung out of very hot water, and soaked with spirits of turpentine, should be applied over the abdomen ; or croton oil rubbed over the stomach. Sir C. Scudamore directs the saline draught, with colchicum, to be given and repeated ; but I doubt the propriety of giving this medicine in cases of consecutive gouty affection of the stomach or intestines. 84. h. Although the internal affection will often assume a nervous or spasmodic charac- ter—especially in the constitutions mentioned in connexion with it, and at the commencement of the seizure, before vascular reaction has taken place—yet active congestion or inflamma- tory determination is not infrequent, particularly in more plethoric and irritable habits. Much care and discrimination are required to ascer- tain the presence or absence of these states; and either is to be inferred chiefly from the causes of retrocession, from the state of the pulse and of vascular repletion, and from the tenderness, fulness, or tension, and tempera- ture of the regions containing the affected or- gan. The patient’s sensations, and the symp- toms connected with the excreting functions, ought also to be carefully estimated. If, from these, inflammatory action of the stomach, intes- tines, or kidneys be inferred, blood-letting, ac- cording to the strength and habit of body of the patient, must be promptly put in practice. But vascular depletions are neither so well borne in such cases, nor so successful, as for inflam- mations occurring primarily, or in previously healthy persons. The amount and repetition of depletion must depend entirely upon the cir- cumstances of the case ; but in every instance depletion should be aided by the derivatives and hot epithems just recommended. A full 64 dose of calomel, with a few grains of camphor, and two of opium, should also be administered, and repeated within two or three hours, if in- dications of relief are not observed. After one general blood-letting, local depletion by cupping or leeches may be employed, and repealed in severe cases, or in plethoric persons. In some instances the powers of the circulation can bear only local depletions. When much flatu- lent distention, and severe colicky pains, either attend the internal seizure, or remain after the above means are employed, equal parts of oil of turpentine and of castor oil (jiv. to 3vj. of of each) may be given on the surface of an ar- omatic water, with or without a warm tincture, or aromatic spirit; and an enema containing the same oil may be administered a few hours afterward, to promote its operation. 85. c. The internal attack, although nervous or spasmodic at its commencement, may be- come congestive, or even inflammatory, as vas- cular reaction supervenes. This fact should not be overlooked, for the seizure that is bene- fited by stimulants at the beginning, owing to this circumstance, may require depletions in its progress. The internal affection may even present a mixed character—one in which it is difficult to determine whether the nervous, or the spasmodic, or the congestive, or the inflam- matory symptoms predominate. In these ca- ses it will be necessary to have recourse to antispasmodics and narcotics, or anodynes, while vascular depletions and evacuations are being employed. Having treated several cases of retrocedent gout, and being thereby induced to observe closely, and to reflect upon the phe- nomena attending it, and the effects of the treatment adopted, I am morally convinced that exclusive views as to either the nervous or the inflammatory character of the internal affections are incorrect; and that it requires the utmost acumen on the part of the practi- tioner to discriminate between these states, and to detect their varying shades. In the more spasmodic forms of these affections, espe- cially when implicating the stomach, opium and camphor are most valuable remedies ; but I have seen great benefit also accrue from hy- drocyanic acid, given in repeated doses with camphor and aromatics. 86. d. When the consecutive seizure is ex- perienced in the heart or lungs, the same prin- ciple of practice should be observed. When the heart is affected, the restlessness, anxiety at the praecordia, and alarm of the patient are most distressing. I have lately seen two ca- ses of this kind. In both the action of this or- gan was frequent, irregular, fluttering, and weak ; in one, it intermitted every fourth beat, the three intervening strokes being success- ively weaker. In both these I am convinced, from the character of the symptoms, that de- pletions would have caused a fatal result. Camphor and opium, with aromatics and ex- ternal derivatives, were prescribed for both, and in a few hours the affection was removed. In the cases, also, referred to above (<) 19), this and similar modes of practice were equally beneficial. 87. e. When apoplectic, epileptic, or convulsive \ seizures follow the retrocession of gout, vascu- lar depletion is frequently requisite, especially in apoplexy. But, even in it, discrimination is GOUT—Treatment op Irregular. imperatively called fur. If the head be cool, and the action of the carotids weak, an entire- ly opposite treatment to depletion is required. In the epileptic or convulsive seizures depletions are often unnecessary, and sometimes injuri- ous. Even when manifestly indicated, they require much caution, and ought not to be pre- scribed in large quantity. In both the apoplec- tic and epileptic attacks, purgatives and ca- thartic enemata, energetic derivation to the lower extremities, and camphor, are beneficial; but narcotics should be withheld, especially in the former, although, when conjoined with an- tispasmodics and cardiacs, they are sometimes of service. When the retrocession of gout has been caused by cold, vascular depletion is more frequently useful than in other circumstances ; but the utmost caution is necessary as to the extent to which it is carried. Derivations by sinapisms, mustard pediluvia, croton oil, &c., however, ought to be most actively employed. 88. /. If the kidneys or neck of the bladder are affected upon the retrocession of gout, the treatment will depend entirely upon the con- comitant phenomena. If the urine be sup- pressed, or pain or tenderness be felt in the region of the kidneys, or numbness in one or both thighs, cupping on the loins, followed by a blister in the same situation, will be requi- site ; but the latter should be removed after a few hours, or sinapisms substituted. Deriva- tion to the lower extremities, and small doses of camphor internally, with diuretics, ought also to be prescribed. Where the neck of the bladder becomes affected, leeches applied to the perineum, the semicupium, and the internal use of alkalies, with camphor and anodynes, or with mucilaginous and diuretic medicines, should be employed. 89. B. Misplaced Gout (<) 21), or those severe affections of internal organs which threaten the life of the patient, and are either followed by the regular disease, or run their course with- out any external affection, although occurring in persons who have previously had gout, must be treated very nearly according to the princi- | pies stated above. If vascular depletion require cautious discrimination in retrocedent gout, it still more imperiously demands it in cases of this kind.—a. Any internal organ may be the j seat of misplaced gout, or, in other words, the internal viscera are disposed to severe disorder in gouty constitutions ; but the stomach, bow- | els, heart, brain, [spinal cord,] and kidneys are most frequently affected. Gouty persons are often affected by spasms of the stomach and colic, after exposure to cold, or after partaking of cold, acid, or improper food. For these ca- ses, large draughts of warm water, and stimu- lant and cardiac medicines, or warm brandy and water, are suitable means. In some, the dis- order alternates between the stomach and heart; or the flatulence attending upon the affection of the former induces palpitation or otherwise disordered action of the latter, with inexpress- ible anxiety. A gentleman who had suffered attacks of gout, but had escaped them for some years, was subject to disorder of the stomach, to severe headaches, and to alarming and sud- den affections of the heart, the action of which was fluttering or tumultuous, and the anxiety and suffering referable to it most distressing. He was late'y seized with one of these attacks GOUT—Treatment op Irregular. 65 at a party. He was assisted into his carriage, and was brought to my house after midnight. The affection approached the characters of an- gina pectoris, but I inferred its aggravation by flatulence ; I therefore prescribed a warm, car- minative medicine. While this was being pro- cured, I directed the patient to swallow a few of the small pods of capsicum. Flatulent eruc- tations and instant relief were the consequen- ces. In a few minutes afterward he walked, unaided, to his carriage. 90. A gentleman well known in the profes- sion had some years ago experienced imper- fect manifestations of gout in the lower extrem- ities, connected with affection of the digestive organs. Recently, after a severe domestic af- fliction, he was seized with distressing disorder of the stomach and heart, with anxiety, alarm, and nervous irritation. Dr. Roots and myself agreed as to its nature, and prescribed anodynes, with antispasmodics, aromatics, and alkaline carbonates. The excretions received due atten- tion, and external derivatives (§ 83) were em- ployed. While improving under this treatment, he was suddenly affected by an alarming in- crease of the disorder of the heart. His pulse had become weak, irritable, and intermitting; the impulse of the heart was feeble, but unac- companied by any abnormal sound ; his coun- tenance was expressive of distress,-and he was constantly changing his position. A draught, containing two drops of hydrocyanic acid with camphor, aromatics, and capsicum, was prescri- bed, and repeated in an hour, and derivations by sinapisms resorted to. He obtained relief in a few hours, and continued improving for two or three weeks afterward ; when he had a second attack in the night, for which camphor and am- monia, with opium, were given him, and car- minatives with magnesia. He was immediately relieved, and has continued afterward to im- prove ; the subsequent treatment consisting of a combination of anodynes and restoratives, and of stomachic aperients. 91. b. When apoplectic or epileptic seizures, or diseases of the kidneys or bladder, thus oc- cur in person who have previously had fits of gout, the treatment should be guided according to the principles just developed. Apoplectic and paralytic attacks arc very common in gouty per- sons far advanced in life, and who have been long without a regular paroxysm. In these, depletions are not so generally beneficial as in other circumstances, although they are often required ; the energetic exhibition of purga- tives and of cathartic enemata, and the applica- tion of sinapisms to the feet, &c., being much more generally appropriate. When epilepsy or convulsions appear in gouty persons, depletions are hazardous, antispasmodic and purgative enemata and derivation being much more use- ful. Whatever organ becomes diseased in such persons, the treatment must be guided by the state of the pulse, the signs indicating the na- ture of the complaint, and the age and strength of the patient; for although large depletions may be necessary in some cases, yet they will certainly destroy the patients in others, although the disorder and its seat are apparently the same. When the disease presents unequivo- cally inflammatory characters, or when the pa- tient has been highly fed, or is plethoric and ro- bust, blood-letting cannot be dispensed with ; the question being as to the extent to which it should be carried; and as to this, the prac- titioner must decide for himself, and be guided by the peculiarities of the case. In the gouty constitution, especially, it cannot be trusted to alone, or even principally, unless in robust and plethoric persons. When apoplexy is complica- ted with gout, the former occurring during the paroxysm, or without the disappearance of the latter, blood-letting and alvine evacuations should be prescribed with an energy suitable to the circumstances just adverted to. Such ca- ses, are, however, comparatively rare. I have never known of an instance of epilepsy while the gouty paroxysm continued, although I have seen it take place upon the retrocession of the fit, and in gouty persons. Van Swieten re- marks that, in cases in which he has seen ari epileptic seizure in the gouty, the occurrence of a regular paroxysm of gout has prevented a return of the epilepsy. 92 c. As to the employment of colchicum in cases of retrocedent or misplaced gout, recent writers have stated nothing in which the prac- titioner can confide. When the stomach is weak, the nervous power depressed, and the pulse irritable, it is generally injurious ; when inflammatory seizures occur, cither upon the sudden disappearance of the external affection, or in the gouty constitution, it may be employ- ed ; and the advantage proceeding from it will be in proportion to the degree of sthenic action indicated by the pulse. Yet cases will some- times occur in which this medicine cannot be endured, although indications of vascular ful- ness and of increased action are present. A gentleman of regular habits, and of a full and large make, had the consequences of chronic gout in his lower extremities, but had not ex- perienced a regular paroxysm for some years. My attendance was required on account of de- termination of blood to the head. The excre- tions were free, bilious, and natural. Desirous of removing the disorder by active alvine evac- uations, I conjoined small doses of colchicum with the purgatives ; but they occasioned a distressing sense of sinking at the epigastrium, and nausea. I soon afterward found that deple- tion could not be dispensed with; and nearly thirty ounces of blood were taken from the nape by cupping, without any tendency to syncope ; and he soon recovered. In all cases of doubt, this medicine should be prescribed in small do- ses, which may be increased ; but, as with di- gitalis, an accumulating effect may result, and it ought to be carefully watched. When, how- ever, increased vascular action exists, in the ir- regular forms of the disease, it may be cautious- ly used. 93. Dr. Barlow remarks “ that the complex conditions and alleged varieties of gout are ref- erable, not intrinsically to gout, but to the state of constitution in which it occurs.” This is all that is meant; for no modern pathologist intends to convey any other idea than that in- ternal affections supervening in that state of constitution which occasions gout are gener- ally more or less modified by this circumstance. It is to the improvement of this state of consti- tution that treatment should be directed ; and, after arriving at rational inferences as to its na- ture, the means ot cure will readily suggest themselves. Having seen that the constitution GOUT—Treatment of Irregular. 66 or diathesis, which has been called gouty, in order to prevent circumlocution, consists in de- bility associated with imperfect secretion and excretion, and, consequently, with fulness of blood, or with redundancy of excrementitious matters—the ultimate products of assimilation in the circulation—the treatment should obvi- ously be directed with reference to the predom- inance of either of these states. Although what has generally been called misplaced gout may thus be viewed as internal affections oc- curring in the gouty diathesis, and although they sometimes present little deviation from those appearing in other circumstances, yet a very remarkable difference is often observed, the symptoms being very different, and often peculiar, and the juvantia and laedentia being also different. The predominance of debility and spasm in many of these affections induced Sprengel, Cullen, and Schmidtmann to pre- scribe musk for them ; and the success of the treatment is a presumption of the justness of their views, at least in respect of the cases in which it was employed. In addition to other stimulants and antispasmodics successfully re- sorted to in similar circumstances, most of which have been noticed above, I may state that a solution of phosphorus in aether has been advised by Trampel and Hufeland ; aconitum and nux vomica, by Stoerck, myself, and others ; the spirits of turpentine, by Theodosius and Good ; and large doses of olive oil, by Brefald, Marino, and Malacarne. If turpentine, how- ever, be resorted to, castor or olive oil should be given with it, in a quantity sufficient to pro- duce a full operation on the bowels ; and the same combination ought to be administered as an enema, in order to promote this effect. Neither of these substances, however, nor cam- phor, ammonia, aether, opium, nor any of the other stimulants and antispasmodics previously mentioned, should be confided in alone, or un- aided by active and persevering external deri- vation. 94. iv. Of Mineral and Thermal Waters in Gout.—Mineral waters are beneficial, 1st, by preventing a return of the paroxysm; 2dly, in cases of atonic and misplaced gout, by giving tone to the digestive and assimilating functions, and thereby either removing the internal affec- tion, or enabling the system to develop the dis- ease in the extremities.—a. Respecting the Bath waters, Dr. Barlow makes several judicious ob- servations. In gouty cases, he remarks, espe- cially where the stomach is very weak, and re- quires some substitute for the wine and stimu- lants relinquished, the Bath waters give tone to the stomach, improve appetite, and renovate strength. They thus accomplish unequivocal good, not by the mere establishment of gout in the extremities, but by reducing it to its simpler and more manageable state, through the amend- ment effected in the general health. In gener- al, it may be inferred, from what has been written on Bath waters in gout by Falconer, Gibbes, Barlow, and Scudamore, that they are either injurious, or of little service, where pleth- • ora, disease of the liver, or determination to the head exists, and that these states should 1 be removed before they are resorted to ; but that they are of service in debilitated, nervous, and irritable habits ; and for those anomalous J or internal affections frequently attacking gouty . , i constitutions. When these affections occur in • weak and nervous persons, and are unconnect- [ ed with plethora, or active visceral disease, the internal and external uses of these waters i are beneficial, especially if due attention be paid to the excreting functions. When gout has debilitated the limbs, and weakened the constitution, so that the nervous system is de- pressed, and the circulation languid, a course of warm sea bathing, with frictions of the weakened limbs, and sea air, may be tried, or may precede the use of the waters of Bath or Buxton. Where swellings are seated in the vicinity of the joints, the Buxton baths, or pumping of the Buxton waters on the affected parts, are generally serviceable, especially if proper friction and shampooing be used imme- diately afterward.—b. Sir C. Scudamore ob- serves that the waters of Cheltenham prove high- ly beneficial to gouty persons, particularly when conjoined with alteratives and proper regimen. When the precursory symptoms are tedious, or assume the form of what is usually called mis- placed gout, their stimulating properties often excite a paroxysm, but it is generally slight. The water No. 4 seems most suitable to gouty patients, especially at the commencement of a course of these waters.—c. The waters of Leamington and Harrowgate are not much in- ferior to those of Cheltenham, when they act sufficiently on the bowels, or when their oper- ation is aide d by aperients. They seem, how- ever, in the circumstances just alluded to, to have considerable influence in exciting a fit of the disease. 95. d. The artificial mineral waters at Brigh- ton, especially the Seidschutz, the Marienbad, the Ems, and Carlsbad waters, may also be em- ployed in the more chronic or misplaced states of the disease. The waters of Wiesbaden are much used, both internally and externally, in a tonic or misplaced gout, as well as others of the Nassau springs ; but they are not superior to the mineral waters of our own country.—c. Piso, Zecchius, Baglivi, and Saunders con- sider the warm mineral waters recommended in gout as little superior to common pump-wa- ter heated to the same temperature. They ad- vise from half a pint to a pint of common wa- ter, of a temperature from 90° to 114°, to be taken, and succeeded by moderate exercise every morning, before breakfast. Dr. Saun- ders states that, in anomalous gout, it allays the irritation of the stomach, and diffuses a generous warmth in the extremities-; and that, if taken at night, it conduces to sleep. [While the Saratoga and Ballston mineral wa- ters have been recommended in cases of gout and rheumatism by some practitioners, others have not only doubted their efficacy, but even considered their use as highly dangerous. Among those who have entertained the latter opinion is Dr. William Meade, who has writ- ten a very excellent treatise on the chemical properties and medicinal qualities of these wa- ters.* “I cannot agree,” says Dr. M., “with the generality of writers who recommend such waters as Ballston and Saratoga in cases of the gout, under any form of it, but more partie- * [“An Experimental Inquiry into the Chemical Proper ties ami Medicinal Qualities of the Principal Mineral Wa ters of Batistan and Saratoga, in the Slate of New-York,’ payia, Hippocrates ; Hcemorrha- gia, Linnaeus, Sugar, Saavages; Hcemorrhagia Narinca, Hoffmann; Epistaxis, Vogel, &c.; Hcemorrhagia Narium, Sanguinis Slillatio, vel Stillicidium e' Narihus, Auct. var. ; Hemorrha- gic nasalc, Saigncment du Nez, Fr. ; Nasen- bliitfluss, Germ. ; Bleeding from the Nose. 65. Defin.— The effusion of blood externally from the pituitary membrane. 66. There is no part of the body more dis- posed to haemorrhage than the pituitary mem- brane, and none in which the recurrence of the discharge is productive of so little injury, as respects either this structure or the constitu- tion. It is necessary to a due consideration of the pathological and therapeutical relations of epistaxis, to recollect that this membrane is supplied by the external and internal branches of the common carotid arteries ; and that its blood is returned partly into the external jugu- lar veins, and partially, by anastomozing branch- es of veins, into the anterior veins and sinuses of the cranium. The blood effused from the pituitary membrane may be discharged either by the nostrils, or by th‘e mouth after having passed into the posterior fauces. This latter very generally occurs when the patient is in a supine posture ; it then not infrequently flows into the pharynx, and is swallowed. If the quantity of blood is great which thus passes into the stomach, irritation of this organ, and of the intestinal canal, sometimes followed by vomiting of the blood, by a pseudo-haemateme- sis, or by melaena, not infrequently supervenes. On the other hand, blood may be discharged through the nostrils without having been effu- sed by the pituitary membrane. This occurs when a sudden or profuse haemorrhage takes place from the pharynx, bronchi, or stomach; but it is not, and therefore should not be con- founded with epistaxis. 67. i. The Phenomena of Epistaxis are well known ; but the signs of its occurrence, and the true pathological states ushering it in, are not so generally recognised or justly estimated. A. The precursory symptoms vary much accord- ing to the grades of vital action, of local deter- mination, and of general or local vascular ful- ness, preceding and attending it; and upon these pathological conditions entirely depend the hypersthenic, sthenic, or asthenic, the en- tonic or atonic, the active or passive charac- ter of the haemorrhage. In proportion as it partakes of a hypersthenic or sthenic form, the more manifestly will it be ushered in by one or more of the following symptoms: by pain of the head or face ; by vertigo, stupor, or som- nolency ; by frightful dreams or restlessness; by redness or heat of one or both cheeks ; in- jection of the eyes or lachrymation ; by flashes ot light before the eyes, or affections of the sight; deafness, or noises in the ears ; in- creased strength of pulsation in the temporal or carotid arteries, and fulness of the veins; HAEMORRHAGE FROM THE NOSE—Causes. 89 and by a sense of fulness, tension, dryness, heat, or of titillation or itching of the nostrils. Not infrequently, especially in the more passive or asthenic states, the htemorrhage occurs without any premonition, or merely after a slight touch or local irritation. The character of the pulse varies with the degree of vascular action and of vital power; and, in proportion to the grades of both, it is full, strong, and re- bounding. According, also, as both action and power are weakened, the pulse becomes fre- quent, soft, compressible, open, small, and un- dulating. The older writers considered that a dicrotic or rebounding pulse indicated the oc- currence of this, or of some other haemorrhage; but no great dependance can be placed upon this symptom. 68. B The haemorrhage may take place from one or both nostrils ; but in the latter case it is greater from one than the other. The quan- tity of blood discharged may vary from a few drops to many pounds ; and, in the more obsti- nate passive states, the patient may be reduced to the utmost danger, or may be carried off in a few hours, or days, according to the contin- uance or violence of the discharge. In some cases, a fibrinous and more or less firm coagu- lum attaches itself to the part whence the hajmorrhage proceeds, and occasionally hangs out of the nostrils over the upper lip, or down into the posterior fauces. As long as this re- mains attached the discharge continues sup- pressed ; but when removed prematurely or otherwise, it returns, even with increased vio- lence and danger. The disease may be contin- ued, remittent, and recurrent, or intermittent. In this last case it may return irregularly or peri- odically. 69. C. The more active or simply sthenic epistaxis is often symptomatic or critical of sev- eral acute diseases, attended by increased ac- tion, especially the more inflammatory kinds of fever, and inflammations of the brain, or of the lungs, &c. The passive forms are frequent- ly symptomatic of several cachectic maladies, and of the last stages of malignant or low fevers. Many writers, even as recent as the Franks, suppose that, in cases of epistaxis consequent upon enlargements or obstructions of the liver, or of the spleen, the haemorrhage is generally upon the same side as the enlarged viscus. 70. ii. Causes.—A. Epistaxis occurs most frequently in children and young persons, es- pecially in its more idiopathic states. It affects most commonly the sanguine, irritable, the plethoric, and florid; and those possessed of great talents, of delicate or relaxed fibres, of weak constitutional powers, and of much sen- sibility. After ten or twelve years of age, it is oftener observed in the male than female sex. It is not infrequent in males about the change to the decline of life; and then, as well as at later periods, often prevents more serious haemorrhagic or inflammatory attacks. Epi- staxis is also often dependant upon peculiarity of constitution or diathesis, and is consequent- ly often hereditary, or observed in several of the descendants of the same parents, or mem- bers of the same family. At advanced ages, it is most common in those who live luxuriously and partake largely of wine or malt liquors. In the more mature periods of life, it is most frequently symptomatic, or dependant upon dis- ease of the heart, of the liver, spleen, or of some other viscus ; or consequent upon the disappearance of some sanguineous or other evacuation. 71. B. The exciting causes are extremely numerous and diversified, for whatever favours an increased flux of blood to the head, and to the pituitary membrane, or retards the return of this fluid from these parts; or occasions general plethora; or weakens the vital cohe- sion of this membrane, or the tone of the ves- sels ramified in it, may occasion haemorrhage from it, when the predisposition already exists. —a. The external causes are, injuries ; irritants or excitants inhaled into the nostrils; stimu- lating vapours or gases ; fractures of adjoining parts; exposure of the face to fires or furna- ces, or of the head to the sun’s rays, either uncovered, or with a black or metallic hat or cap.—b. The internal causes are, whatever in- creases the flow of blood to the head, as anger, shame, or other states of mental excitement or mental disorder; protracted study, and great exertions of the mind; stooping, or a low or depending position of the head ; frequent sneez- ing ; catarrh ; febrile, inflammatory, and ex- anthematous diseases; headaches, and rheu- matic affections of the face ; whatever retards the return of blood, as deep sighs, exertions of the voice, laughing, singing, crying, &c. ; playing on wind instruments ; severe cough, or difficulty of breathing ; sudden terror ; dis- ease of the heart or adjoining large vessels ; tumours pressing upon the jugular veins, or other causes of obstruction to the circulation in them, or in the subclavians ; congestion of the lungs ; neckcloths or collars worn too tightly round the neck, &c. ; whatever causes absolute or relative plethora, as too full living, the ingurgitation of large quantities of wine, or other exciting liquors ; the suppression of ac- customed evacuations, especially the catame- nial and hasmorrhoidal, &c. ; whatever inter- feres with the equal distribution of the blood, as wearing tight clothes or corsets, obstruc- tions in any of the large viscera, the gravid uterus, excessive distention of the stomach or bowels, or enlargement of the spleen, epileptic or convulsive seizures, cold applied to the ex- tremities, suppression or retention of the natu- ral discharges, and unnatural positions of the body; whatever weakens the tone of the ves- sels in the pituitary membrane and diminishes the crasis of the blood, as the advanced states of low fevers, scurvy, and other cachectic mal- adies, frequent returns of the complaint, &c.; whatever determines the blood to the super- ficial parts of the body, as diminished pressure of the air, high range of atmospheric heat, &c. The epidemic prevalence of epistaxis (which is of very rare occurrence) may be attributed to this last cause. (See Morgagni, Episi. xiv., ch. 25.) 72. c. The blood is chiefly exuded from the capillaries of the pituitary membrane, as in haemorrhages from other mucous surfaces; but the question frequently agitated, as to whether it proceeds from arterial or venous capillaries, can hardly be solved, nor does it deserve the trouble of inquiry. J. P. Frank observes that he has frequently seen a varicose state of the veins after cases of chronic epistaxis. The more important considerations as to the pa- 90 HAEMORRHAGE FROM THE NOSE—Treatment. thology of the disease are those which relate, 1st. To the states of vascular action, and vital tone attendant upon it; 2d. To the constitution and habit of body of the patient; 3d. To pre- vious attacks of haemorrhage, either from the nose or from other parts; 4th. To antecedent and associated disorders, or to tendenci.es to be affected by dangerous maladies, as apoplexy, palsy, haemoptysis, phthysis, &c.; 5th. To the causes, predisposing and exciting; 6th To the probable consequences of an immediate arrest, or of a continuance of the discharge ; and, 7th, To its critical influence. 73. iii. The Prognosis should have more or less reference to the circumstances just enu- merated. It is generally favourable when the disease occurs in children, or persons about the age of puberty, who are otherwise healthy; but, if epistaxis affect the cachectic, the stru- mous, those who have evinced a tendency to affections of the lungs, or of the glandular and lymphatic system, or those labouring under disease of the heart, lungs, or spleen, or who are aged, the prognosis ought to be more guarded, inasmuch as the haemorrhage may be difficult to restrain ; or, when arrested, it may return, or may be followed by still more se- rious results, as by haemoptysis, or by an ag- gravation of the associated malady, or by fatal syncope, upon using exertion or assuming a sitting posture. The more sthenic the epi- staxis, the less the risk from it, unless it be prematurely restrained. But when it is mani- festly asthenic and copious—if the means of cure fail, and if the blood is thin, dark, or does not coagulate—if the powers of life sink, and the skin and lips assume a pale or waxy hue, the prognosis should be unfavourable, in proportion to the prominence of these chan- ges. 74. In persons who have arrived at or passed middle age, the above circumstances (<) 72) and considerations should especially have due weight; and even the contingencies of the at- tack—whether suppressed, or allowed to con- tinue as far as the immediate safety of the pa- tient will warrant—ought to be fully estima- ted. Where disease of the heart, especially passive dilatation of one or more of its cavi- ties, or attenuation of its structure, or a dispo- sition to apoplexy or palsy, or engorgement of the liver or spleen exists, an Opinion of the im- mediate or ultimate consequences should be stated with caution. When slight epistaxis takes place in the plethoric, or in those addict- ed to indulgences at table, the circumstance ought to be viewed as indicating the danger of the habit, and the probable occurrence hereaf- ter of apoplexy or palsy, if a more spare diet and suitable regimen be not observed. In forming an opinion of the terminations of nasal haemorrhage, the remote consequences of the continuance or suppression of it upon related organs should be considered in connexion with the causes and the accompanying phenomena. When the epistaxis appears as a salutary evac- uation of an overloaded vascular system, when it has been caused by full living or intemper- ance, or preceded by headaches, noises in the ears, injected eyes, affections of any of the senses, &c., the prognosis ought to have ref- erence chiefly to the cerebral disease which it has averted ; and the indications which it has evinced should not be lost upon the practition- er, nor upon the patient. 75. iv. Treatment.—a. Upon visiting a pa- tient with epistaxis, the first glance will often enable the practitioner to decide whether or not he ought to arrest it without delay. When the countenance does not at first furnish suffi- cient grounds for immediate determination, in- quiries blight to be made as to the age, consti- tution, habits, and previous ailments of the pa- tient ; the causes which occasioned the at- tack ; the symptoms ushering it in, and attend- ing it; the quantity and appearance of the blood discharged, and the existing indications of internal disease, in order that a safe conclu- sion may be arrived at as to this and other parts of the treatment. When one or more ot the following circumstances appear at all prom- inent, if the patient be robust or plethoric ; if he have lived fully, and drunk wine or malt liquors freely or daily ; if he have experienced active disease in the head, or attacks of con- gestion, or determination of blood to this part; and if headache, redness of the eyes or face, increased heat of the scalp, throbbing of the vessels, or a beating noise in the ears have ushered in the attack, and more especially if they still attend it, the discharge should not be arrested until the vascular system is relieved; and when this is accomplished, the epistaxis will cease of itself. If it should seem to cease prematurely, and particularly if the above symptoms still continue, depletions, purga- tives, and an antiphlogistic regimen ought to be prescribed. 76. b. When it is desirable to arrest the dis- charge, the means of cure should be directed wdth the intention, 1st, of deriving the current of circulation from the seat of haemorrhage; and, 2d, of constringing the capillaries of the pituitary membrane. With these views, the patient ought to be placed in a cool and airy apartment, with the head elevated, or held up- right, and the feet plunged in wrarm water. The neck should be bared, and cold fluids as- persed over it and the face, or cold substances applied upon the nape, or upon the forehead. If these fail, evaporating or iced epithems may be placed over the whole of the head, or the cold affusion may be directed to this part, and an active cathartic exhibited. The most ap- propriate cathartics, in such cases, are calomel, with rhubarb or jalap, and the spirits of tur- pentine with castor oil; but a full dose of the latter may be given in two or three hours after the former has been taken. Emetics have been advised by Stole, but they ought not to be given early in active epistaxis. They are most serviceable when the attack has been in- duced by an overloaded stomach. 77. Bleeding is required chiefly in the cir- cumstances just alluded to (§ 75), and in the more sthenic forms of the disease; but it should not be neglected, in these circumstan- ces especially. It may be necessary to repeat it, even oftener than once, and after longer or shorter intervals. The older writers recom- mended bleeding from the feet, and many mod- ern Continental practitioners order leeches to be applied to the anus or to the vulva, when the epistaxis has arisen from the suppression of the haemorrhoidal or catamenial discharge. When it has become habitual, or periodic, and HAEMORRHAGE FROM THE NOSE—Treatment. 91 especially if it be vicarious of menstruation, the recurrence of the discharge may be antici- pated by the application of leeches to the tops of the thighs, near the groins ; by aloetic pur- gatives; by the semicupium or hip-bath, and by the exhibition of emmenagogues, especially biborate of soda, with the aloes and mirrh pill. In other circumstances, cubing over the nape or mastoid processes is preferable to other modes of vascular depletion. When the quan- tity of blood discharged is too great to admit of the loss of more, dry cupping in the former situation should not be overlooked. In the great majority of cases, however, the sitting posture, with the head held backward ; cold ap- plied to the face, or a piece of cold metal placed between the nape of the neck and the clothes, and cooling drinks, especially those with acids, nitre, &c., will be sufficient to arrest the dis- charge. 78. c. When active epistaxis has proceeded so far as to require to be arrested, and has still continued, notwithstanding the foregoing means, the treatment then called for is also ap- propriate to the passive or atonic states of the disease. In these circumstances, the chief re- liance must be placed upon astringents, applied to the pituitary membrane, and taken internal- ly with tonics ; upon pressure made locally ; and upon the insufflation of substances into the nostrils that may promote the coagula- of the effused blood. A solution of the acetate of lead, or of the sulphate or acetate of zinc, or of the sulphate of iron or of copper, or of the sulphate of alumina, or of the vegeta- ble or mineral acids, or of the pyroligneous acid with creasote, or of any of the numerous vegetable astringents (§ 40, 45), may be inject- ed into the nostrils; or lint, moistened with either of them, introduced ; but while astrin- gents are being used locally, the exhibition of them internally should not be neglected. The acetate of lead, with acetic acid, and small do- ses of opium, may be given internally ; or other astringents may be taken with tonics ; or small doses of spirits of turpentine resorted to, in the manner above recommended (<) 41). 79. Finely levigated astringent powders, es- pecially those of alum and of gall-nuts, may be blown through a quill into the nostrils ; or sub- stances of a glutinous nature may be employed in this manner, particularly powdered gums, as tragacanth or acacia; or astringents may be conjoined with these. Finely powdered char- coal may be employed in the same way. Pun- gent or irritating substances are often of less service than the pow'dered gums, which will, without exciting the Schneiderian membrane, favour the coagulation of the blood on its sur- face. Plugging the nostrils with lint moistened with some astringent solution is sometimes successful; but wffien the haemorrhage proceeds from the more posterior parts of the nares, it will fail, unless the lint be pushed so far back- ward as to reach nearly to the pharynx. Care, however, ought to be taken that it does not ir- ritate this part. J. P. Frank advises a piece of the intestine of a pig, closed at one end, to be introduced into the nostrils, and injected with a cold fluid. Some writers recommend thick mucilage, others a paste with charcoal or with astringents, and others the white of egg, to be conveyed into the posterior nares, in or- der to coagulate the effused blood. When a coagulum has formed, either spontaneously or by any of the foregoing means, it ought not to be disturbed for three or four days, or even longer, lest the haemorrhage return. 80. d. Besides the above measures, others have been advised. In order to derive from the seat of haemorrhage, Zacutus Lusitanus directs the cautery to the lower extremities ; Chrestien, warm pediluvia, with mustard flour put into the water; Borelli, bruised nettles •to the feet and hands; Niemann, blisters to the nape, and Cheza to the arms; Riedein, the exhibition of active cathartics; and Gaelics Aurelianus, cupping on the occiput, Galen on the hypochondrium, and Forestus on the ex- tremities. With the view of constringing the extreme vessels, cold drinks are prescribed by Hoffmann ; cold injections through the nos- trils, by Morand and Morgagni ; the immer- sion of the head in cold water by Darwin; cold clysters, by Leuthner and Andrieu ; and cold applications to the genitals, by Diemer- broeck, Theden, and Mercier. In addition to the local astringents already noticed, powdered agaric is recommended by Rochard ; writing ink, by Riedlin ; lemon juice, by Blankard ; and spider’s web, with vinegar, by Chesneau. The introduction of plugs moistened with spir- its of wine is directed by Morgagni and Rath, and with the expressed juice of the common nettle by ; and plugs consisting of dough, or chalk-paste, by Avicenna and Diem- erbroeck. The injection of a strong solution of isinglass is prescribed by Lentin ; and card- ed lint, drawn or pushed into the posterior nares, is employed by Audouin. 81. The internal use of the acetate of lead, with opium, is advised by Reynolds and La- tham ; of the phosphoric acid, by Herder ; of the aromatic sulphuric acid, by Hufeland ; and of the ergot of rye, by Spajrani, Cabini, Ryan, and Negri. The first of these may be employ- ed in either the active or passive states of the disease ; but the phosphoric acid is admissible only in the latter. In passive epistaxis, cam- phor, with opium ; the spirits of turpentine, in small and frequent doses, with aromatics and restoratives; the chlorates of potash or of lime; the sulphate of quinine with camphor, &c. ; as- afeetida with myrrh, and opiates in small quan- tity (Sydenham), are among the most energetic medicines that can be taken internally ; but ex- ternal means ought also to be resorted to. 82. e. If epistaxis be vicarious of menstrua- tion, the return of an attack should be pre- vented only by endeavouring to restore the cat- amenial discharge. If it be periodic, especially in persons who have suffered from agues, con- gestion or enlargement of the liver or spleen should be dreaded ; and if either be found to exist, deobstruent purgatives, followed by ton- ics, particularly quinine or the other prepara- tions of cinchona, or Fowler’s solution of arse- nic, ought to be prescribed ; but local deple- tions should be freely employed previously to these, whenever the liver is the seat of such disorder. When epistaxis occurs in aged per- sons, either the early suppression of the dis- charge, or its continuance, may be followed by serious results. It is generally connected with a disordered state of the circulation within the cranium in such cases. What has been stated 92 HAEMORRHAGE FROM THE NOSE—Treatment. above will indicate the circumstances in which it will be advisable to interfere ; but repeated blistering behind the ears, in some instances cupping in this situation, a seton in the nape, and other measures which the peculiarities of the case will suggest, with a suitable regimen, ought not to be neglected. 83. /. If the haemorrhage from the nares seems to be critical, the observations offered in the article Crisis are altogether applicable. When it appears in the last stage of low fevers, or in scurvy, or in purpura, and is merely the consequence of the lost tone of the extreme vessels, with diminished vital cohesion of the mucous surfaces, and a deteriorated state of the blood, the treatment directed for the pass- ive form of epistaxis, or for putro-adynamic fever, is quite appropriate, if the discharge be so considerable as to require measures to be adopted for it. 84. g. The after-treatment of epistaxis is often of great importance, especially in persons of middle or advanced age. An attack, whether slight or severe, in those who live fully, ought to be followed by an antiphlogistic regimen. Where the discharge has prematurely ceased, blood-letting should always be prescribed. In order to derive permanent advantage from this treatment, abstinence, regular exercise in the open air, and a due subjection of the mental emotions, ought to be constantly observed. How fatally this may be neglected is shown by the following case: A gentleman, aged about fifty, of a very full habit of body, accustomed to live richly, and to take his wine freely, but not in excess, became subject to severe head- aches. He afterward had an attack of eoi- staxis, which continued until the loss of blood was very great, although means were used to arrest it. He recovered, and remained well for many months ; yet his usual diet and regimen were persisted in. His headaches, as may have been expected, returned ; he became de- pressed in spirits, and disliked society ; but no appropriate treatment was prescribed, or, at most, aperients only were directed. The indi- cations furnished by the epistaxis were entire- ly lost upon the patient and his medical attend- ants ; abstinence was not adopted by the for- mer, nor precautionary blood-letting by the lat- ter. The consequences may be readily antici- pated. He shortly afterward was struck with apoplexy associated with hemiplegia, for which I was consulted just before his death. This is, however, not the only instance of the kind which has come belore me in practice. I could state the particulars of several cases in which the neglect of the indications afforded by epi- staxis has been followed by apoplexy, palsy, epilepsy, mania, and inflammation of the brain and its membranes. [The art of the physician will generally be more advantageously displayed in removing the condition of the system which occasions this affection than in checking the haemorrhage it- self. In a vast majority of cases, we look upon it as a salutary effort of nature, which should rather be encouraged than checked, and the recurrence of which may be obviated by pur- ging, low diet, revulsives, moderate exercise, and the avoidance of the exciting causes. The blood should certainly be allowed to flow where there is evidence of cerebral determination, or vascular fulness and force, and the effect may be aided by a general antiphlogistic regimen. But under opposite circumstances the interfe- rence of art will sometimes be required, and the resources pointed out by our author will be ample for perhaps any emergency that may arise. In these cases, where the pulse is fee- ble, the skin cdol and pallid, the general strength diminished, and the vital functions languid, we have ample reason to infer a diminution in the fibrinous element of the blood, and our meas- ures should be shaped to supply this deficiency, as already pointed out under article Haemor- rhage. But in the mean time the haemorrhage is immediately to be checked ; the patient is, perhaps, already nearly exhausted, and the blood looks thin and of a light colour, as if di- luted with water. We do not believe that any measures are to be depended on, under such cir- cumstances, but actual plugging of the nostrils, which should be done either by dipping dossils of lint in a strong solution of the sulphate of alu- mine, carrying them high up by means of a plug, or by using the dry sponge, which is, perhaps, the more effectual. It has been recommended, where the bleeding proceeds from vessels situ- ated very high up, to tie a piece of catgut to the sponge, carry it through the posterior nares by a probe, and out of the mouth, by which the sponge can be completely drawn up. But this will be found very difficult to execute, besides causing much discomfort to the patient. Mr. Abernethv states that he never failed in ar- resting the hasmorrhage by passing up a dossil of lint, wound round a probe, exactly fitted to the cavity of the nostril, and then withdrawing the probe and allowing the compress to remain for several days. Dr. Negrier, of Angers, has lately called attention to a very simple means of arresting epistaxis, which consists in closing with the opposite hand the nostril from which the blood flows, while the arm of the same side is raised perpendicularly above the head. This plan has proved successful in a great number of instances, and may be thus explained. When a person stands in the ordinary posture, with his arms hanging down, the force needed to propel the blood through his upper extremities is about half that which would be required if his arms were raised perpendicularly above his head. But since the force which sends the blood through the carotid arteries is the same as that which causes it to circulate through the brachial arteries, and there is nothing in the mere position of the arms above the head to stimulate the heart to increased action, it is ev- ident that a less vigorous circulation through the carotids must result from the increased force required to carry on the circulation through the upper extremities (Brit, and For. Med. Review, Oct., 1842, p. 550). For cases illustrating the benefits of this treatment, see Braithwaite’s Retrospect (Am. ed., No. 7, p. 88). Dr. Buckler has recommended what he terms /uemostasis as a remedy for ha3morrhage resulting from either rhexis, diapedesis, or from wounds inflicted on blood-vessels ;* also to relieve inflammatory engorgement and remove simple vascular congestion, and restore the balance of the circulation. This consists sim- ply in arresting the circulation in a portion of the body, as the arm or leg, by the application * [Maryland Med. and Surg. Jour., March, 1843, p. 265.] HJ2MORRHAGE—Bibliography and References. 93 of a ligature sufficiently tight to allow the blood to permeate the arteries, while the venous cir- culation is completely arrested. In this way a large amount of blood is withdrawn from the circulation, and is as effectually cut off from the brain and other vital organs as if it had been drawn in a basin. In this manner, Dr. B. contends that we can produce syncope, and ex- ert a more powerful control over the heart’s action than by the lancet, antimony, or digital- is, while we do not exhaust the vital forces, nor give rise to the ill consequences which the protracted use of most of the sedative agents is likely to do. The plan is at least worthy of trial in the different forms of haemorrhage, as well as in the other cases pointed out by the writer.—{Loc. cit.) Mercury, carried to the point of salivation, has been recommended by Latham, Southey, and others, as almost a specific remedy for obsti- nate haemorrhage; but it certainly ought not to be indiscriminately employed ; and in a cachec- tic or scrofulous state of the system would manifestly prove injurious. Where it proves useful, it doubtless does so by restoring the se- cretions, which are often deranged; and for the relief of which epistaxis occurs as a timely remedy. Where it is the result of metastasis, we are to endeavour to restore the original discharge, whether it be hemorrhoidal or cat- amenial, and to relieve the original affection, of whose derangement it is merely sympto- matic. The ancients appear to have had nearly as correct views with respect to the management of epistaxis as the moderns ; in proof of which we may refer to the works of Hippocrates, Celsus, and Galen. “ Since a trickling of blood from the nose,” says Paulus JEgineta, “ indicates a fulness in the whole body, or in the head, being occasioned either by expression or contraction, and as a free evacuation would relax them, and diminish the quantity, it may be proper to evacuate where nature points. With this view, I have ventured, in cases of quartan epistaxis, to open the vessels in the nos- trils with the reed called typha. We must not be contented with a small evacuation, but must take away blood in proportion to the strength. Spontaneous haemorrhages from the nose in fe- vers, when critical, are not to be interfered with ; but yet, if the flow of blood be immod- erate, it ought to be restrained. In the first place, tight ligatures ought to be applied to the patient’s extremities, and his head elevated. It would appear that a ligature to the privy parts is particularly adapted for restraining bleeding from the nose. The nostrils ought not to be wiped, nor the part irritated, so that a clot of blood may be allowed to form. Let the nose be cooled by a sponge soaked in oxy- crate, and the nostril plugged up with a pledget dipped in some of the astringent applications.” According to Hippocrates, profuse bleeding from the nose indicates a disposition to convul- sions, which venesection is calculated to re- move ; and Galen observes that convulsions are brought on by the unseasonable use of cold applications to stop the hemorrhage, and rec- ommends bleeding from the arm of the side from which the blood flow's. Avicenna rec- ommends ligatures to the extremities, and cold and styptic applications to the nose and adjoin- ing parts. Serapion agrees with most of the ancient authorities in commending a mixture of frankincense and aloes, applied on the down of a hare. He also directs to apply a sponge soaked in cold water to the temples and fore- head. When bleeding at the nose occurs in a fever, Rhases forbids us to stop it unless it prove excessive; in which case he directs us to apply a cupping instrument, without scarifi- cation, to the hypochondrium ; to tie ligatures about the testicles; to pour cold water on the head ; and to drink cold water (Adams’s Com. in Paul. HCgineta, p. 326).] Bibhog. and Refer.—Hippocrates, Hcpl SiaiTrjg o(tuv, v., Opp., p. 406.—Scribonius Largus, De Compos. Medicam., cap. 7.—Aretarus, Chronic., 1. i., cap. 2.—Galen, De Com- pos. Medic. Sec. Loc., 1. iii., c. 4.—Aetius, Tetr. ii., serm. 11., c. 94, 95.—CeeHus Aureh, p. 403Paulus jEgin , I. iii., c. 24.—Actuarius, 1. vi.—Avicenna, Canon, 1. iii., fen. 5, tract, i., cap. 7.—Rliodius, Cent, i., obs. 89, 90.—Horstius, Opp-, iii-, p. 41.—Forestus, 1. xiii., obs. 10, 13, 14.— Came- rarius, Memorab., cent, xv., n. 22. — Petermann, Observ. Med., dec. iii., n. 1.—llorellus, Cent, i., obs. 93.—Zacutus Lusitanus, Med. Pr. Hist., 1. i., bi.—Amatus Lusitanus, Cent, ii., cur. 100.—Bartholinus, Anatom. Renov., 1. ii., c. 6 ; et Hist. Anat. Rar., cent, iv., hist. 36.—Schenck, 1. i., obs. 188, 360, 368 ; 1. ii., obs. 78; Ephem. Nat. Cur., dec. 1., ann. iii., obs. 243 (Continuing for six weeks).—Riverius, Observ. Communic., p. 658, cent. i.—Freitag, Observat., n. 23, 25.—Diemerbroeck, Observ. et Curat. C., n. 62.—Fabri- cius Hildamis, Cent, ii., obs. 18.—Augenius Horatius, t. ii., 1. ii., p. 95.—Benedictus, De Re Medica, 1. iv„ cap. iv.— Hagendorn, Cent, i., obs. 60.—T. Brugis, Vade Mecum, with a Treatise on Bleeding at the Nose, 12mo. London, 1670.—Sydenham, Opusc., p. 86.—Pravotius, Med. Pauper., p. 239.—7. G. Sartorius, Admiranda Nariurn Htemorrhugia, Sec., 4to. Aldt., 1680.—G. Braschius, Disput. Med. dun; de Htemorrhagia Nariurn, 4to. Kilon., 1680.—Heister, Wahr- nehmungen, i., n. 167, 207.—Chesneau, 1. iii., cap. 13, obs. 5.—Paullini, Cent, ii., obs. 51, 77, 96.—Mercurialis, tom. iv., cons. 35.—Hagendorn, Cent, i., hist. 20.—Reidlin, Lin. Med. Anti., vi., Febr., obs. 16.—Hoffmann, Do Delirio Mel- ancholico Curat., t) 5, v., Opp., ii., p. 258 ; De Haem. Nari um, Ob. 1,2, 3, &c„ Opp., t. ii., p. 200.—Alberti, Diss veram Pathologiam Htemorrhagiarum Nariurn sistens. Hal., 1704.—Ruland, Cur. Emp., cent, i., c. 58; cent, ii., cur. 27 ; cent, iii., cur. 38 ; cent, v., cur. 14 ; cent, x , cur. 57. —Blankard, Collect. Med. Phys., cent. v„ n. 68 ; cent, vi., n. 74 ; cent., n. 27.—J. F. Flato, De Nariurn Fabrics!, Usu. et Morbis, 4to. Lugd. Bat., 1721.—Buchner, Miscell., 1728, p. 930.—Morgagni, De Sed. et Caus. Morb., ep. xiv., art. 25.—Morand, Vermischte Schriften, b. ii.—Boehmer, Diss. de Sanguinis Profluvio e Naribus, Max. eo, quod in Sen. observ. Hal., 1774.—Piderit, Practische Annalen, 1 st., p. 40.—Polisius, Myrrhologia, p. 176.—Muralt, Chirurgische Gesehichteu, n. 158.—Helwig, Obs. 26.—Bloch, Medic. Be- merk., p. 71.—Sugar, Systema, i., p. 444.—Stoll, Prael.. ii„ p. 94.—Gooch, Cases, p. 59. —E. Onofrius, De Nariurn Ila-.morrhagiil Comment.. 1779.—Hamilton, Med. Comment Edin., vol. i., p. 245.—Lindt, Diss. de Alummis Virtute Medica. Goett., 1714.—Sebald, Annalen znr Geschichte der Klinik., p. 103 (Twenty pounds within twelve days).— H. R. Reynolds, On the Use of the Preparations of Lead in some Haemorrhages. Trans. Coll, of Phys. London, vol. 111., p. 217, 1785.—Bucholz, v. Tode, Bibl., b. i., p. 84.— Christini, Prattica Medic. Osservaz., 82.—Rochard, Journal de M6decine, t. iii., p. 43.—Chrestien, in Ibid., t. xvi., p. 429.—Caestryk, tn Ibid., t. xxii., p. 49.—Sumcire, in Ibid., t. hii., p. 413.—Laborie, in Ibid., t. lvi., p. 513.—Audoin de Chaignebrun, in Ibid., t. lxvi., p. 438.— Balmes, in Ibid., May, 1787 (Those accustomed to the use of tobacco never ex- perience critical haemorrhages).—Mercicr, Scdillot's Jour- nal, Sec.., t. xxxv., p. 253.-7. P. Frank, De Curand. Horn. Morb., t. vi., p. 124.—Lentin, Observ Med., fas. ii., obs. 12; et Beytrage, b. iv., p. 171.—Sachse, in Lentin, Bey- tvagen, b. iv., p. 171.—Darwin, Zoonomia, Sec.. vol. ii.— Thomann, Annalen ad 1800, p. \W.—Rath, Horn's Archiv., b. i., p. 162.—Doemling, in Ibid., b. iii., p. 50.—Hufeland, Bemerkungen iiber Blattern, &c., p. 108.—Herder, Hufe- land's Journ. der Practischen Heilkunde, b. ix., 3 st., p. 175.—P. Vignes, Diss. sur les Epistaxis Spontandes, &c., 4to. Par., 1808.—Spangenbcrg, Horn's Archiv , May. 1809, p. 35.—A. Fournee, Diss. de 1’Epistaxis ou Ilhmorrhagio Nasale, 4to. Par., 1811.—Cheza, Bulletin de la Faculto de Paris, 1812, p. 155. — Esquirol, Dirt, des Sc. M6d., t. xii. Par.. 1815.—7. Frank, Piax. Mcdicinae Universte, t. v., pars it., p. 442 8vo. Taurin., 1822.—H. Cloquet, Osphrd- siologie, ou Traitd des Odeurs, Sec., avoc 1’Histoire des Maladies du Nez et des Fossds Nasales, 8vo. Par., 1821. —Rochoux, Diet, de Med , t. viii. Pur., 1823 — W. Howi- son, On Epistaxis, 8vo. Edin., 1826.—Blandin, Diet, do 94 ILEMOltilllAGE FROM THE MOUTH AND THROAT. M6d. Pract., t. vii. Par., 1831.—Kerr, Cyc. of Pract. Med., vol. ii., 8vo. Lond., 1833. [Am. Bibliog. and Refer. —(See Bib. of “ Hemor- rhage.”)] IV. HAEMORRHAGE FROM THE MOUTH ANI) THROAT. —Synt. Hcemorrhagia Oris, H. Faucium, Sto- matorrhagia, J. P. Frank; SanguinisProfluvium ex Ore, Hcemorrhoidcs Oris, Vogel; Hcemor- rhagie buccale, Fr. ; Mundblutjluss, Germ. 85. A discharge of blood from one or more of the parts forming the mouth and throat. 86. Haemorrhage may take place to a great or even fatal amount from the gums, the tongue, the fauces, or the pharynx, and even from the insides of the cheeks and lips. Blood is rare- ly, however, discharged from one or more of these parts unless in the advanced stages of cachectic diseases, or of malignant or low fe- vers.—a. IIiverius mentions a case in which four or five pounds of blood were discharged from the lips every month. Haemorrhage from this part has been observed also by Zacutus Lusitanus. J. P. Frank met with a case in which it proceeded from varicose veins of the upper lip. I lately saw an instance of varicose veins of this part, but there was no haemorrhage. Bleeding from the interior surface of the cheeks is generally owing to injury from the teeth or to tumours. 87. b. Discharges of blood to a small amount from the gums are very common, especially in the advanced stages of the diseases just ad- verted to, and more abundantly after suppres- sion of accustomed discharges, as the catame- nial or haemorrhoidal. Vicarious menstruation may even take place from this situation. Se- vere or dangerous haemorrhages from the al- veolar processes have been most frequently caused by the extraction of teeth. Frank has seen several pounds of blood lost from a vari- cose state of the veins of, and in the vicinity of the gums ; and similar discharges have more frequently taken place from tumours in this sit- uation, and from the excessive use of mercury. Vogel met with an instance in which the dis- charge was produced by a combination of mer- cury and belladonna. Hirsch, Frank, and oth- ers have met with periodic haemorrhage from this part vicarious of menstruation. Fatal ef- fusions from the gums have been seen by Hor- stius, Fabricius, Hildanus, and several more recent writers. The occurrence of haemorrhage in this situation in purpura haemorrhagica, scur- vy, and the diseases adverted to above (<$ 86), is too well known to require farther notice. 88. c. Haemorrhage from the tongue very rare- ly takes place to any very considerable amount, unless in cases of injury of the raninal veins or arteries, as in dividing the frcenum linguae, when it may prove fatal. Slighter injuries from the teeth, especially during epileptic fits, sel- dom cause more than small discharges of blood. But the more serious diseases to which the tongue is liable (see art. Tongue) may be fol- lowed by dangerous or even fatal hamrorrhage. Such instances are recorded by Plater and others. Mari saw 24 lbs. of blood discharged from this part; and J. P. Frank met with a case of glossitis, which, upon passing into gan- grene, terminated fatally with profuse haemor- rhage. 89. d. Haemorrhage from the palate and fau- ces to a very considerable amount has been ob- served by Bundl, Vogel, Frank, and Kluige. J. P. Frank believes it generally to proceed from a varicose state of the veins in this sit- uation, and hence the appellation Hcemorrhoides Oris, applied to it by Vogel and Bundl. He mentions an instance in a young man who, for many years, suffered repeated attacks of haem- orrhage from the state of the veins of the pal- ate, and who was permanently cured, after a profuse discharge, by a strong solution of alum. Portal met with a case where the haemorrhage took place from the uvula. A more or less co- pious effusion of blood may also proceed from the velum palati or tonsils, especially in the course of cachectic diseases, or as a conse- quence of a varicose state of the veins of the part, or of those in the vicinity. 90. e. Effusions of blood from the surface of the pharynx occur more frequently than is com- monly supposed, and are overlooked in conse- quence of the fluid having passed into the stom- ach. When the haemorrhage from this situa- tion is very considerable, the quantity of blood which is swallowed is often so large as to cause vomiting, and to lead to the supposition that the stomach is the seat of the disease. The small veins in the pharynx are not infrequent- ly varicose or obstructed, and when this'is the case, haemorrhage sometimes takes place from comparatively slight causes. The most dan- gerous discharges from this part occur in the ad- vanced stage of putro-adynamic fevers, and of eynanche maligna, in which the pharynx is more or less affected. J. P. Frank has noticed the occasional supervention of pharyngeal haem- orrhage independently of those diseases ; but the subject has been overlooked by other wri- ters. Some years ago I attended a lady, about 70 years of age, residing at St. John’s Wood, who complained of dyspeptic disorder compli- cated with psoriasis and sore throat. The veins of the pharynx were reticulated and var- icose. I was afterward called to her suddenly on account of a very severe haemorrhage, attend- ed by vomiting and cough. Much of the blood evidently was brought up from the stomach, but a great part passed directly from the throat. The cough arose from the irritation caused by the fluid on the epiglottis and pharynx. The effusion was arrested for a time by powerful astringents. Two days afterward, the haemor- rhage returned more violently than before, and terminated life before I reached her. On ex- amination after death, the pharynx was found softened, black, and studded with soft aphthous ulcerations, between which dark blood was in- liltrated. The veins of this part wrere numer- ous and dilated. The stomach contained a considerable quantity of blood. The upper part of the (Esophagus was softened and congested in its internal surface. In this case the blood had passed into the stomach, the position in bed having favoured this occurrence, and had irritated this organ so as to produce vomiting. 91. i. The Symptoms and Diagnosis of haetn- orrhage from the mouth or throat are not al- ways as distinct as may be supposed, particu- larly as respects the source of the discharge. The symptoms preceding the effusion are very uncertain, and are those most commonly indi- cating congestion of the head or adjoining parts, or disease in one or other of the above situa- tions. Headache, vertigo, noises in the ears ; Haemorrhage from the respiratory organs. 95 soreness, irritation, titillation, tension, or a sense of fulness or heat in the throat; a bloat- ed appearance of the countenance, and throb- bings of the vessels in the vicinity sometimes usher in the haemorrhage. If the patient be in bed when attacked, the irritation of the fluid on the glottis causes cough, and the passage of it into the stomach is followed by vomiting, when the quantity is considerable or the stomach ir- ritable. If haemorrhage take place from the pharynx while the patient is asleep, the blood will flow into the stomach; and the first inti- mation of the occurrence will often be the vom- iting of blood. Hence the utmost care is re- quired to distinguish this species of attack from hemoptysis on the one hand, and from herna- temesis on the other, as it may closely simulate either. In order to do this, the mouth ought to be well washed by a slightly astringent and colourless fluid, or the throat gargled, and af- terward carefully examined. If the haemor- rhage be too copious to admit of inspection of the mouth and throat, the patient should lean forward so as to allow' the blood a free passage from the mouth ; and if it flow without cough- ing or retching, and is neither frothy or very florid, nor very dark or grumous, there can be no doubt as to the situation whence it proceeds. If the patient feel it collect in the throat, and .•reate a disposition to deglutition, or if he re- quire no effort to bring or hawk it up, it mani- festly proceeds from the fauces or pharynx. In many instances, causing the patient to drink some fluid instantly before examining the throat will assist the diagnosis; and in others, the history of the case will be sufficient to settle the question. When the fauces or pharynx is the seat of the discharge, deglutition of food or drink, or the use of a gargle, either before or during the haemorrhage, will cause more or less pain. (See Diagnosis of Haemoptysis and Haematemesis.) 92. ii. The Causes of stomatorrhagia are those of haimorrhages generally, but more es- pecially previous diseases of a cachectic or ma- lignant character; affections of the gums and teeth ; repeated attacks of sore throat, partic- ularly when connected with chronic disorder of the stomach and other digestive organs ; the use of mercury; injury or previous lesion of the vessels, especially the veins; and ob- structed discharges, as the catamenial or haem- orrhoidal, of either of which the haemorrhage from the mouth may be vicarious. The acro- narcotic poisons may even cause it. In a case of poisoning by aconitum, which I saw some years ago, remarkable swelling of the tongue and fauces took place, followed by moderate haemorrhage from these parts. 93. iii. The Prognosis entirely depends upon the circumstances in which stomatorrhagia oc- curs, upon the previous state of disease, and upon the quantity of blood lost, and the effect thereby produced upon the constitution. The general principles above stated will also guide the practitioner. 94. iv. The Treatment of haemorrhage from the mouth or throat requires to be materially modified, according to the parts from which the blood is effused, and the causes producing the effusion. Cases rarely occur in which it is either necessary or proper to have recourse to blood-letting. Purgatives, however, especially those of a stomachic or tonic kind, are often beneficial, more particularly when the disease is connected with disorder of the digestive or- gans, and with accumulations of morbid mat- ters in the prima via. The chief dependance is to be placed in the local and internal use of the more energetic astringents noticed above, as the sulphates, the acetate acid with creasote, the acetate of lead or o( zinc, spirits of turpen- tine, the chloride of lime, &c. These may be used in gargles, in more or less concentrated solutions, and in various states pf combination, as with gums or mucilages. If the haemor- rhage take place from a single vessel, or from a limited extent of surface, the actual or poten- tial cautery is quite appropriate. If it proceed from the alveolar process, powerful styptics, and various mechanical measures, may be re- sorted to. 95. When haimorrhage from the mouth de- pends upon general cachexia, or supervenes in the latter stages of putro-adynamic fever, or of purpura or scurvy, the above means should be aided by the internal use of tonics, conjoin- ed with vegetable or other astringents and an- tiseptics, as the chlorides, the chlorate of pot- ash, the nitrate of potash, or the hydrochlorate of ammonia, &c., and by an appropriate regi- men. If the effusion seems to proceed from the pharynx, the position of the patient should be such as will favour the flow of the blood from the mouth, and prevent it from irritating, or escaping into the larynx. Biblioo. and Refer.—Celsus, 1. iv., c. 4.—Avicenna, Canon., 1. iii., fen. 8, tract, i., ch. 3.—Plater, Observ., 1. iii., p. 773.—RoIJink, Diss. de Variolis. Jen., 1658.—Boolius, De Affect. Omissis, cap. 7.—Horslius, Opp . ii., p. 279.— Riverius, Observat. Coramun.,p. 660.—M. Cagnati, Obser- vat., ]. iv. ; Bphem. Nat Cur., cent, vii., obs. 73.—Zacutus Lusitanus, Med. Pr., 1. ii., hist. 10 ; Prax. Admir , 1. i., obs. 84, 85, 90, 91", 92.—Fabricius Hihlanus, Cent, vi., obs. 77. —Meckrew, Observ. Med. Chir., c. 17.—Bundl, in Diss. Obs Morb. Rar. (Hiemorrhoides oris).— Bartholinus, Hist. Anat., cent, i., n. 19.—Schurig, Ilaeniatologia, p. 254, 256. — Solennander, Consih, sect. v.. n. 15.—Fischer, Diss. de Hiemorrhoidibus Exhalato profluentibus. Erf., 1723. — Buchner, Miseell., 1730, p. 1139.— Vogel, Diss. de Rariori- bus qmbusdam Morbis. Goett., 1762, p. 23 ; Eicken Samm- lung, b. i , p. 64.— Jourdain, Des Maladies de la Bonche, t. 11., p. 605.— Ranoe, in Act. Reg. Soe. Med. llav., vol. iii., p. 362.—Hirsch. Loder's Journ. fiir die Chirurgie. b. i., p. 356.— Mari, in Nouva Giornale della piu Recente Litt. Med. Chir., t. iii., p. 198.— Wichnann, Ideen zur Diagnostik, b. 1., p. 89,93.—Thiel, in Loder's Journ. fiir die Chirurgie, b. 11., p. 384.—J. P. Frank, De Curand. Ilom. Morbis. 1. v., pars ii., t. vi.. b 505.—Portal, Cours d’Anatomie Med., t. iv., p. 507.—Kluige, in Hufelani's Journ. der Pr. Arzneyk, b. v., p. 180. V. Haemorrhage from the Respiratory Or- gans.—Syn. Haemoptysis (from alga, blood, and nrvu, I spit, or nrvmq, a spitting); al- pomvGic; 1 alyoTTTviKoc, Galen, Dioscorides ; Sanguinis Sputum, Celsus; Emoptoc, Gor- don ; Sputum Cruentum, Cruenta Expuitio, Sanguinis Fluor, Vomilus Pulmonis, Auct. Lat.; JEmoploica Passio, Gilbert; Passio hamoptoica, Plater ; Hamoptoe, Boerhaave, Vogel, Darwin ; Hamotismus, Auct. var.; Haemoptysis, Sauvages, Vogel, Cullen, &c. ; Hamorrhagia Pulmonum, Ham. bronchica, Hamorrhaa. pulmonalis, Auct. var.; Pneumon- orrhagia, J. P. et J. Frank ; Blutspeyen, Blut- hustcn, Lungenblulfluss, Germ. ; Crachement dc Sang, Expectoration de Sang, Fr. ; Emolisi, Emotisea, Sputo di Sa.ngue, Ital. ; Blodspyting, Dan. ; Pulmonary Haemorrhage, Spitting of Blood, Coughing of Blood. 96. Defin.—After a sense of heat, oppression, 96 HEMORRHAGE FROM THE RESPIRATORY ORGANS. or pain in the chest, and titillation in the throat, the rejection of florid, frothy, or pure blood from the bronchi or lungs, with a hawking or short cough. 97. Haemoptysis is one of the most frequent varieties of haemorrhage, owing to (a) the very extensive bronchial and vesicular surface to which the blood is circulated for the purpose of undergoing the requisite changes during res- piration ; (b) to the delicate conformation of the capillaries and mucous membrane of this part; (c) to the liability of the lungs to conges- tions, from impaired organic nervous power, from obstructions of the pulmonary veins and of the circulation through the left side of the heart, and from tubercular or other lesions of the substance of the lungs ; (d) and to the lia- bility of this organ to derangements of its cir- culation from hypertrophy and other lesions of the heart, and from alterations of the large vessels. Of all these morbid causes and con- nexions, tubercular formations in the lungs are the most common, either as a cause of the hemoptysis, or as associated lesions conse- quent upon the same antecedent changes in the states of vital power and vascular action, or as both. 98. i. Symptoms, &c. — A. The premonitory signs of hemoptysis are, horripilations, passing redness and heat of the face, or flushings of the cheeks, headache, coldness of the extremi- ties, with a collapsed or empty state of the veins of the surface; lassitude, and sense of weight of the limbs; occasionally cramps or spasms of the lower extremities ; a feeling of internal warmth, particularly in the chest; pain or tension at the epigastrium or hypo- chondria ; a burning sensation under the ster- num, with more or less anxiety, inquietude, constriction, or oppression at the chest, or dyspnoea; a short, dry cough ; dyspnoea, or shortness of breath on slight exertion ; a dull pain or soreness under the sternum, between the shoulders, or beneath the clavicles ; palpi- tations ; a quiek, hurried, or excited pulse, which is sometimes also hard, full, bounding, or oppressed, &c.; flatulence, or borborygmi, costiveness, and pale urine. A few only of these symptoms, or several variously modified, may be present in individual cases ; they may exist for a longer or shorter time before the attack. In some instances, neither cough, nor difficulty of breathing, nor any symptom refer- able to the chest, has been complained of; or it has existed in so slight a degree as to es- cape the observation of the friends of the pa- tient ; and yet the most extensive changes had taken place in the lungs, and caused the haemorrhage. A case of this kind was attended by Mr. Bushell, Dr. Clark, and myself while this article passed through the press. Such \ instances, however, are not uncommon, as j shown by Rhodius, Muller, Wedel, Gram- I berg, the Franks, Louis, Clark, and others. 99. B. Progress.—As the blood rises to the | larynx, a sense of titillation is felt in the tra- j chea, or of irritation in the throat, with dysp- noea ; and a gurgling or bubbling sensation in the chest or trachea; and the blood is either hawked or coughed up, exciting a sweetish- salt taste. As soon as this occurs, much alarm is sometimes caused, particularly in delicate or ! nervous persons; and several of the general symptoms, particularly those connected with the action of the heart and pulse, are owing chiefly to this circumstance. When the blood is in considerable quantity, the discharge of it is attended with a feeling of suffocation ; the chest is forcibly dilated, a convulsive reaction or cough follows, and this fluid is ejected from both the mouth and nostrils. In some instances the irritation at the top of the pharynx and in the fauces excites retchings ; and in others the blood, as it collects in the pharynx, is in- stinctively swallowed ; and, when it has accu- mulated in the stomach, causes vomiting, and gives rise to a suspicion, from this circum- stance and from the presence of portions of ingesta, &c., as shown hereafter (§ 118), that the hannorrhage is seated in the stomach. Oc- casionally the blood is brought up without any effort whatever, beyond a strong expiration, which it accompanies in a full stream ; and when retching or full vomiting is occasioned in the manner just stated, another, and often a greater discharge of blood from the lungs at- tends it. 100. The quantity thus discharged varies from a few drops to many pounds. Rhodius (Obs., cent, ii., 31) saw 23 lbs. lost in three hours; Pezold (Obs. Med. Chir., No. 49) and Zacchiroli (Weigel’s Ital. Bibliolh., b. iii., p. 154) observed larger quantities during a much longer period. J. Frank (Prax. Med., &c., ii., 2, 1, p. 417) had a patient who lost 192 ounces in twenty-four hours ; and a friend of my own experienced nearly as great a discharge in the same time, and afterward recovered. [Dr. Chapman states that he once saw two quarts come away in twenty or thirty minutes.* We have seen a still larger quantity, in one instance, discharged in the course of an hour. Laennec says that he has known 30 pounds lost in about 15 days, and, in a very extraordinary case, 10 pounds in 48 minutes. J. Frank speaks of a case in which 25 pounds of blood were voided in three hours.] When the blood is not con- siderable as to quantity, it is frothy, or contains bubbles of air, and is of a florid hue ; when it is very abundant, it is fluid, generally more or less florid, but not frothy; it is seldom mixed with muco-puriform matter, unless it be small in quantity, and it then is often semi coagula- ted, and of a darker or brownish tint; but to- wards the termination of an attack this appear- ance is very common. If the haemorrhage is very great, extreme faintness, or even full syn- cope, may come on; but a sense of depression, or sinking, with a quick, sihilous, and short res- piration ; a small, weak, interrupted voice and speech; and coldness of the extremities, are more commonly complained of. Occasionally, the least exertion of the voice, or of the body, or a fit of coughing, increases or brings back the discharge ; but as often it returns without any such cause. 101. In some instances the attack is follow- ed by great frequency of the pulse, and gener- ally excited vascular action, with heat of skin, thirst, &c., although the pulse had been per- fectly natural before or at the time of seizure. In these the congestion of the substance of the lungs connected with the production of the haemoptysis has passed into inflammatory ac- * Lectures on the more important Eruptive Fevers, Hemorrhages, &c., p. 173. Phil., 1814. HAEMORRHAGE FROM THE RESPIRATORY ORGANS. 97 tion, in one or several parts of the organ ; or, rather, the infiltration of a portion of the effused blood through the smaller bronchi has excited , inflammation of them, as demonstrated by the j stethoscope and by dissection. In many cases, especially when the haemorrhage occurs in weak or lax frames, and scrofulous or tubercular states of the lungs, not only the external dis- charge of the blood, but also its passage along j the bronchi into the more depending parts of the organ, and even its infiltration into the sub- stance of the lungs, or its effusion in the dis- tinct form of pulmonary apoplexy, takes place, as I have several times recognised during life, and ascertained afterward by dissection. 102. An attack of haemoptysis may be so se- vere and sudden as to suffocate the patient be- fore a large quantity of blood is lost; or so continued as to destroy life by the loss of this fluid. Only one violent seizure may occur, the patient recovering perfectly, without suf- fering materially, after the immediate effects have passed off; but this is seldom the case, more or less disease of the lungs, although un- apparent to the friends previous to the attack, following rapidly afterward. In some cases, particularly when tubercles have proceeded to softening, &c., without exciting much disorder, the haemorrhagic congestion, infiltration, and atonic inflammation of the substance of the lungs, attendant and consequent upon the seiz- ure, soon destroy life. In several instances to which I have been called, the patients had pursued their usual avocations, unconscious of ailment, been attacked by haemoptysis, and died in three or four weeks afterward in conse- quence of these associated lesions of the lungs. In the case above alluded to (§ 98) death took place 26 days after the attack. More frequently the haemoptysis is followed by pulmonary con- sumption in a much less rapid form. When the blood is ejected in small quantity, or of a brown colour, or is mixed with a rose-coloured lymph, or mucus, latent inflammation or active congestion most likely will be found to exist in the substance of the lungs ; and this inference ought not be doubted, if febrile symptoms, with cough, be present, or if the blood taken from the arm be buffed. In a few instances, the lymph effused from the vessels towards the close of the attack is moulded into the form of several bronchi, and is expectorated in this state ; in others, cretaceous or other earthy concretions, consequent on the degeneration, or the partial absorption of tubercles, or even ossific matters, are brought up with the blood, or soon afterward ; but most frequently, and especially when the haemorrhage is scanty, or towards its close, or after more than one at- tack, muco-puriform matter, with or without minute portions of softened tubercular sub- stance, may be detected ; and these become more manifest as the blood disappears. 103. Hsemoptysis may recur at irregular, or even at distant periods ; the patient experien- cing but little ailment in the intervals, or pre- senting merely a marked susceptibility to con- gestion or inflammatory affections of the lungs. When supplemental of suppressed or retained catamenia, or of the disappearance of haemor- rhoids or epistaxis, it sometimes returns peri- odically. In such cases, the evacuation de- pends more upon vascular plethora than upon serious lesion of the substance of the lungs, although this may also exist. Some instances of a constitutional recurrence of haemoptysis I (§ 49) have been observed, and yet a far ad- i vanced age has been reached. [Dr. Chapman mentions the case of a lady who, for eleven successive days, had haemop- : tysis at precisely nine o’clock in the morning, | always preceded by a slight chill. — (Loc. cit., \ p. 173.) Many similar cases are on record.] 104. C. The appearances after death comprise | almost every lesion to which the lungs, heart, and large vessels are liable, but. some of them are more immediately connected with haimop- | tysis than others. Tubercles are the most j common of all these, in one stage or other of their progress, and frequently they are found in every stage even in the same case — either disseminated through the lungs or clustered, in | a crude, softened, and ulcerated state, in con- nexion with small or large excavations — in , some instances the seats of the softened and partially absorbed tubercular matter containing earthy or cretaceous concretions ; and, in rarer cases, the parenchyma of the lungs around them presenting a cicatrized or puckered ap- pearance. When haemoptysis has been very recent, the lungs are frequently more or less ! congested, and their substance infiltrated with dark blood, both throughout many of the minute bronchi and cells, and in the connecting cellu- lar or parenchymatous tissue, large portions of the organ exhibiting a spleen-like appear- ance. In some cases, portions of the lungs are more or less obviously inflamed; the in- flammatory appearances having been either antecedent to, or consequent upon the haemor- rhage, most frequently the latter. In rarer in- stances, blood is effused in the substance of the organ, forming a distinct cavity filled with coagulated blood. 105. Adhesions between the pulmonary and costal or diaphragmatic pleura, both old and re- cent, frequently exist. The bronchial mem- brane is generally injected, congested, and of a deep or dark red, or purplish, or nearly black, either throughout a large extent, or in parts or patches ; but the state and colour of this sur- face vary with the period at which haemoptysis took place, and the mode in which the disease of the lungs terminated the life of the patient. (See art. Bronchi, § 3-14.) In rarer cases, gangrene of portions of the lungs, or erosion or ulceration of one or more vessels connected with softened tubercles or cavities, is observed. These cavities are generally lined with a more or less thick secreting membrane. In a few instances, osseous deposite has been found in the membrane of the cyst. (See art. Lungs.) 106. Alterations of the large vessels in the chest, and of the heart itself, are occasionally found, especially in the cases of aged persons. The pulmonary veins have been seen diseased, inflamed, or partially obstructed by humours, or morbid depositions, either externally or in- ternally. I found them inflamed, and a large branch partially obstructed by lymph, in one case. A dilated or varicose state of the pul- monary veins has been noticed in connexion with haemoptysis, by Morgagni, Gillibert,. Portal, and J. Frank. Lesions of the pul- monary artery have also been met with, espe- ! daily rupture (Matani, De Aneurism, Pracordior. 98 HEMORRHAGE FROM THE RESPIRATORY ORGANS. Morbis, p. 120) and aneurismal dilatation (J. Frank, &c.). Mr. Semple has detailed a case wtych he considered haematemesis, but which was probably haemoptysis attended with vomit- ing, owing to the circumstances above pointed out (§ 90), wherein the left pulmonary artery was obliterated, and the lung was extensively diseased. Aneurisms of some part of the aorta opening into the trachea, bronchi, or lungs, have been oftener observed than these. Cruick- shanks found the lymphatics of the lungs tur- gid with blood, absorbed from the air cells, in patients who had died of haemoptysis. 107. Diseases of the heart, particularly such as occasion obstructed circulation through the left cavities, as narrowing of the auriculo-ven- tricular opening, lesions of the valves, &c., are not infrequently found in connexion with hae- moptysis (Wilson,Watson, &c.). Hypertrophy of the ventricles, especially of the right ventri- cle, has been remarked, in rare instances. Bertin, Bouillaud, and other French writers, attach considerable importance to this lesion as a cause of the haimorrhage; but I agree with Dr. Watson in considering the alterations which obstruct the passage of blood from the lungs as more frequent causes than this. 108. ii. Causes.—A. The Predisposing Causes of haemoptysis comprise most of those already enumerated in connexion with haemorrhage gen- erally (§ 21), and of those which favour the formation of tubercular consumption. (See that article.) Those which are more especially concerned in the production of haemorrhage from the respiratory organs are: Hereditary constitution ; the scrofulous and the haemor- chagic diathesis ; sanguineous, irritable, and sanguineo-irritable temperaments ; a plethoric habit of body; the period of life between sev- enteen and thirty-five ; tallness of stature ; a narrow or deformed chest, curvatures of the spine, rickets, or severe hooping-cough in early life; sedentary occupations, especially at the writing-desk or drawing-table ; a change of modes of life, as from active employments to inactivity ; certain trades, as shoe-making and weaving; the spring and summer seasons; sudden or frequent vicissitudes of temperature and weather, especially rapid changes from cold to heat; suppression of accustomed ex- cretions and discharges ; and congestions or enlargements of the liver or spleen. M. Louis found haimoptysis to occur among men nearly in the same proportion at all ages. Galen, Strampin, Goltz, and Louis consider it to be more frequent in females than in males. Frank and Conring entertain a different opinion ; the latter remarks that men are more prone to the disease than females, unless when the cata- menia of the latter are suppressed. Louis found it more frequent in females in the pro- portion of three to two, and that their age was most commonly from 40 to 65. I believe that the predisposition to haemoptysis is less, or at least not greater, in females than in males, un- til the period at which menstruation usually ceases, but that, after this period, the frequent occurrence of vascular plethora favours the production of pulmonary haemorrhage. There is no doubt of the influence of premature and excessive venereal indulgences, and more espe- cially of solitary vices of this kind, in favouring the occurrence of this and its allied diseases. 109. B. The ExcAting Causes are chiefly ex- ternal injury ; fracture of the bones of the tho- rax ; wounds of the chest and lungs ; falls or concussions on the chest; physical efforts, par- ticularly in lifting or carrying great weights; compression of the thorax by straight lacing, &c. ; running, especially against the wind, and hunting ;* protracted exercise with the arms, great exertions of the voice, reading aloud, or speaking for a long time ; playing on wind in- struments ; inhaling irritating fumes, as those of acids, &c., or particles of dust, as in various occupations (see art. Arts and Employments, § 40); foreign bodies fallen or drawn into the trachea and bronchi; [irritation from an elon- gated uvula; enlarged tonsils; the tying of large arteries in surgical operations;] cold in any form or mode of application ; rarefaction, or great dryness of the atmosphere ; thp suppres- sion of other sanguineous discharges ; anger, and the more violent mental emotions ; vene- real excesses ; terror, frightful dreams, or sud- den surprise ; severe fits of cough, of laughter, or of sneezing; straining at stool, and chan- ges in the state of the blood. Besides these, many of the lesions just mentioned (§104, ct seq.), act as exciting causes, especially tuber- cles and their consequences ; alterations of the vessels either in the seat of haemorrhage, or near the centre of circulation ; and difficult or impeded passage of blood through the heart, pulmonary vein, or aorta. &c. [Dr. Rush informs us that those religious de- nominations who do not sing, and generally worship in silence, are very subject to haemop- tysis, from weakness of the lungs, induced by want of exercise. Dr. Chapman, however, re- marks that his experience does not confirm this observation. Clergymen, it is well known, are extremely liable to this affection, for which a variety of causes have been assigned, but which we have thought is generally attributa- ble to exercising the organs of voice dispropor- tionately to the rest of the body. High living and want of proper exercise predispose to at- tacks of local disease, and those organs which are debilitated from any cause are most liable to invasion. “ As regards public singers,'1 says Dr. Chapman, “ especially those of the opera, where the vocal powers are strained to the ut- most, it is acknowledged that they are singu- larly liable to haemoptysis, or, if they escape it, they soon begin to suffer from some pulmonary affection, and either prematurely die, or retire from their profession with a shattered voice and infirm health. Three or four years, I was informed by one of them, are, perhaps, the aver- age of the full preservation of their powers.”] 110. C. The Scat of hcemorrhage, in cases of haemoptysis, has not always been recognised with precision. P/evious to the writings of Bichat, the effusion was very generally sup- posed to proceed from a ruptured or ulcerated vesseL, arterial or venous. Subsequently it has been generally referred to exudation from the capillaries of the bronchial membrane. I be- lieve that at present it is too exclusively im- puted to this source ; and that, although this is much the most common mode of its production, it not infrequently proceeds from an ulcerated * -A- physician, in whose case 1 was consulted, experien- ced a severe attack of haemoptysis on his way to London on one of the railroads. HAEMORRHAGE FROM THE RESPIRATORY ORGANS 99 or diseased vessel, particularly when the dis- charge is sudden, very copious, or rapidly fatal, ft has been supposed by some that the blood is exuded from the general surface of an ulcer- ated cavity, when this lesion has preceded the discharge. This may possibly be the case in a very few instances; but, when the cavity is the seat of haemorrhage, one vessel, or a few only, are most likely its source. In most of the cases of haemorrhage, in connexion with cavities in the lungs, that I have seen, the in- ternal surface of these cavities, or fistulous ul- cers, appeared not in a state indicating that haemorrhage either had, or could have taken place from them. The circumstance of the small bronchi being filled with blood, or their membrane being deeply tinged, or even inject- ed or inflamed, is no proof of the discharge having taken place from them, as the blood when once effused, even as high up as the tra- chea, will frequently gravitate or pass down- ward into the minute air-vessels, especially when the lungs are in a state of disease or of debility, and will discolour, irritate, or even in- flame them.* III. J. P. Frank has endeavoured to estab- lish a variety of haemoptysis under the denom- ination of tracheal, from its seat. Admitting the occasional occurrence of haemorrhage from this situation, it rarely can be distinguished from other states of the disease, even with the aid of percussion and auscultation ; for, as this very able and practical writer has shown with great truth and originality, a considerable por- tion of the blood effused in this situation pass- es down into the bronchi, and gives rise to the same phenomena as depend upon the more common forms of the malady. This, however, he concedes. In cases, also, of profuse haem- orrhage from the pharynx or parts adjoining, a portion of the blood may escape into the tra- chea, descend into the bronchi, and afterward be coughed up, thereby simulating haemoptysis. The blood may thus pass into the lungs as well as into the stomach ($ 91, 99), and may either be coughed up, or both coughed and vomited up, thereby simulating true haemoptysis ; or, if the quantity be great, it may suffocate the patient. Dr. Watson mentions a case which he saw, in which suffocation occurred from the passage of blood into the respiratory passages, from an ulcerated opening into one of the lingual ar- teries, the bronchi containing a considerable quantity of this fluid. From the foregoing, therefore, it may be inferred that the blood in true haemoptysis proceeds from one or other of the following sources : 1st. From the mucous membrane of the bronchi—Bronchial Haemor- rhage. 2d. From the substance of the lung, constituting the of Laen- nec, or, more correctly, Pulmonary Haemorrhage. 3d. From an ulcerated or tuberculous cavity, one or more vessels having been eroded or rup- tured. 4th. From aneurism of the aorta, or of some other artery. 112. D. Certain Pathological Relations of Hcemoptysis have been very generally overlook- ed by writers on this and other pulmonary dis- eases.—a. The intimate connexion, however, between it and tubercles in the lungs has been very diligently investigated by Louis, Andral, and others. Andral refers to cases of haemop- tysis in which there appeared to be no evidence of the previous existence of tubercles in the lungs. Such cases are rare, and are to be re- ferred chiefly to extreme congestion of the lungs. Instances are certainly not infrequent of the haemorrhage occurring in a state of ap- parent health ; but, in many of these, tubercles in an early stage of their existence may have previously been formed, or even have been de- tected upon close examination. Baillou re- marked that profuse haemorrhage from the lungs is less dangerous than small, and there is much truth in the observation; but Portal went too far in saying that those who habit- ually spit blood are rarely phthisical. My own observation is more in accordance with that of Louis, who states that, with the exception of some cases in which haemoptysis depends upon external injury, or is connected with suddenly- suppressed catamenia, it indicates with very great probability the presence of tubercles in the lungs. Dr. James Clark, in his able work, observes that haemoptysis is occasionally idio- pathic, or dependant upon a temporary pleth- ora or congestion of the lungs, especially when it is a consequence of suppressed sanguineous discharges. In tubercular phthisis, congestion of portions of the lungs, or even of the whole of the organ, is not infrequent, and is, in many cases, followed by a more or less copious hae- moptysis. Such congestion may also develop tubercles, or hasten their progress, as well as occasion the effusion of blood. In some in- stances, the discharge will afford relief to all the pulmonary symptoms, especially when the effused blood is entirely thrown off; hut, in others, it will accelerate a fatal issue, particu- larly when a portion of it remains in the bronchi and irritates them, as shown hereafter 114). 113. It has been supposed by Andral and others that hsemoptysis occasionally is a cause of phthisis, the blood effused into the lungsf forming a matrix for tubercular deposites. But to produce this effect the effusion must take place in a scrofulous constitution. I agree, however, with Dr. James Clark in considering haemoptysis rarely to be a cause of phthisis, unless by the debility it induces when very co- pious, or by the depletion employed to suppress it; or, still more probably, by the irritation pro- duced by the effused blood in the minute bron- chi. It is a frequent symptom during the whole course of phthisis, and may appear at any stage. Louis states that it was present in some degree or other in two thirds of his cases. It is rare * This, as well as other points connected with hemopty- sis, are very justly stated by the elder Frank : “Si rani- tus, et ex vasis conspicuis, tnajore cum impetu cruor in bronchium ruit; ex hoc, in alia, vicina, altiora, assurgit; ex istis, jier ramos hronchiorum laterales, declives, in sub- jectam pulmonis afFecii, ant rtiam in sani, suhstantiam de- sceudit, ac novo reflexu. sub sumnne anxietatis ad priecordia sensu, violenlA diaphragmatis actione, sod interdum sine tussi et per solam quasi expirationem fortiorem, torrentis adinstar, per tracheam, laryngem, per oris, et na- rium per ostia, tain fluidus tic floridus. qnam partim concre- tus, obscurits, horrendo spectaculo prircipitat. Sub tanto cruoris ad fauces impetu, pars ejus, in pharvngem regurgi- tans, vomitum, ut vidimus, violentum siepe provocat, cilios- que, forsitan ventriculo contentos, novie sanguinis undie, per tracheam simnl expuls.e, commistos, expellit, ac validum medico, tussis ipsum aliquando per vomitum cruentuin cx- citatie, non ignaro, quo dernuui ex cavo saneuinis scaturiat, dubitandi argumentum relinquit. Haec dubia non minus in casu. quo tuSsis violenta pneivit, ac, istiusob impetum, san- guis non modo pulmonum, sed Simnl narium e vasis ex pell i- tnr, urgebunt; aut facile pulmo, ob nares cruentas, proflu- vii insons. cum tnagno judieii errore, declaraliitur.”— De Curand. Horn. Morb., &c., class v., ord. iii., gen. 3, $ 60C. 100 HAEMORRHAGE FROM THE RESPIRATORY ORGANS. in the phthisis of children and old persons, and occurs in them chiefly towards the close of the disease. 114. b. The connexion between haemoptysis and inflammation of the lungs has been very generally overlooked. The former occurs in very rare cases as a termination or crisis of the latter; but when the inflammation is asso- ciated with tubercles, the development of these is frequently promoted by the haemoptysis. One of the most common consequences of haemor- rhage into the bronchi is inflammatory action. The effused blood irritates the mucous mem- brane of the bronchi, especially in the minuter ramifications, and the morbid action often ex- tends to the air-cells and substance of the lungs. This is very frequently observed in weak and susceptible constitutions, and when the effused blood has been imperfectly excreted from the bronchi. The softening and discoloration of the bronchial surface, generally seen in fatal cases of haemoptysis, arise from this consecu- tive inflammatory irritation ; and the puriform matter sometimes poured into the bronchi, with or without fibrinous concretions, or a coloured lymph, proceeds from the same source. A part, doubtless, of the fibrinous matters arises from the effused fluid ; but a part also consists of the lymph given out by the capillaries, which had shortly before discharged blood. In all cases, therefore, of haemoptysis, it is not mere- ly the development or accelerated progress of tubercles which is to be dreaded, but also the supervention of circumscribed or diffused pneu- monia, which may assume any of the forms de- scribed in Inflammation of the Lungs. 115. c. The relation of haemoptysis with dis- ease of the heart has been already alluded to. The momentum caused by hypertrophy of the right ventricle is rarely sufficient to rupture any branch of the pulmonary artery, although it may probably overcome the resistance op- posed by the tonicity of the extreme capillaries in the bronchial surface, or in the substance of the lungs. Dr. Watson, who has taken a very sound view of this, as well as of some other subjects connected with haemoptysis, states that every instance of pulmonary haemorrhage dependant upon organic disease of the heart which he had observed coincided with disease on the left side of that organ, mechanically ob- structing the return of blood from the lungs. The obstacle has sometimes been placed at the entrance of the aorta, but it has most common- ly consisted of narrowing of the left aurieulo- ventricular orifice, and a rigid condition of the mitral valve. Facts illustrative of this relation have also been adduced by Dr. Wilson {Med. Gazette, yol. vi., p. 25), and observed by myself. I believe, moreover, that those powerful mental emotions which affect suddenly the functions of the heart, which seriously disturb its ac- tion, and favour congestion of its cavities, as terror, fear, anger, grief, &c., sometimes pro- duce haemoptysis by impeding the return of blood to both the right and the left sides of this organ. 116. B. Other complications besides the above occasionally present themselves in practice; but in these, haemoptysis is merely a symptom arising from some predisposition to pulmonary or haemorrhagic affections.—a. It has been sta- ted that bronchitis and pneumonia often follow haem ptysis, and the reason has been assigned ( 26, et seq.) At these periods, the uterus is still more or less unyielding, and the resistance to farther effusion is considerable. But in slight attacks, or at the commencement, the obstacle afforded by the plug may hasten the complete detach- ment of the ovum, by favouring the accumula- tion of blood between it and the uterus ; and either a copious internal haemorrhage may thereby be produced, or the ovum, being de- tached, may be prevented by it from being thrown off, and be retained for a long period, keeping up irritation and haemorrhage, or a continued draining, with occasional exacerba- tions or a putrid discharge. Indeed, this oc- currence is not rare in the early months, inde- pendently of the plug, although the use of it before the expulsion of the ovum, and when the os uteri is soft or yielding, is more likely to occasion than to prevent it. When, how- ever, the os uteri is firm, and the discharge copious, it is often of service ; but it is chiefly after the ovum is expelled, in cases of flooding before the fifth month, that plugging is most efficacious if efficiently employed. Care should be taken that the plug do not press injuriously upon the urethra. Mr. Ingleby directs that it should remain undisturbed for twenty-four hours or longer ; but the supervention of inter- nal haemorrhage should be kept in view, and the case carefully watched. 254. When the blood escapes in small quan- tity only, and there are no pains present, and no disposition in the os uteri to dilate, the con- stitutional powers being unimpaired, an attempt should be made to prevent a return of the dis- charge, by the means already described both in this article and in that on Abortion. But, as Dr. R. Lee justly remarks, where the flooding is profuse at first, or is renewed with violence, in spite of efforts to check it, the continuance of pregnancy to the full period cannot be ex- pected, and it will be of no avail to take blood from the arm, and to administer internal rem- edies with any other view than with that of arresting the discharge, and thereby averting danger. In these circumstances the speedy evacuation of the uterus is the chief indication, as the slightest cause may reproduce the haem- orrhage in an alarming manner, while the par- tially-detached ovum remains. But, in the early months of pregnancy, this intention is not so easily accomplished as at later periods. Puncturing the membranes, in order to excite the uterus, is advised by Rigby, R. Lee, and Merriman : but before the fifth or sixth month this may not be easily performed ; and, until the sixth or seventh, the hand, however small it may be, will not readily be admitted into the uterus. The ergot of rye has been recommend- ed by Neale, Negri, Ryan, and numerous American as well as European practitioners, in order to procure the contraction of the womb in such cases. It may be given in powr- der, or in decoction, with three or four drops of the oleum Pulegii, as advised by Dr. Ryan.* I have prescribed it successfully both alone and with from ten to twenty grains of the bi- borate of soda. An enema, containing an ounce or an ounce and a half of spirit of turpentine may be thrown up, if these fail. A judicious recourse to these means will generally super- sede the use of the plug or puncturing the membranes, the propriety of which latter, be- fore the sixth month, is denied by Mr. Ingleby and some others. Wherever, in such cases, the end can be obtained by the use of medicine, recourse to any operation, however trifling, should be avoided. Instances, however, may occur about the fifth or sixth month in which perforating the membranes is required, in ad- dition to the other means just advised. The cold affusion, or the dashing of a wet napkin against the external parts, or the application of the turpentine epithem on the hypogastrium, may be also resorted to when the case becomes urgent. 255. b. WThen in the third or fourth month the haemorrhage is continued, draining, or re- mittent, a merely partial evacuation of the ute- rus should be suspected, especially if the dis- charge become offensive ; or if the foetus, with the whole of the appendages, have been ascer- tained to have come away, a flaccid or relaxed state of the uterus may be inferred. In such cases, a careful examination will discover one or other of these states, which will generally be removed by the medical means just advised, and especially by the exhibition of the spirit of turpentine by the mouth, or in enemata. The recommendation of Drs. Haighton and Blun- dell to inject the uterus with astringent fluids, if at all advisable, is most likely to be service- able in cases where a portion of the ovum has been retained in the uterus, and is passing into decomposition. [The blood-vessels of the uterus do not at- tain a sufficient size until the seventh month of pregnancy to pour out blood in so great a quantity as suddenly to destroy life, though the discharge may be very profuse, and produce alarming symptoms. The remedies on which we rely to check haemorrhage in the early months are, venassection, where the patient is plethoric and the circulation excited; rest in the horizontal position; cool air; ice in a bladder, or cold vinegar and water over the hy- pogastrium ; cold, acidulated drinks; pills of the acetate of lead and opium ; the introduction of a sponge into the upper part of the vagina; and where these all fail, puncturing the ovum, and bringing on uterine contraction by the use of the ergot. Where the bleeding is kept up by the presence of the ovum in the uterus, and it cannot be reached by the finger, a curved wire, or a polypus or lithotomy forceps may be intro- duced, provided the os be sufficiently dilated, and thus the ovum may be extracted.] 256. c. Haemorrhage after the sixth month, al- though occurring most frequently from attach- ment of the placenta upon the cervix uteri, may also take place wffien this does not exist. In no remedial effect except on the gravid uterus. Given un- der other circumstances, it appeared to be utterly inert, even in relation to the system of the female, the womb in- cluded. Were it, too. endowed with the power ascribed to it, should it not be displayed in regard to haitnorrhages gen- erally? But in epistaxis, htemoptysis, and hsematemesi* it has none, I am persuaded from all my observations.”— (Lectures on Hemorrhages” &c., Ihil., 1S450] * [Dr. Chapman observes that “ergot is shown, by the well-conducted experiments of Dr. Charles JIyrd, to have 136 HAEMORRHAGE FROM THE UTERUS—Treatment. this stage of pregnancy, as well as at earlier periods, if the discharge be in small quantity or moderate ; if it have not proceeded with much rapidity; if it stop soon ; if no large clots be formed in the vagina; if the cervix have its usual feel, showing that the placenta is not at- tached there, and that no large coagula are re- tained in the os uteri; if the child be still alive ; if there be no indication of the accession of la- bour ; and if the discharge become pale and watery, we may conclude, with Dr. Burns, that the full period of gestation may be reached. In this case the treatment already directed in ac- tive haemorrhage ought to be adopted. But where the effusion is profuse, or continues, and the strength of the patient is impaired by it, the fetal membranes should be punctured, the liquor amnii evacuated, and the uterus roused to action by the means just advised (§ 254), aided by frictions over the hypogastrium, and by dilatation of the os and cervix uteri. 257. d. When the placenta is attached over the cervix uteri, as evinced, on a careful examina- tion, by its fibrous vascular structure, by its ad- hering to one part of the uterus and being sep- arated at another ; by the renewal of the haem- orrhage during labour pains ; and by its occur- rence without any obvious exciting cause, the utmost decision and dexterity on the part of the practitioner are required. If flooding occur to an alarming extent in the seventh or eighth month, an examination should be instantly made, and while the blood is actually flowing. In some cases, where a small portion of the placenta lies over the os uteri, coagula may close the orifices of the bleeding vessels, and the patient may go on to the full time.* In these, the haemorrhage is seldom very pro- fuse ; and this result cannot be expected. The general recurrence and increased violence of the effusion, until the patient either expires, or is delivered by art, demand that a rule of prac- tice should be laid down ; and the rule first de- vised by Levret, and now generally received, is the speedy performance of artificial delivery. Dr. R. Lee states that he has seen only one case of flooding from the position of the pla- centa, followed by recovery, without artificial delivery; and, in order to accomplish this, he recommends the hand to be passed into the va- gina, as in turning, without waiting for the pains of labour, or the dilatation of the os uteri, and carried steadily forward through the os, in a conical form, between the uterus and placen- ta, at the part where their separation has taken place. The membranes are then to be rup- tured, and an inferior extremity of the child brought down, and the infant and placenta slowly extracted. The hand, however, should not be forcibly introduced while the os uteri is rigid and undilatable. Until it becomes soft, the flow of blood should be checked by the re- cumbent posture, by cold applications, and the ■plug. But this latter ought not to be inserted when the os uteri is soft and dilatable. In the rigid state of this part, in hemorrhage from this cause, it will command the effusion, until the operation of turning can be safely perform- ed ; but, as soon as this may be attempted, it becomes inadmissible. [According to the statistics of the Maternity at Paris, from 1797 to 1811, out of 20,357 wom- en delivered, there were eight cases of pla- cental presentation, or 1 in 2554. During six years and nine months, in the Dublin Lying-in Hospital, during Dr. Clarke’s attendance there, four cases of placental presentation, or 1 in 2596 ; and Dr. Collins met, in the same institution, with 11 cases of placental presentation in 16,654 labours, being in the proportion of 1 to 1492. Out of 174 cases of placental presenta- tion recorded by different authors, Dr. Church- ill states that 48 proved fatal, or nearly 1 in 3; and about the same proportion where the placenta was attached at the fundus. Dr. Robert Lee states that he had seen 38 cases of uterine haemorrhage in the latter months of pregnancy from partial or complete attachment of the placenta to the neck of the uterus, of which 14 proved fatal.] 258. e. If flooding occur during the first stage of labour, at the full time, the membranes should be immediately ruptured, as recommended by Clement, Puzos, Kok, Rigby, Baudelocque, Denman, Merriman, D. Davis, Blundell, Lee, Ramsbotham, Sweatman, and others; but if the discharge should still continue, and the pains become more and more feeble, and the patient exhausted, delivery must be accom- plished by turning, by the forceps, or even by embryotomy, according to the circumstances of the case. In less imminent cases, the ergot of rye and other means already mentioned (<) 254) may be tried before recourse be had to these operations. Mr. Inglebv, however, con- siders that many of this description of cases are occasioned by the injudicious use of the ergot; but, when it is employed for the arrest of the discharge, and for the purpose of procu- ring uterine action, this objection does not ap- ply either to it, or to other means intended to exert a similar operation. After the liquor am- nii has escaped, the os uteri still remaining rigid, there are objections to the exhibition of the ergot; and in such a case, plugging the vagina, as advised hy Burns, Dewees, Capu- ron, Gardien, Davis, &c., may be resorted to, with the aid of friction and moderate pressure on the abdomen, in order to increase uterine action. The possible occurrence, however, of internal haemorrhage should not be overlooked ; and if this take place, the still more active in- terference just mentioned must not be delayed. But the plug should not supersede rupturing the membranes when flooding occurs at the commencement of labour at the full term. 259. f. Haemorrhage after the birth of the foetus, and before the expulsion of the placenta, is frequent, and often sudden and profuse. In this case, strong pressure should be made over the hypogastrium, in order to excite uterine ac- * [The fact was first established hy Dr. Jones, that when an artery is divided, nature employs certain means adapted to arrest.the flow of blood ; the artery contracts and retracts, and a coagulum is formed within its orifice. The same means are employed by nature to prevent fatal haemorrhage from the uterus when the placenta is detached ; and if this were not the case, death from hsemorrhage would probably take place in all cases immediately after the expulsion of the child and separation of the placenta. The same mus- cular contractions which expel the contents of the gravid uterus close the mouths of the exposed vessels in the lining membrane until coagula of the fibrin of the blood are form- ed within them, which effectually prevents the farther ef- fusion of blood ; a result which is facilitated by the oblique valvular manner in which the veins open into the cavity of the uterus. All the different means which prove efficient in checking the discharge in uterine lia-morrhage either excite the contractions of the uterus or promote the coag- ulation of the blood within the vessels.] HAEMORRHAGE FROM THE UTERUS—Treatment. 137 tion. A binder ought to be firmly applied over the abdomen, several folded napkins being placed under it, so that the fundus uteri be compressed. Dr. R. Lee advises the hand af- terward to be introduced to remove the placen- ta, but the removal of it should not be attempt- ed until contraction of the uterus commences. After contraction, and the expulsion or with- drawal of the placenta, he directs a cloth, wet with cold vinegar and water, to be applied to the external parts, cold acidulated drinks to be given from time to time, and the patient to be preserved for two or three hours in a state of perfect repose. This plan will, generally suc- ceed when the haemorrhage and retention of the placenta are caused by inactivity of the uterus. But when irregular action of the or- gan, or spasmodic contraction of the os inter- num or externum uteri, retains the placenta either altogether or partially, and thus causes internal haemorrhage, additional means, espe- cially the exhibition of opium by the mouth, are required. The passage of the hand, in order to remove the placenta, then demands caution and perseverance. If it cannot be accomplish- ed, the turpentine enema or embrocation will generally aid in removing the difficulty. If the flooding arise from morbid adhesion of a portion of the placenta, the adhesion must be separated by the hand in a manner that will readily suggest itself. Dr. T. Ramsbotham at- tributes these adhesions to partial separation of the placenta during pregnancy, from some accidental cause, followed by a slight discharge, the extravasated blood exciting inflammation of the separated surfaces with effusion of lymph, and the consequent agglutination of them. This opinion is probably correct. 260. g. Flooding after the expulsion of the pla- ccnta requires a modified practice, according as it arises, 1st. From atony of the uterus; 2d. From imperfect or remitting contractions ; 2d. From a portion of the placenta left in the uterus ; and, 4th. From inversion of the organ. As in haemorrhage previously to the complete expulsion of the placenta, so in this the blood may be retained in the cavity of the viscus, by coagula, or by a portion of the secundines lodged in the os uteri or vagina. In every case, therefore, the state of the uterus and the integrity of the placenta should be ascertained. Where simple atony of the uterus is the chief cause, constant and well-directed pressure on the fundus uteri, especially by the hand ; the sudden application of cold, or effusion of cold water ; the turpentine enema, or draught; the ergot, &c., are the most efficacious means. If the haemorrhage be internal from any of the causes just stated, the same measures will gen- erally procure their removal, by contracting the uterus ; but if these fail, they should be removed by the hand. The draining or recur- ring haemorrhage, the expulsion of clots, the offensive nature of the discharge, and the con- stitutional effects consequent upon the presence of a portion of the placenta in the uterus, de- mand at first the same means as other states of the disease ; but afterward, and particularly | when serious constitutional symptoms super- ! vene, indicating a remarkable diminution, and marked vitiation of the vital current, additional j or other remedies should be employed. Weak solutions of the chloride of lime, or of soda, i should then be injected per vaginam, or even into the uterus; and the decoction of cincho- na with the chlorate of potash, or with hydro- chloric acid ; camphor in frequent doses ; an occasional enema with spirits of turpentine or draught with the same and castor oil; the biborate of soda, and other means calculated to support the vital energies, to increase the ex- creting functions, and to enable the uterus to retract and discharge the matters retained in it, should be prescribed. [Dr. Thomas Radford, of England, has em- ployed galvanism with great success in the treatment of cases of uterine haemorrhage, ac- cidental or unavoidable, accompanied by ex- haustion, and occurring before, during, or after labour. “ I am satisfied,” he says, “ from pos- itive trial of the remedy, that it will be found a most important agent in tedious labour, de- pending upon want of power in the uterus, and where no mechanical obstacle exists. I would also suggest the probability of its proving val- uable in originating uterine action de novo, in cases where it may be considered necessary to induce premature labour. It seems to me, al- so, to be worthy of trial in certain cases of menorrhagia in the ungravid state, where, on vaginal examination, the uterus is found to be atonic, as evidenced by its large, flaccid con- dition, and the patulous state of the os uteri.” His mode of applying galvanism is the fol- lowing : The brass ball of the vaginal conduct- or is to be passed up to the os uteri and moved about, at intervals, on to various parts of this organ ; at the same time, the other conductor must be applied to the abdominal parietes over the fundus uteri. Shocks may be also passed transversely through the uterus, by simultane- ously applying the conductor on each side of the belly. The application should be used at inter- vals, so as to approximate, in its effects, as nearly as possible to the natural pains. It may be continued until it meets the exigences of the case. Dr. Radford has also been led by his expe- rience to conclude that on a complete separa- tion of the placenta the haemorrhage is imme- diately and completely suppressed, provided the uterus is in a condition to so far contract as to force down the head with the placenta upon the uterine openings. By this practice it may be said that the life of the child is sacri- ficed ; but this will not always happen. We find from hospital and individual reports, that the child is usually dead, when the case has been treated by the present recognised means. “ In nearly all the cases which I have col- lected and referred to in my paper.” he remarks, “ of expulsion of the placenta by the natural ef- forts, we find that the mother recovered ; and when this fortunate event did not happen, it depended upon the serious impression made upon the vital powers before the placenta w'as completely detached. “ It may also be stated that uterine phlebitis takes place more frequently in cases of placen- ta praevia, when the ordinary practice is adopt- ed, than we observe in the same number of cases of accidental haemorrhage. This result, in the opinion of the writer, arises from the contusions and slight lacerations which are consequent upon a forced delivery.” 138 HAEMORRHAGE FROM THE UTERUS—Treatment. Dr. Radford has, from these circumstan- ces, been led to recommend the following prac- tice : “ 1st. Then, as neither delivery, nor detach- ing the placenta, ought ever to be attempted until the cervix and os uteri will safely allow the introduction of the hand ; rest, the applica- tion of cold, but, above all, the use of the plug must never be omitted in cases where they are respectively required. “ 2d. If there are unequivocal signs of the child’s death, the placenta is to be completely detached, and the membranes are to be rup- tured. The case is then to be left to the natu- ral efforts, provided there be sufficient uterine energy ; if otherwise, the ordinary means are to be used, and, in addition, galvanism. “3d. When a narrow pelvis exists in con- nexion with placenta praevia, the practice is to detach the placenta and to remove it, then to perforate the head as soon as the condition of the parts allow, and to extract it by means of the crotchet. “ 4th. When the os uteri is partly dilated, and dilatable so as to allow the easy introduc- tion of the hand, when the membranes are ruptured and strong uterine contraction exists, the practice is to detach the placenta com- pletely. “ 5th. In all cases of exhaustion, as already referred to in my paper, the practice is to draw off the liquor amnii by perforating the placenta, as then recommended, then to detach com- pletely this organ, and apply galvanism. “ 6th. In all cases of partial presentation of the placenta, the artificial rupture of the mem- branes will generally be found sufficient to ar- rest the haemorrhage ; but if that should prove ineffectual, then we must apply galvanism. “The practice of detaching and removing the placenta was adopted by some of the older writers; and as I have mentioned in my paper ‘ On Galvanism applied to the Treatment of Uterine Haemorrhage,’ I detached this organ in the year 1819, although it was not my custom to do so.”—Prov Med. and Surg. Journ., 1844.- Dr. Simpson, of Edinburgh, has proposed, in these cases of haemorrhage from placental presentation, that the placenta should be first extracted, leaving the foetus to be expelled by the natural efforts of the uterus or otherwise. Dr. S., as well as Dr. Radford and Dr. Kinder Wood, relate instances where this procedure has proved successful; in one case the placen- ta was extracted two hours before the birth of the child. This method is particularly recom- mended in those cases in which turning or rup- ture of the membranes is inexpedient or im- practicable ; as in cases where haemorrhage occurs to an alarming extent while the os uteri is still small and rigid ; in unavoidable haemor- rhage in first labours; in placental presenta- tions where the patient’s strength is already so sunk, from the flooding, as not to allow, with- out danger, of immediate turning or forcing de- livery ; in cases where the child is known to be dead, &cc.—(Lond. and Ed. Month. Jour. Med., Feb , 1845.)] 261. The occurrence of haemorrhage after delivery, while the uterus appears to be con- tracted, upon which Dr. Gooch has so unneces- sarily insisted, is nothing more than its con- nexion with an imperfect, remitting, or irreg- ular contraction in some cases, and with de- termination of blood in others ; states pre- viously known to the profession, and requiring, at most, but a modification only of the means insisted upon in the course of this article. In these, as well as in other cases, the applica- tion of pounded ice has been much praised ; but the continued application of great cold is less beneficial than the shock produced by the atfusion of moderately cold water, or by dash- ing a wet napkin upon the hypogastrium and external parts. Indeed, the former may cause an imperfect or irregular contraction to pass into a state of relaxation, and thereby perpet- uate the haemorrhage. With respect to the hour-glass contraction of the uterus, insisted upon by Dr. Burns and others, in connexion with flooding, the perspicacious remarks of Dr. Malins should be borne in mind. This acute physician observes that, as the contraction of the uterus in the unimpregnated state, dividing it into two portions, disappears under gesta- tion, the whole uterus then forming but one spheroidal cavity, so the removal of the dis- tending causes allows the organ to recover, in a great degree, its original shape during con- traction, and that thus two cavities again ex- ist, in some measure divided by that contrac- tion usually denominated the os internum ute- ri, perfectly natural, indeed, in character, but to which the name of hour-glass contraction, as denoting a preternatural state, has been in error so constantly applied. The contraction of the circular fibres, which thus takes place, dividing the upper part of the genital canal into two chambers, when excessive, the other por- tions of the organs being relaxed, is not infre- quently associated with haemorrhage, either while the placenta is still retained in the upper chamber or after it has been thrown off, coag- ula filling the lower cavity formed by the cer- vix uteri. The introduction of the hand into the uterus in order to excite it to action, or to press upon the part to which the placenta was attached, as advised by Dr. Gooch and others, can seldom, under judicious management, be necessary; and it is very doubtful if it will ever prove serviceable. Plugging the vagina, after delivery at the full time, requires the ut- most caution and constant watching, even when the uterus is firmly contracting, as it may fa- vour dangerous internal effusion. 262. D. The management of a •patient after dangerous uterine haemorrhage constitutes an im- portant part of the treatment. Although the uterus is firmly contracted, and the patient seems comfortable, yet she ought not to be considered as altogether safe, as the uterus may again relax and the haemorrhage return. This contingency ought to be guarded against by applying a proper binder, by perfect repose, and by a full dose of opium, if irritability or restlessness exist. Her position ought not to be changed for several hours, and the horizon- tal posture must not be departed from on any occasion. The room should be darkened and well ventilated, and nutrient but light fluids, in moderate quantity, should be given at stated intervals. 263. iv. The particular remedial Measures ADVISED BY AUTHORS FOR UTERINE HEMORRHA- GES require but little notice after the full ex- position of the treatment given above.—a. Vas- cular depletions, either general or local are di- rected by several writers, and particularly by Schenck, Lefevre, and Pelargus ; but they are admissible only in the more active states, and as means of prevention, especially in these. When practised so as to derive from the seat of haemorrhage, some advantage may accrue from local depletions, more especially from cup- ping over the sacrum or under the mammae, as advised by Hippocrates and Actuarius. Sev- eral of the ancients resorted to cupping on the breasts; Gai.en directed this operation to be performed over the hypochondria; and Gon- dret prescribed dry cupping, with large glasses, between the shoulders. Emetics have been prescribed, in order to derive the circulation from the uterus, after blood-letting has been resorted to, by Stoll, Gendron, Reidlin, and Kortom. Conradi employed them to procure contraction of the uterus, and the expulsion of coagula in uterine hannorrhage after delivery. They are certainly serviceable in some cases, but they require discrimination, and their ef- fects ought to be carefully observed. 264. b. Internal refrigerants, particularly nitre and cold drinks, have been praised by several of the older writers. MM. Martinet and Des- landes have recently given the nitrate of potash tn remarkably large doses — as much as six drachms in the twenty-four hours. It is not appropriate in cases of puerperal haemorrhage, although it is sometimes of service in the ac- tive forms of the disease unconnected with pregnancy. I have given it in haemorrhage af- ter abortion, but with little or no benefit. The hydrochlorate of ammonia is more likely to be serviceable, especially in cases of debility, and when the discharge is draining or remittent. It may then be given with cinchona, or small doses of opium. 265. c. Of the application of cold little farther need be stated. It has been generally prescri- bed by writers from Hippocrates to the pres- ent time. Collomb, Doemling, Gauthier, Hi- ensius, Chaussier, and most modern authors, recommend it, both internally and externally, in the forms of epithem and injection. Ranoe, Loeffler, Josephi, D. D. Davis, and Olivier direct cold drinks; while Fieliz and Thomann consider cold in any form inappropriate in ute- rine haemorrhage after delivery, and in the pass- ive states of the disease. There is much jus- tice in this. The recourse to cold requires great discrimination ; for, if too long applied, or if the cold be too great, much mischief may be produced by it. The sudden and tempora- ry application of cold, so as to produce more or less shock to the frame, is certainly more beneficial, and more generally appropriate than a prolonged recourse to it. 266. d. Astringents have been very generally administered, both by the mouth and per vagi- nam, in metro-haemorrhagia. Aluminated whey has been prescribed by Lentin, Pasta, Mul- ler, Lindt, Stroem, and Hufeland. Thileni- us has directed it to be employed topically, by means of a sponge. Wendt and Aaskow have recommended the sulphuric acid with lauda- num ; Gebel, the tincture of the sesquichloride of iron; and Fotiiergill, Carron, and Wen- delstatt, the preparations of kino or of catechu. These medicines are even now in general use, but are most beneficial in the more passive HAEMORRHAGE FROM THE UTERUS—Treatment. states of the disease, unconnected with preg- nancy or childbirth, and when the discharge is moderate and prolonged. Of the numerous as- tringents mentioned by writers, the acetate of lead, in doses of two grains to six or seven, re- peated according to the urgency of the case, has been most praised by modern authors, and especially by Reynolds, Heberden, Mitch- ell, Young, Williamson, Amelung, Thomson, &c. When the flooding is profuse, or occurs in connexion with childbirth or abortion, only the most energetic astringents and the most rapid in their effects ought then to be given internally ; and of these, the spirits of turpen- tine; the ergot of rye (Spajrani, Cabini, &c., in Ann. Univers. di Med., 1830); and the acetate of lead, in large doses, with opium in acetic or py- roligneous acid, are most deserving of notice. 267. e. The more energetic tonics, in large do- ses, have likewise been directed. They are appropriate in cases of debility, when the dis- charge is prolonged without being excessive ; and when it is unconnected with pregnancy or active determination to the uterus. In these circumstances, and when the disease is period- ic, the preparations of cinchona have been pre- scribed by Stroem, Starke, Duncan, Bang, Picque, &c. ; the tincture of cinnamon by Plenck, Vogel, and Schneider ; and the sul- phate of iron, and other chalybeates, by Rath, Thilenius, and Doemling. The sulphate of quinine, with sulphuric acid and tincture of cin- namon, or with sulphate of iron in the form of pill, will be given with advantage in many ca- ses of this description. 268. /. Ipecacuanha in small doses has been much used by Paulisky, De Meza, Bruck, Holst, Loeffler, Stoll, Dalberg, Denman, and others ; and small quantities of tartar emet- ic have been recommended by Chalmers. The former of these may be useful when the uterus contracts irregularly, and when the placenta is retained from this cause. But it is chiefly in combination with opium, or in frequently re- peated doses, that any advantage can be ex- pected from it. In haemorrhage after delivery but little benefit will be derived from opium, es- pecially if given in large quantity, or depended upon chiefly. When thus exhibited, it will rather impair than promote the contractions of the uterus. Yet circumstances will some- times arise to justify the praises of opium ex- pressed by Horstius, Heister, Young, Smel- lie, Ranoe, Chesneau, and Garthshore, es- pecially in uterine haemorrhage unconnected with pregnancy, or in that occurring in the ear- lier months of gestation. In these cases it may be given with dilute sulphuric acid (Aaskow) ; or in clysters, as directed by Mr. Copland. Harcke advised it to be used in injections thrown into the vagina—a method by no means to be advocated ; and every practitioner of ex- perience will be aware of the danger of admin- istering opium, unless in very small quantity, in the form of enema. [“The more I prescribe opium,” says Dr. Chapman, “ the stronger is my conviction that it exercises a very general power over haemor- rhage, provided adequate depletion has been practised, and which I think it does by its oper- ation on the nervous system. Commonly it, or some of its preparations, is given alone, but the Dover’s powder often answers better; and 139 140 HAEMORRHAGE FROM THE UTERUS—Treatment. in some instances a union of opium, ipecacuan- ha, and camphor is still more to be preferred.” Our experience coincides with that of Dr. C. in relation to the use of this article. A full dose of Dover’s powder, after proper and suit- able venaisection, will generally check haemor- rhage, whether it be from the uterus or any other organ.] 269. g. In passive metro-hcemorrhagia, partic- ularly when the powers of life are depressed or exhausted, brandy ox other spirits have been resorted to by many practitioners, often in large quantity. Stimulants of this description are apt to give rise to a very serious affection of the head, and to protract convalescence. Am- monia, or camphor (Ettmuller), is less objec- tionable in such circumstances; and a judi- cious recourse to spirits of turpentine, as advi- sed above, is much more efficacious and less hazardous. Of other internal medicines rec- ommended by writers, no farther notice than the simple enumeration of them need be taken. The fungus militensis has been mentioned by Linnaeus ; the bursa pastoris, by De Meza ; the geum urbanum, by Stroem ; the decoction of the fruit of the hippocastanus, by Hufeland ; tannin, by Cavalier ; savine, by Rave, Fiest, and Wedekind ; purgatives, by Lentin, Strack, and Conradi ; and the pimpinella, by Riedlin. Whatever effects these may produce in the haemorrhage occurring independently of preg- nancy, but little benefit can be expected from them in those supervening during the puerpe- ral states. [We believe that a current of galvanism, passed directly through the uterus, as directed above by Mr. Radford, will speedily induce ute- rine contractions, and thus check haemorrhage from this organ. Farther trials with it are, however, needed, before its efficacy can be con- sidered as fully established. Monesia has been recommended by various writers, in different forms of haemorrhage from the uterus ; and Prof. Simpson, of Edinburgh, recommends gallic acid, in doses of from ten to twenty grains in the twenty-four hours, made into pills. He states that it possesses the ad- vantage of not confining the bowels; and it forms the active ingredient in Ruspini’s styp- tic. The infusion of matico has also been given with decided benefit, where an internal styptic was needed (Braithwaite’s Retrospect, part vi., art. 79, and part viii., art. 7). Dr. Dewees is a strong advocate for the sugar of lead.] 270. h. Various external means of arresting flooding after delivery have been adopted, and frequently with success. Friction of the abdo- men, particularly when the uterus contracts ei- ther imperfectly or irregularly, and compression over the fundus of the organ by the hand, or by compresses, bandages, &c., have been very properly insisted upon by Levret, Tallony, Zeller, Vogel, Smellie, Osiander, Ingleby, Ramsbotham, R. Lee, and by most modern wri- ters. Loeffer directed that pressure should be made by means of a sand-bag. Dr. D. Da- vis and Dr. Beatty have recommended banda- ges constructed on purpose. Pressure on the descending aorta, through the abdominal pari- etes, has been favourably mentioned by La- tour and Ingleby. Ploucquet advised the pressure to be made by the hand introduced into the relaxed uterus ; and Eichelberger has adduced an instance of tlje success of this method. Injections of various kinds into the uterus have been employed. Prosper Alpinus, Thilenius, and Pasta prescribed the mineral acids much diluted; Galen, the juice of the plantago ; Astruc, diluted vinegar ; and Kok, astringent infusions, in this way. Fieliz di- rects the hand wet with vinegar; Wendel- statt, lint moistened with much-diluted sul- phuric acid ; and M. Gorat, a decorticated or divided lemon, to be passed into the uterus. 271. i. Plugs or tampons, moistened with va- rious astringent fluids, have been very general- ly resorted to since the praises bestowed on them by A. Parey, Hoffmann, Leroux, Thile- nius, Trioen, Held, Loeffler, Humberg, and Smellif. Some modern British authors have, however, supposed that the addition of astrin- gents is unnecessary, although they approve of the plug in nearly the same circumstances in which I have recommended it above (§ 253), namely, when the os uteri is rigid. Soft lint or sponge may be used ; but in such a manner as to fill completely the upper part of the vagina. 272. k. When all other means have failed— when the face is blanched; respiration is scarcely audible, or gasping or hurried; the pulse almost imperceptible or gone ; the ex- tremities cold or clammy ; the power of deglu tition lost—transfusion should be resorted to, although the chances of success from it are few. Dr. Hamilton has, however, seen recov- ery take place from this state by the ordinary means ; but so fortunate an issue is rare. The question only is, whether the practitioner should still persist in the use of some of the more ap- propriate means, or have recourse to transfu- sion. The contingencies of resorting to it ought not to be kept out of view; for if air pass into the vein, immediate death will follow. Phlebitis may even supervene, although the operation has succeeded, and carry off the pa- tient. The propriety and success of this meas- ure have, however, been so far established by Dr. Blundell, Dr. Ingleby, and by some oth- ers, who have attempted it in circumstances of more doubtful propriety, as to justify the having recourse to it as an ultimum sed anceps remedium. 273. 1. The prevention of uterine haemorrhage, particularly in the puerperal states, is a subject of great importance. In the early months, the precautions recommended in the article on Abortion (§ 26, et seq.) should be adopted. In order to prevent haimorrhage after delivery, Dr. Beatty and others advise an appropriate binder to be passed loosely round the abdomen, and drawn tight, as circumstances may require. I am convinced that a moderate degree of pres- sure on the parietes of the abdomen after de- livery is of service in preventing, not only ute- rine haemorrhage, but also some other diseases, especially the different forms of puerperal fe- vers, &c. [As haemorrhage from the lungs indicates, for the most part, something wrong in the con- dition of that organ, so haemorrhage from the uterus should lead us to suspect a morbid state of this viscus. We should particularly inquire whether there is a sense of pain or heat in the organ, extending to the lumbar region and low- er extremities, and whether the flow of blood may not alternate with other depraved and non- HAEMORRHAGE FROM THE UTERUS—Bibliography and References. 141 sanguineous discharges of an offensive nature. If we cannot ascertain satisfactorily by the touch the precise pathological state of the ute- rus, we shall be warranted in having recourse to the speculum—an expedient which we never wish to see resorted to on ordinary occasions, and never, indeed, except as a last resource. In many of these cases, the suppression of the discharge is a subordinate consideration ; it may even prove a salutary evacuation, design- ed for the relief of a phlogosed condition of this important organ, as it often prevents the oc- currence of organic disease. Our chief object should be to arrest the progress, or relieve that condition from which the haemorrhage ema- nates. To this end, general and local bleeding ; the latter, by the occasional application of leech- es to the os itself; an alterative use of iron and conium, iodine, or mercury ; a mild diet; fre- quent sponging the body ; pure country air ; moderate but regular exercise ; and especially a cheerful and placid state of mind. When, in a later stage, we detect the presence of scir- rus and other serious organic derangements, we are obliged to resort to the use of narcot- ics and anodynes, especially the iodides, with conium, opium, sarsaparilla, &c. Lisfranc has recommended and practised the removal, by the knife, of diseased portions of the uterus ; but, in our judgment, such operations, like those for diseased ovaria, are entirely unjus- tifiable, and should be abandoned.] Bibi.iog. and Refer.—Hippocrates, yyvaiKtitnv, ii., v., Opp., p. 638.—Galen, De Hirud. Revulsione, &c., c. 2.— Aetius, Tetrab., iv., s. iv., c. 64, 66, 140.—Paulus JEgineta, Works by F. Adams, p. 337,452.—Oribasius, Synops., 1. ix., c. 44 —Actuarius, 1. iv., c. 8.—M. Adamus, Diss. de Im- mod. Mensium Profluv., 4to. Basil, 1605Primerosius, De Morb. Mulierum., 1. i., c. 3, 9.—Zaculus Lusitanus, Prax. Hist., t. ii., 1. iii., c. 11.—G. W. Wedel, Diss. de Mensium Fluxu Immodico, 4to. Lond., 1688.—A. Helvetius, TraitA des Pertes de Sang, &c., 12mo. Par., 1691.—L. F. Jacobi, Diss. de Nim. Mensium Fluxu, 4to. Erford, 1710.—Bar- tholinus, Hist. Anat., cent, ii., hist. 42. —J. A. Helvetius, Trait6 des Pertes de Sang, avec leur Remede specif., 12. Paris, 2d edit., 1706.—P. T. Schacher, Diss. de Haemorrhag. Gravidarum, 4to. Lips., 1717. — Freind, Emmenologia, c. 12, 13.— Werner, Diss. de Affectibus cum Hiemorrhagiis Uteri, 4to. Erford, 1715.—Mead, Medica Sacra, cap. 4.— Brunner, Diss. de Partu Praternaturali ob Situm Placenta: super Orific. Uteri internum, 4tn. Argent., 1730.—F. Hoff- mann, Diss. de Htemorrhoico Mensium Fluxu in Virgine Observato. Hal., 1730. Consultat, cent, ii., iii.. n. 110; et De Eturi Hsemorrhagitt Immoderate, obs. 7. Opp., ii., p. 230.—Chomel, Ergo Pra gnante superveniente Uteri flsun- orrhag. Partus Mauu Promovendus, 4to. Paris, 1743.— Riedlin, Lin. Med., p. 50, 1695. — Puzos, Mdmoires de l’Acad£mie de Chirurgie, tome premier, 4t<>.—Gebauer, De Salubritate Ileeinorrhagia Uteri, 4to. Erlang., 1746. — C. Linnb, Haemorrhagia Uteri sub Statu Gravid. Upsal, 1749. —Thurneysen, De Cans. Hiemorrhag. in Gravidis, 4to. Basil, 1750.—Erichson, De Ilaemorrhagiil Uteri sub Statu Gravid., 4to. Upsal, 1750.— TVUrbann, De Iliemorrhag. Uteriuft, 8vo. Edin., 1753 — Wessel, De Partu cum Iff ot- orrhagia ob Placentam OriOcio Uteri Adlnerenteni, 4to. Basil, 1753.—A. Pasta, Discorso In'erno al Flusso di Sau- gue dell’ Utero delle donne Gravide, 4to. Bergamo, 1752.— Staehlin, De Partu cum Himorrhagi& Uteri conjuncto, 4to. Lugdun. Batav., 1753. — Reichard, De Hamorrhag. Uteri Partum Insequente, 4to. Argent., 1755.—A. C. Lorry. Qusstio Medica. — An Partur. Aecedente Hicmorrhagia Uterina, Partus, Diverse pro Diverse Casu Encheiresi, promovend. ? 8vo. Paris, 1758.—Mauriceau, Des Maladies des Femmes Grosses, t. i., p. 386.— Dentin. Beytr&ge, iv.. p. 28 —Young, On Opium, p. 76. —Thilenius, Medic, and Ghirurg. Bemerkungen, p. 151.—Futhergill, Med. Observ. and Inquiries, vol. v., p. 160.—Trioen. Observ. Med. Cliir., p. 18. — Heberden, Comment, in Morb. Ilistor e et Curat., cap. 62.—Astruc. Traite des Maladies des Femmes, t. ii., p. 65, 110.—Stoll, Pnelecl., t. ii., p. 104, 381 ; Rat. Med., P. iii.. p. 48; P. vii., p. 279.—P. Copland. Med. Facts and Observations, vol. iv., n. 9. p. 188. — Douglas, Med. Com- munications, 1., n. 6 —J. W. Gulbrand, De Sanguilluxu Uterino. and Edin Medical Commentaries, vol. vi., p. 21.— K. Rigby, An Essay on the Uterine Hemorrhage, &r„, 8vo. Lond., 1775. — C. Roux, Observations sur les Pertes de Sang de Femmes en Couche, &c., 8vo. Dijon, 1776.— Aaskow, De usu Opii in Hmmorrhagiis Gravidarum, 1777. —Eyeril, Sylloge, iv., p. 37.— Carron, Journ. Gen. de Med., t. xxxi., p. 241, 257. 353.— Wallis, Essay on the Conse- quences attending injudicious Bleeding in Pregnancy, 8vo. Lend., 1781.—Denman, Essay on Uterine Haemorrhages de- pending on Pregnancy and Parturition, 8vo. Loud., 1786. —Fothergill, Memoirs of the Medical Society of London, vol. ii., n. 9.—Bang, Collect. Soc. Med. Hafn., i., no. 93.— Aaskow, Act. Reg. Soc. Med. Ilavn., vol. i., p. 49; Ibid., vol. ii., n. 4, p. 32 ; Ibid., vol. iii., p. 366 ; Ibid., vol. iv., p. 271, 284.—J. P. Frank, Dissertatio de Hiemorrhag. Uteri ex Spasmo Secundinas Incarcerente, 4to. Ticini, 1789.— C. Strack, Observat Medicinales de Una prae Caeteris Cau- sa propter quam Sanguis e Fsminarum Utero nimis proflu- it, 8vo. Berlin, 1794 (Accumulation of sordes in the diges- tive canal).—Millot, Oliserv. sur les Pertes des Femmes, 8vo. An., vi.—Thomann, in Roeschlaub, Magazin der Heil- kunde, b. v., p. 257 ; et Annales Wurceb., ii., p. 215.— Siebold, Diss. Menorrhagia Uteri Hsmorrhagia. Wurceb., 1799. — Clarke, Trans, of Soc. for Promoting Med. Knowl- edge, n. 13.—Boucher, Journ. Gen. de M6d., t. xxiv., p. 380. —A. Leroy, Legons sur les Pertes de Sang pendant la Grossesse, 8vo. Paris, 1801. — Demangeon, De Fallac.t atque Noc. Obturamenti in Hiemorrhag. Uteri Cohibend. Usu., 4to. Paris, 1803.—St. Amand, Diss. sur les Pertes de Sang, &c. Paris, 1803.—J. Burns, Practical Observa- tions on Uterine Haemorrhage. Lond., 1807.—C. H. Val- entin, Diss. sur les Pertes, qui precedent, accompagnent, ou suivent les Accouchemens. Paris, 1808.—Mitchell, Med and Phys. Journ., Jan., 1808.—Robertson, Ediri. Med. and Surg. Journ., 1809.—Gaston, Sur les Pertes Uterines pen- dant et apres 1’Accouchement, &c. Paris, 18,12.—D. G. A. Richter, Die Specielle Therapie, b. iii., p. 477.— Feist, Gemeinsame Zeitschrift fur Geburtskunde, tom. iv. (Savine in passive uterine haemorrhage.)—Doemling, Horn's Archiv., b. iii., p. 50, 53, 61.—Osiander, Denkwiirdigkeiten, b. i., 2» n. 1.— Unger, in Siebold, Lucina, b. ii., 2 st., n. 5.— Wege- lin, Stark's Archiv., b. iv., p. 101. — LoeJJler, Stark's Ar- chiv., b. vi., p. 10.—Humborg, Stark’s Archiv., b. vi., p. 399.—J. Ramsbotham, Pract. Observations in Midwifery, p. 105.—Osiander, Loder, Journ. fur Chirurgie, b..ii., p. 382. —Fieliz, in Lodcr's Journ. flir die Chirurg., b. iii., p. 329. —Gebel, in Hufeland's Journ. der Pract. Arzneyk., b. i., 1 st., p. 180.—Conradi, in Ibid., b. vi., p. 498, 501.—Holst, in Hufeland's Journ. der Pract. Ileilk., b. vii., 4 st., p. 150. —Muller, in Ibid., b. ix., 4 st., p- 166.—Kortum, in Ibid., b. x., 2 st., p. 26.—Amelung, in Ibid., b. xxii., I st., p. 12, 63.—Bigeschi, Bulletin de la Faculte a Paris. 1812, n. viii., p. 178.—Baudclocque, Recueil Periodique, t. iii., p. 3.— Gcndron, in Ibid., t. vii., p. 177.—Stewart, Transact Med. Chir. Society, vol. iv., p. 361.— Goffm, Essai sur les H87,710, 786.— W. Laidlaw, Ibid., vol iii., p 727.—J A. Hinge ston, Ibid , vol. xi.. p. 76.—Rigby, Ibid., vol. xiv , p. 331.— S. Malins, Ibid. vol. xiv. — F. H. Ramsbotham, Ibid., vol 142 HAEMORRHAGE INTO SEROUS OR SHUT CAVITIES. xiv., p. 025, et seq. — Roberton, Ibid., vol. xvii., p. 924.— M. Nauche, Des Maladies propres aux Femmes, t. u., p. 483. — M. Ryan, Manuel of Midwifery, p. 204. — A. B Granville, Illustrations of Abortion, 4to. I.ond., 1833.— J. Maxwell, Glasgow Medical Journal, Oct., 1833.—R. Lee, Researches on the Pathology and Treatment of Diseases of Women, p. 18f, 8vo. Loud., 1633.—J. E. Beatty, Dub- lin Med. Journal, vol. iv., p. 329.—R Collins, Pract. Trea- tise on Midwifery, p. 89, et seq., 8vo. Lond., 1835.—V. 1). Davis, Principles and Practice of Obstetric Medicine, &o.., 2 vols., 4to, 1836, vol. ii., p. 1029. [Am. Bib. and Ref.—[See Bib. of art. “ Haemorrhage,” &c.l 274. X. Of Haemorrhage into serous or shut Cavities.—Owing to the organization of serous membranes, haemorrhage very seldom takes place from them, the vessels with which they are supplied rarely experiencing that de- gree of relaxation admitting of the exudation of blood, or even of a portion of its colouring particles. When blood is effused into cavities formed by serous membranes, it proceeds from one or other of the following sources: 1st. From the rupture of an aneurism. 2d. From the erosion, ulceration, or rupture of an artery or vein. 3d. From rupture or ulceration of an organ or part. 4th. From relaxation of the vital cohesion with which the serous tissues and extreme vessels are endowed. 5th. From deficient crasis, or other changes in the blood ; and, 6th. From the coexistence of the last two conditions. Haemorrhage may occur from the first, second, or third of these causes, without any manifest indisposition or disorder suffi- cient to induce the patient to resort to medical advice ; but it never appears as the conse- quence of the other pathological states, unless in the advanced stage of the most dangerous, depressing, or malignant maladies. When the hemorrhage occurs from the former of these, it is often to a very great amount; but it very rarely is excessive when it proceeds from the latter states. In all, the existence of the ex- travasation is to be inferred from the presence of the constitutional symptoms (§ 25) usually produced by profuse ha?morrhages. When the states of vital power and of the blood cause sanguineous exudation into the shut cavities, ecchymoses or petechiae in other parts of the body, and haemorrhage from mucous canals are very generally also observed. 275. i Haemorrhage from the serous Mem- branes of the Brain or Spinal Chord very rarely occurs, unless as a consequence of con- cussions or injuries of the head or spine, or from violent exertion, particularly in warm weather, or under a hot sun. Sanguineous ef- fusion between the membranes may, however, follow the rupture of small superficial aneu- risms or varices, and the growth of malignant or other tumours, or the occurrence of ulcera- tion, implicating the membranes. Haemorrhage in these situations causes apoplexy and para- plegia, or other comatose and paralytic states. I have seen very slight effusion in the spinal canal in a case of tetanus ; and Dr. Thomson observed it in a case of rabies. Bonrt, Mor- gagni, and Ollivier have seen effusion si- multaneously between the membranes of the brain and spinal chord. (See arts. Apoplexy, Brain (<) 26), Palsy, and Spinal Chord.) 276. ii. Haemorrhage into the Pericardium may take place without rupture of the heart or large vessels within the pericardium, although more or less manifest rupture is the most fre- quent cause. Rupture of the parietes of one or other of the cavities of the heart has been observed by Salzmann, Morgagni, Morand, Portal, Corvisart, Laennec, and several oth- ers enumerated in the subjoined references. In the larger proportion of these cases, the pre- existent lesions which occasionally give rise to rupture have existed. (See art. Heart.) But rupture of the coronary artery (Viridet), of the vena cava (Wright), or of one of the pul- monary veins, or of an aortal aneurism, or per- foration of the aorta (Fiorati) within the peri- cardium, may be the source of hasmorrhage. Several instances of these are referred to be- low. Blood may also be effused, or, rather, ex- uded into the pericardium in greater or less quantity, or mixed with more or less water, without laceration or rupture of any vessel. Cases of this kind have been observed by Va- ter, Baader, Sandifort, De IIaen, Thomson, Hooper, myself, and others (see references), and occur chiefly in the advanced stages of adynamic, scorbutic, putro-adynamic, or ma- lignant diseases. Sometimes the blood is poured out between the layers of the pericar- dium, forming sanguineous vesicles or ecchy- moses. (Morgagni, De la Faye, Stoll). When heemorrhage into the pericardium arises from any of the kinds of rupture just enumerated, death generally takes place suddenly ; but when it is exuded, in the manner just stated, the already depressed vital power is still far- ther depressed, and the oppressed action of the heart is more slowly abolished by the ef- fusion. 277. iii. Haemorrhage into the Pleural Cavities has been observed by Morgagni, Plenciz, Caldani, Stoll, Frank, Johnson, myself, and others. It most frequently arises from rupture of an aortal aneurism within the thorax. In this case the blood is effused, in the first instance, into the posterior mediasti- num, death seldom occurring until the accu- mulated blood lacerates this part, and opens the way to suddenly fatal effusion into one of the pleural cavities. The aneurism may be so large as to occasion symptoms which will lead to its recognition ; or it may be so small, and attended by so little disorder, as to escape de- tection, as in the case of Sir David Barry, an eminent member of the profession. In him, the symptoms before, and the appearances af- ter death, illustrated this procession of the morbid phenomena. Haemorrhage into the pleural sac may proceed, also, from erosion or ulceration of the aorta (Morgagni, Portal) ; from rupture of the pulmonary vein (Eicken) ; from rupture of the vena cava (Portal) ; or from rupture, or a varicose state of some of the veins near the pleural surface (Caldani, Portal, &c.). Haemorrhage into the thorax is frequently consequent upon fractures of the ribs and wounds ; and many of the instances where it seems to have arisen spontaneously, have been induced or hastened by external in- jury or muscular exertion. More or less blood may be exuded from the surface of the pleura, in states of very intense inflammation, attend- ed by diminished vital resistance, or during the advanced stages of putro-adynamic fevers, and of other malignant diseases. But these are comparatively rare occurrences ; and the blood effused is seldom pure, but mixed with much serum or watery exhalation ; or. rather, HAEMORRHAGE INTO THE AREOLAR TISSUE. 143 the effused serum is more or less deeply col- oured by an admixture of red particles. 278 iv. Haemorrhage into the Peritoneal Cavity, like haemorrhages into other serous cav- ities, seldom occurs, unless as a consequence of external injuries or wounds. It sometimes depends upon rupture of a large vessel, or the laceration of some viscus, especially the spleen, liver, or stomach ; but it may proceed from other lesions. Ballonius, Portal, Dan- iel, and others have recorded instances of its occurrence from rupture of the spleen, a case of which has come under my own observation. Ayrault mentions an instance in which it arose from ulceration of some of the vessels of this viscus. Blane found it to proceed from the surface of the liver. When the spleen or liver is engorged or enlarged, after repeated attacks of ague, particularly in warm or mias- matous countries, a comparatively slight ex- ternal injury, or a concussion of the trunk may occasion laceration or rupture of either, with extravasation of blood in the abdomen. Haem- orrhage in this situation may arise also from operations for strangulated hernia, especially when a portion of omentum has been removed ; or from paracentesis in cases of ascites (Bel- locq), or of encysted dropsy. Rupture of an aortal aneurism, or of the aorta without any pre-existent aneurism (Ferro, J. P. Frank, James, Arnott, Rose, Hume, &c.), of the vena cava (Bonet, Lancisi), of the vasa brevia (Sandifort), of the mesenteric artery (Ferro), and of the splenic artery (Nenei), with haemor- rhage into this cavity, have been severally no- ticed. Jenty mentions a case in which rup- ture of the vena cava seemed to have been fa- voured by curvature of the spine. Heim traced the haemorrhage to the ovarian vessels ; Pal- fyn, to the vessels of the omentum ; Godelle, to rupture of a Fallopian tube ; and Portal to the mesenteric vessels, in a female who had experienced sudden suppression of the cata- menia in one instance, and to the ovarian ves- sels in another. In cases of tubal or ovarian fetation, extravasation of blood into the ab- dominal cavity is a necessary consequence of the growth of the ovum; and it has been ob- served in such circumstances by Buttner, Heim, Clarke, Painter, myself, and many oth- ers. Osiander met with haemorrhage into the peritoneal cavity after delivery, that had arisen, in his opinion, from dilatation of the Fallopian tubes. The exudation of blood, or of a bloody serum from the peritoneal surface occurs only during morbid states of the system, similar to those in which it has been observed to take place into the pericardium or pleura. (See art. Peritoneum). Bibiiog. and Refer.—i. Hemorrhage from the Membranes of the Brain and Chord.—Bonet, Scpulch , lib. i., s. ii., p. 64.—Morgagni. Epist iii., s. 2 —Boerhaave, Pralect. ad Institnt.. b 501.—Chevalier, in Medico- Cliirurg. Tians , vol. ii., art 9. — Brera and Harles, Ueber die Entiindung des Rii< kenmarkes. Nftremb , 1814, p. 26. — Heirship, Pract. OLservat. on Surgery, rase 30.—A. T. Thomsen, Medico-Ohirurg. Trans., vol. xiii., p 2.— Otto. Compend. of Patholog. Anat., transl. by South, vol. i., p. 427.— (Illivier, Traill; de la Moelle Epiniere. et de ses Mal- adies. 2 tomes. Paris. 1827.—(See, also, the Bibliog. and Refer io arts. Brain and Spinal Chord.) ii Hemorrhage into the Pericardium.—A. From Rupture of the Heart or of the Vtssels within the Pericar- dium.— Aria Nat. Cur., vol. ii., obs. 107 ; vol. v.. obs. 37.— Salzmann, De Sol-Maned Morte tf Sang. in Pericardium ef- fuso, in Haller's Col. Disput. ad Prax. Med.,t. ii.—Viridet, in Haller's Bibliolh. Chirurg., vol. ii., p. 103.—Morgagni, De Sed. et Caus. Morh., epist. xxvii., sect, i., 6-11 ; ct epist. Ixiv., sect. 15,—Ho.zon, Journ. de M6d,, t. xix., p. 516, 1758.—Haller, Elementa Physiol., t. i.,p. 407.—Double- day, in Med. Observ. and Inquiries, vol. v., p. M4.— Wright, Ibid., vol. vii.—Morand, M6m. de l’Acad. Roy. des Scien- ces, an. 1782.—Portal, ini bid., an. 1784, et (Jours. d’Anat. M6d., t. iii., p. 94.— Schmucker, Verm. Chir. Schrifteu, t. iii., p.294, ed. 1788.—A. Olmi, Memor. di una Morte repen. cagionata dalla Rottura del Cuore. Flor., 1803.—Fxorati, in Saggi Scien. di Padova, t. iii.—Brera Syllog. Opusc. Select., vol. x., p. 202.— Hodgson, Dis. of the Arteries and Veins,.case 8.—Langlade, Journ. de M6d., t. Ixxxviii., p. 199.—H. Chequet, Bullet, de la Fac. de Med. de Paris, t. 111., p. 214.— V. Molt, Trans, of the Med. and Phys. Soc. of New-York, vol. i., 1817.—Rostan. Nouv. Journ. de Med., t. vii., p. 265, 1820.—Laennec, De l’Ausoultation Mediate, t. ii„ p. 357.— Bland, Bibliotheque Mddicale, t. lxviii., p. 364, 1820.—Ashburner, London Med. and Phys Journ., Dec., 1822.—Bertin, Traitfi des Mai. du CtEur, &c., p. 52.— R. Adams, Dub. IIosp. Rep., vol. iv., p. 414.— Bayle, Rev. Med. Juillet, 1824.—Baron, Archiv. Gen. de Med., t. vi., p. 619. —Andral, Ibid., t. iv., p'. 616.—J. Frank, in Praxeos Med. Univers, Praecepta, vol. viii., part ii., cap. 13, t 54, p. 314. —Zecchinelli, Sulla Rottura del Cuore, in Nouvi Saggi della Caesar. Acad, di Sci. di Padova. Pad., 1825, t. ii.— Abercrombie, in Transac. of the Med. and Chirurg. Society of Edin., vol. i.—Dezeimeris, Recherches sur les Ruptures du Cceur, in Archives G6n. de Med., t. v., ot vi., 2d ser., 1834. B. From Exudation without Rupture.— Vatcr, in Miscel. Nat. Curios., dec. iii., ann. ix , p. 293.—De la Faye. Ilist. dp l’Acad. des Scien. de Paris, ann. 1735, p. 20.—Baader, Observ. Med. Incisionibus Illustratae, 1762, obs. i.—Sandi- fort, Thesaur. Diss.,vol. iii.—Lieutaud, Ilist. Anat. Med., t. ii., obs. 659.—De Haen, Rat. Med., &c., vol. ix., cap. i., t) 6.—Thomson, In Med. Observ. and Inquiries, vol. iv. Lon- don, 1772.—Hooper, in Memoirs of Med. Soc. of Lond., vol. 1., art. 18.—Alston, in Edin. Med. Essays and Observ., vol. v., p. ii., p. 609.—Otto, Selt. Beob., vol. i., p. 95.—Hufeland and Harles, Journ. der Pract. Ileilk., Jan., 1815, p. 85.— Fitzpatrick, in Lond. Med. Repos., vol. xvii., p. 295.—Au- thor, in Ibid., p. 298.—(See, also, Bibliog. and Refer. to arts. Heart and Pericardium.) iii. Haemorrhage into the Pi.eural Cavities.— Acta Nat. Curios., vol. i., observ. 142.—Marcellus Donatus, 1. iii., c. 9, p. 263.— Wepfer, De Apoplexia, p. 351. — Wei- kard, Vermischte Schriften, b. ii., p. 36.—Morgagni, Sed. et Caus. Morb., epist. ix., art. 4 ; epist. xvii., art. 17 ; epist. xxvi., arts. 3, 11, 17, 29.—Plenk, Samml. von Beobacht., b. ii.—Plenciz, Acta et Observ. Med., p. 162 —Collomb, in Haller's Bibl. Chirurg., vol. ii., p. 172.—Eicken, Sammlung, b. i., p. 145.—Chappe, Journ. G6n. de M6d., t. xxvi., p. 352.— Henkel, Samml. Med. u. Chir. Anmerk., b. ii., art. 1. De Horne, in Mem. de la Soc. Roy. de M6d. nd ann. 1779, p. 300.—Lieutaud, Hist. Anat. Med., 1 ii., obs. 794, 795, 798, 922.—Salle, N. Beytrdge, b. ii., p. 25.—Stoll, Rat. Med., oof, a flux), Hippocrates, Ga- len, Celsus. Hcemorrhois, Pliny, Linnams, Sa- gar, Sauvages, Cullen. Hcemorrhoides, Junck- er. Fluxus Hcemorrhoidalis, Hoffmann. Proc- torrhea, Auct. var. Proctalgia Hcemorrhoi- dalis, Macbride. Marisca, Good. Hamor- rhischesis, Ploucquet. Hcemorrhcea Vasorum Hxmorrhoidalium, Swediaur. Hemorrho'idcs, Flux Hemorrhoidal Fr. Goldaderjluss, H'din- orrhoideu, Germ. Morice, Ital. Piles. Classif.—1. Class, Febrile Diseases; 4. Order, Haimorrhages (Cullen). 1. Class, Diseases of Digestive Organs ; 1. Order, 1 Affecting the alimentary Canal (Good). II. Class, II. Order (Author). 1. Defin.—Pain, tension, weight, heat, or oth- er uneasy sensation, referred to the rectum and anus, accompanied or followed by tumours in these parts, or by a flow of blood from them when the pa- tient is at stool; recurring after intervals, and sometimes periodically■ 2. Preliminary Remarks.—There are few dis- eases upon which so much has been written— ignorantly and dogmatically written—as upon haemorrhoids. In modern times, the pathology and treatment of this disease have been too generally viewed in a limited point of view, and usurped by persons who have endeavoured to convince the public that they have made it the subject of especial investigation, or even of exclusive study. Judging, however, from their writings, more mischief than benefit has thus arisen from the mechanical division of labour they have adopted; and not only have they failed in advancing our knowledge as to the na- ture and treatment of the malady, with which they profess so intimate an acquaintance, but they have actually overlooked, or been ignorant of the part it occupies in the circle of morbid action, and they have frequently, even when affording temporary benefit by empirical means, or by local or surgical aid, caused most serious consequent mischief. Those affected by this complaint are unable to foresee the consequen- ces that may result from injudicious interfe- rence, especially if appropriate medical treat- ment be not afterward pursued; and, while immediate relief, when procured, is made a matter of high commendation, both by those who receive and by those who administer it, the remote or contingent bad effects are rare- ly traced by them to their origin, and are often of such a nature as to terminate all inquiry. 3. Of those who have professed an infallible cure for haemorrhoids, there have been few who appear, from their writings, to have been ac- quainted with the nature ofthe complaint; with the relation in which it often stands to other morbid conditions ; with its frequent existence as the more manifest part of a more important and concealed state of disease, and with the most safe and appropriate means of removing it. They have viewed it as a local disorder which is to be cured by local or surgical treat- ment, and not as a visceral disease often de- pending upon latent or extensive morbid, con- ditions, to which surgical measures may prove injurious, and for which such measures are, at most, only occasionally required, and then as adjuvants merely of a strictly medical, and oft- en constitutional treatment. Owing to an im- perfect knowledge of the varieties of hcemor- rhoidal tumours, and of their pathological rela- tions, a. Fatal haemorrhage has not infrequent- ly resulted from excising or puncturing them ; b. Enteritis, peritonitis, and even internal phle- bitis, have followed the extirpation of them by “ligature ; and, c. Fatal diseases of the brain, or of the lungs, or even of the liver, have arisen from the permanent stoppage of a discharge by these means, to which the system had become habituated, and which had warded off these and other serious maladies. This evacuation being arrested by these or other local meas- ures, the safety-valve to an overloaded state of the vascular system is permanently closed, and a source of local derivation and of dis- charge that had preserved a vital organ from impending disorganization is cut off, without either preparing the system for the changes thereby produced, or substituting some other evacuation in its place. Persons who thus ex- tend the division of labour principle to a sci- ence which admits npt of it with advantage ei- ther to the branch which is thus attempted to be cultivated, or to those upon whom it is prac- tised, may reply that they have seen no mis- chief result from the means they employ ; but the mischief in such cases is strictly of a med- ica. nature, is often remote, and falls not with- in the sphere of those who thus unscientifically and empirically limit the practice of their pro- fession. Division of labour may improve man- ual dexterity, or may extend mechanical con- trivance ; but it cannot improve pathological knowledge, nor illustrate the relations or asso- ciations of morbid actions, nor lead to truly sci- entific, and safe, and appropriate, and perma- nently beneficial modes of cure. 4. 1. Pathological History of the Disease. —The term hemorrhoids, signifying literally a flow of blood, was made use of by Hippocrates ; and, down even to the present time, has been applied to a dilatation of the veins at the ex- tremity of the rectum, accompanied with a flow of blood, and the vessels of this part have been consequently called the haemorrhoidal vessels. Many of the ancient and of the older writers have extended the term, not only to every com- plication of this complaint, but also to haemor- rhages from natural outlets ; and thus haemor- roids of the uterus, of the bladder, and of the mouth have been frequently used to denote haemorrhage from these parts. Since the time of Morgagni, the term has been applied indif- ferently to that morbid condition which was generally attributed to dilatation of the haem- orrhoidal veins, and to haemorrhage from the rectum, although some authors have endeav- oured to restrict it to one or other of them. But as the tumours and the flow of blood, whether appearing separately or in conjunction, arise from the same source, I shall consider them as varieties of the same disease. It will, however, be shown that the haemorrhoidal tu- mours consist of different kinds or modifica- tions of structural lesion, and that either of them may take place independently of, as well as in connexion with a discharge of blood from the anus. 5. i. General Character and Symptoms of Hem- orrhoids.—The first attack is usually slight, and often attended by little constitutional disorder. Slight pain, heat, weight, or fulness are felt at the extremity of the rectum, or about the sa- crum, sometimes extending to the perineum, with obscure tenesmus or pain at stool, often with costiveness, and occasionally with an ir- regular or irritated state of the bowels. The sensibility of the bladder or urethra is frequent- ly, also, increased. After a short time, or in two or three days at most, a slight flow of blood, generally of a bright colour, is observed with the faeces, or smearing their surface. In some persons this flow does not take place, particularly in early attacks ; but when it does, fc. is usually critical, and all the symptoms sub- side. When this discharge does not occur, as well as very frequently when it does, one or HAEMORRHOIDS—General Character and Symptoms. more tumours, of varied size, begin to appear within or at the verge of the anus. These tu- mours are preceded by a stinging or pricking pain, which increases as they enlarge; or are compressed by the sphincter ani. Sometimes blood oozes from their surface, or is squirted out through small apertures when at stool. Occasionally they remain dry, or are moistened by a colourless serum ; but in either case they collapse after a short time, and entirely or partially disappear. 6. After a longer or shorter interval the same train of symptoms returns, generally in a great- er degree, and acquires increased severity by the repetition. The pains are more acute, es- pecially when sitting, standing, or walking; and often extend down the insides of the hips and thighs ; the blood is discharged in greater quantity ; and the tumours, if they have pre- viously been developed, become larger or more numerous. Subsequently, when they collapse, and particularly when they have been often distended, they present so many flaps of skin, and, when external, form a serrated margin to the anus. 7. In irritable or weak persons, especially when the complaint is simple or primary, is se- vere, or returns often, the local alteration af- fects more or less the general health. Fre- quent chills or coldness, alternating with flush- es, dryness of the mouth, hardness or frequen- cy of pulse, costiveness, pallor of the counte- nance, and other febrile symptoms are com- plained of. The functions of digestion are also more or less deranged, and the bowels are ei- ther costive or irregular, especially when the complaint is dependant upon disorder of the hepatic organs. When it is associated with disease of the lungs, the symptoms referrible to the chest are generally materially alleviated by it, especially if it be attended by sanguine- ous discharge ; and a similar result follows its occurrence in plethoric persons liable to head- aches, or to congestion of the brain or liver. In all cases, however, care should be taken not to mistake the constitutional disorder, or the af- fection of remote organs, often occasioning the disease, for sympathetic disturbance preceding the haemorrhoidal attack. A minute examina- tion of the relation of the complaint with other ailments should always be instituted before the indications of cure are determined upon. 8. Such is the usual course of haemorrhoidal attacks ; but the sense or weight, heat, fulness, or constriction, with more or less pain about the anus, and slight constitutional disturbance occasionally occur without either effusion of blood or the formation of tumours, even in old cases; and the haemorrhage sometimes takes place without the tumours, but seldom without being ushered in by the other symptoms. In- deed, in all cases, indications of congestion, or of increased action of the vessels of the -part are present in some degree, these states of the vessels constituting a principal feature of the complaint. Both the local and constitutional symptoms, and the structural lesions, show that increased determination of blood to the extreme vessels of the part in most cases, and impeded return of it from them in others, are the chief pathological conditions of the disease. 9. ii. Of the Hemorrhoidal Tumours — The nature of these tumours was not understood 145 146 until lately. They were usually distinguished into internal and external, and into bleeding and blind piles, according to their situation in re- spect of the verge of the anus, and to their con- nexion with a sanguineous discharge. But most of the older writers and many of the mod- erns, and among the latter the Bells, Home, Baillie, Cooper, &c., imputed them to dilata- tion of the veins. More correct views as to their structure were entertained first by Le Dran and Richter, perhaps also by Cullen and Abernethy ; and more certainly by Chaus- sier, De Larroque, De Montegre, Calvert, and Colles. From my own observations, as well as from the researches of these and other pathologists, hereafter referred to, there are three kinds of haemorrhoidal tumours, differing essentially both in their structure and appear- ance. *-a. The first, or most common kind, is first seen in the form of fleshy tubercles of a brownish or pale-red colour, situate within the anus, or descending from the rectum. They have a somewhat solid or spongy feel; and, when divided, they present a compact or po- rous and bloody surface. As the blood oozes from the cut surfaces, they become pale and flaccid. When the tumours are external, they are paler and more elastic ; are infiltrated by serum ; and are sooner produced, and disap- pear more readily than when they are internal. In either case, they often contain a central cavity filled with fluid or coagulated blood, of a dark colour. This cavity is either smooth or granulated, and minute vessels may be traced into it; Mr. Calvert states that it has no di- rect connexion with any larger vessels. It is usually small; generally about the size of a pea, but sometimes that of a bean or walnut, or even larger. More frequently, however, there is no regular cavity or cyst; the substance of the tumour being as if infiltrated with blood, which becomes coagulated and dark; but this appear- ance is not owing to extravasation, but rather to dilatation of a number of small vessels which traverse the tissue in the direction of the axis of the rectum, as, upon dividing the part longi- tudinally, numerous dark streaks are seen in its substance, while a section made transverse- ly shows only small, roundish specks. 10. The patient is usually made sensible of the development of these tumours by a pecu- liar pricking or stinging sensation, within or at the margin of the anus; and one or more are found slightly elevated, or pressed downward by the sphincter. The increase of these tu- mours takes place more by elongation than by expansion, and they assume a conical form, and are larger than their necks. Sometimes blood is exhaled from their surface ; in other cases, or on other occasions, a serous fluid is exuded ; and occasionally they are entirely dry, especially when they are external. In either case they generally disappear in two, three, or four days, but return again at an uncertain or at a regular period, and increase in size, be-' coming firmer in texture. After some blood is evacuated from them, or after the determina- tion of blood to the parts has ceased, they col- lapse, leaving small pendulous flaps of skin, which ultimately disappear if the tumours have been small; but if they have been large, these flaps continue conspicuous, and give a project- ing and irregular margin to the anus. Having HAEMORRHOIDS—Consequences and Complications. been strangulated by the sphincter, or repeat- edly engorged with blood or lymph, or chroni- cally inflamed, these tumours become more solid and almost permanent, are a source of constant discomfort, and give rise to several of the consequences and complications about to be noticed 20). 11. The permanent state of the tumours is owing partly to the development of capillary vessels, and partly to the effused blood and lymph becoming organized ; this latter circum- stance, especially, giving rise to the excres- cences or irregular mass of tumours found around the anus in those subject to haemor- rhoids. Occasionally the tumours acquire a very great size, arising from the effusion of much blood in the central cavity, and of blood and lymph in the cuticular envelopes. In- stances of the enormous size of these tumours have been recorded by Schmucker, Calvert, and other writers about to be referred to. 12. b. Haemorrhoidal tumours formed bxj a varicose state of the veins of the rectum are not so common as those just described. They seldom attract attention until they have made some progress, for the distention takes place very gradually, without causing much sympathetic disturbance, or materially increasing previous disorder. They are not so disposed to enlarge at particular periods, and are more permanent and less painful than the form already noticed. They are commonly of a dark or bluish colour, and soft and elastic to the touch. When com- pressed by the finger they become sensibly less, but return to their former state when the pres- sure is removed. They are round and broad at the base, and often distributed in irregular or ill-defined clusters. They evince little dis- position to bleed, unless when ruptured or in- jured. They appear crowded together, extend up the rectum, are more or less internal, or become external chiefly during costiveness, or when the patient is straining at stool, or after a faecal evacuation; while the former kind is limited, and generally external, or within the reach of the finger. Valsalva, Ludwig, Petit, Richerand, Begin, Calvert, and others have seen ha;morrhoidal varices extend upward along the rectum to the colon, especially in per- sons who had experienced obstruction of the portal circulation. M. Begin observes that, in most cases, the dilated, superficial, submu- cous, or subcutaneous veins are only the small- er part of those surrounding the rectum. Some- times the lower part of this intestine appears as if plunged in the middle of a network of di- lated and engorged veins, forming a thick vas- cular ring, the incision or puncture of which may give rise to dangerous haemorrhages. M. Richerand found, upon dissection, those vari- cose tumours filled with clotted blood, and their interiors continuous with those portions of the veins which retained their usual size. These dilated vessels presented alternately a state of distention and their natural caliber, and were continued in every direction, forming a plexus around the outlet of the bowel, the dilated por- tions being covered only by the thinned mu- cous membrane. 13. As the varicose tumours arise from many of the causes that produce the preceding form (§ 9), and as both varieties occupy nearly the same situation, it may be reasonably inferred HAEMORRHOIDS—Discharges from. 147 that they may exist together, or that the latter may often give rise to the former in connexion with it. Now this is sometimes the case ; in- flammatory irritation supervening in the course of the varicose form of the disease, superin- ducing the mariscce, or the first variety of tu- mour, and thereby obscuring the varicose char- acter of the former. Or a different procedure, as Mr. Calvert supposes, may take place ; the veins becoming dilated in consequence of the previous formation of the cellular tumours. These complications of the tumours can be as- certained only by a careful examination, and by attention to the history, progress, and symp- tomatic relations of the case. 14. c. A third form of haemorrhoidal tumours, of an erectile character, was first noticed by Sir James Earle, and more particularly described by Mr. Colles. These tumours are of differ- ent sizes; are soft and spongy to the touch, of a purplish colour, with a number of minute but distinct vessels on the surface of each. One, two, or more of these tumours protrude through the anus when the patient is at stool. Early in the disease the protruded parts retire spontaneously; but, in advanced stages, they require to be replaced by the hand. Alvine evacuation is followed by pain, which, especial- ly when the disease is prolonged, does not cease for two or three hours, and is attended by losses of blood, which sometimes occasion exsanguine exhaustion, the sphincter ani be- coming wide and relaxed, and the tumours pro- truding. Dr. Colles states that, on examina- tion after death, he found blood-vessels as large as crow-quills, running for some way down the intestine, and then dividing into a number of branches ; each of these vessels ramifying pro- fusely, and each forming, by the interlacing of its numerous branches, one of these erectile or vascular tumours. The trunks and branches of these vessels were covered only by the lining membrane of the intestine. [The late Dr. George Bushe, of New-York, thus speaks of haemorrhoidal tumours : *' I have repeatedly injected these tumours with coloured water, both from the arteries and the veins, and when cut into while the fluid was injected, small jets were observed to issue from many points. I have frequently dissected them with the greatest ease, and found that they were spongy, reddish, and contained both arter- ies and veins, the latter being most copious, but always perfectly healthy.”* Dr. John Watson, of New-York (Neio-York Journ. of Med. for July, 1844), states that, so far from finding the veins in haemorrhoidal tu- mours “ healthy,” he has often observed them not merely distended enormously beyond their natural size, but tortuous, convoluted, and thrown into irregular pouches, with their coats thickened, the blood within them coagulated, and the cellular tissue surrounding them hyper- trophied and consolidated, precisely as we see in some of the worst forms of varices in the veins of the limbs. Dr. W. also remarks, “ On one occasion, in which I assisted Dr. Stevens in an operation for the removal of an immense protrusion of the anus, depending on a vast number of haem- orrhoidal tumours that lay beneath the surface, and in which the parts were removed by ex- cision, I took occasion to examine the diseased structure carefully. After the excision, the exposed surface bled profusely. The haemor- rhage was checked with difficulty, and only after repeated and protracted efforts with the tampon, in which the patient appeared to suf- fer infinitely more than if ligatures had been applied. On inspecting the well-exposed bleed- ing surfaces in this case, I could readily distin- guish the minute capillary arteries pouring out their delicate jets of red blood from the num- berless dilated veins, each of the size of a crow-quill, or larger, which gave the whole surface the perforated appearance of the top of a watering-spout, and from which issued a torrent of venous blood. I took occasion after- ward to examine the mass that had been re- moved. After it had lain a day or two in diluted alcohol, the dilated veins on its surface had contracted nearly to their primitive size; but, on tracing them inward, I found them communicating with pouches at least the sixth of an inch in diameter, which, when dissected from the surrounding parts, might, in size and form, be compared to small leeches. Many of these pouches communicated with a capillary vessel at either extremity. Their coats were rather thick; they were filled with coagulated blood ; they were very numerous, pressed upon one another in all sorts of wrays, and were held together by thickened and indurated cellular tissue. They were, in short, varicose pouches, formed in the course of the haemorrhoidal ves- sels, just as such pouches are seen to form in the branches of a varicose saphena vein, only more numerous, and in closer apposition than is usual in the latter case.”—(Loc. cit.)] 15. iii. Of the Hcemorrhozdal Discharges.—A The ancients believed the blood to be dischar- ged from the tumid extremities of the haemor- rhoidal veins. Morgagni found these veins more or less dilated in several cases, and it was very generally considered that the blood oozed through, or proceeded from rupture of these vessels. The investigations of modern pathologists have satisfactorily shown that the haemorrhage may arise from various sources: 1st. From congestion of the vessels of the part, followed by exhalation or exudation from the internal surface of the rectum; 2d. From irri- tation of this bowel, followed by vascular de- termination and sanguineous exhalation ; 3d. From the surface of the haemorrhoidal tumours, especially those belonging to the first and third varieties ; and, 4th. From the rupture of vari- cose or enlarged vessels. When the blood proceeds from the first or second of these sour- ces, it may be seen to exude from the surface of the protruded portion of bowel; and the discharge generally removes all the symptoms characteristic of the complaint. It is also fre- quently preceded and followed by an exhalation of a serous nature from the same source. Haemorrhage, in connexion with the common form of tumour, may arise from exhalation from its surface; or from the contraction of the sphincter forcing blood, in a fine stream, from one or more points of it; or from exha- lation from the adjoining mucous surface, in consequence of congestion of, or of sanguineous determination to the affected bowel. Where * [“ A Treatise on the Malformations, Injuries, and Dis- eases of the Rectum and Anus,” by George Bushe, M.D. New-York, 1837, p. 182.] 148 the vascular or erectile tumours exist, blood is always discharged, and uniformly from their surface. The varicose form of tumour is less frequently attended by haemorrhage than any of the others. When the blood proceeds from the rupture of enlarged or varicose vessels, it generally flows in a stream while the patient is straining at stool, the flow increasing or re- turning when this effort is repeated. The pas- sage, also, of hardened faeces over the congested or inflamed mucous surface of the rectum, or over the tumours developed beneath this sur- face, or over the enlarged or distended vessels, may lacerate or injure them in such a manner as to be followed by haimorrhage, but in such cases the discharge is usually slight. 16. In many cases the blood flows for a short time only, and is not again seen until the next attack; but in others it is observed re- peatedly when the bowels are acted upon, or the discharge is renewed, when the faeces are expelled, for several days. It is generally of a red colour, and either covers or follows the faecal evacuation; but when it is consequent upon venous affection or dilatation, it is of a dark hue, and follows, or is partially mixed with the feces. 17. B. The ret urns and amount of the haemor- rhoidal discharge are extremely various, but in many instances a periodical return is observed in both males and females. In females the haemorrhoidal not infrequently takes the place of the catamenial discharge, especially at the age when the latter usually ceases, and assumes a periodic form. In some instances these evac- uations alternate. When the morbid action has once commenced in this part of the body, it being favoured by peculiarity of structure and by several pathological relations ($ 30), there is always a predisposition thereby formed to the recurrence of itand the same causes still operating, it at length becomes habitual, and even necessary to the prevention of more serious maladies. It has been satisfactorily shown by observation that, as long as the caus- es of haemorrhoids continue, the evacuation attending them is a wholesome occurrence, inasmuch as an overloaded state of the vascular system, that would otherwise induce dangerous visceral disease, is thereby removed. In all cases, therefore, when haemorrhoidal affections depend upon constitutional causes, or are con- nected with any indications of visceral disease, or have existed for a considerable time, their return should not be prevented, unless other sources of discharge, or other sanguineous evacuations are substituted for them; but when they proceed from causes which are chiefly or entirely local, neither the vascular system nor constitution, nor any important in- ternal organ manifesting disorder, a more ac- tive interference may be attempted, although even then with caution, especially if there be any tendency to vascular plethora, and if the principal causes of the disease are still in oper- ation. 18. The quantity of blood lost in each attack may be very trifling, may not exceed a drachm or two ; or it may amount, at one time, to sev- eral pounds. Instances are adduced by Rno- dius, Fernelius, Lanzoni, Harris, Spindler, Moehring, Hoffmann, Earle, Calvert, and fliers, in which the quantity discharged seem- HAEMORRHOIDS—Consequences and Complications. ed enormous. Mr. Calvert supposes that the vessels in such cases are in a state of extreme excitement; but this is by no means a correct inference, as in most cases of excessive dis- charge the haemorrhage is passive or venous, or is consequent upon congestion, or upon in- terrupted circulation through the haemorrhoidal vessels. The evacuation more commonly is excessive from its frequent return than from its quantity at any one time; and it not infre- quently induces a state of exsanguine exhaus- tion, requiring the most decided interference. 19. C. A colourless Haemorrhoidal Discharge —Mucous or Serous Haemorrhoids (H. mucoscE vel serosae) of authors; Hemorrhoides blanches, Begin ; Medorrhoea Ani, J. P. Frank—some- times takes place, and either follows the dis- charge of blood, or attends the haemorrhoidal tumours, especially those belonging to the first variety. It varies much as to quantity and ap- pearance. It is either watery or mucous, or resembles a weak solution of gum, or it is al- buminous and like the white of egg. When watery, serous, or mucous, it usually exudes slightly from the anus ; when more abundant or albuminous, it is commonly passed at stool. In cases attended by much heat and irritation ’about the anus, a colourless exudation, consist- ing chiefly of an increased secretion from the follicular glands of the part, takes place. These varieties of colourless discharge are most fre- quent when there is little or no hajmorrhage, and when the disease is associated with ascar- ides, or with leucorrhcea, or with pregnancy. 20. iv. Of the Consequences and Complications of Haemorrhoids, local and constitutional.—A. In- flammation is one of the most frequent morbid associations of haemorrhoids. It is attended by more or less swelling and redness of the lower part of the rectum and anus ; by throb- bing, and by increased sensibility and heat, ag- gravated by the passage of faeces. The san- guineous discharge is slight or absent, but if it become abundant the symptoms subside. A mucous discharge is, however, not uncommon. Sometimes the inflammation is severe, and implicates not merely the mucous membrane and subjacent cellular tissue, but also, in a slighter degree, the prostate gland and neck of the bladder, occasioning much pain in the perineum, sacrum, &c., with dysuria, or even strangury. The irritation may even extend to the womb in females. The tumefied state of the lower part of the intestine in these cases, together with the inflamed tumours, and the spasmodic constriction of the sphincter, pro- duces obstinate constipation and straining or tenesmus. Not infrequently the protrusion of the tumours, when internal, with a portion of the mucous membrane, follows the action of the bowels, and the inflamed tumours, being strangulated by the sphincter, become remark- ably painful, or even ultimately slough. With the severity of the local symptoms, the consti- tution generally sympathizes; and febrile symp- toms are developed, particularly in irritable or nervous temperaments. 21. B. Fissures or rhagadcs of the anus are not uncommon in cases of hamnorrhoidal tu- mours. They may commence in small longi- tudinal ulcerations ; but they more frequently seem to take place as follows: When the tu- mours are large and numerous, hardened fecal HAEMORRHOIDS)—Consequences and Complications. 149 matters, in passing forcibly between them, crack or slightly tear them at their bases, the chronic inflammation in this situation harden- ing and rendering the tissues less yielding to any distending power. These fissures are most apt to occur when the tumours are situated upon the sphincter. They are usually slight at first, but they enlarge, owing to the frequent operation of the causes that produced them and to the lodgment of faecal matters, and oc- casion great pain, which continues for some hours after each stool, and spasmodic constric- tion of the sphincter. Herpetic or other chron- ic eruptions sometimes also appear about the anus, and favour the supervention of these fis- sures, by rendering the surface harder and less capable of distention, or by diminishing its vital cohesion. Fissures of the anus mostly occur as a consequence of the first and third variety of haemorrhoidal tumour. 22. C. Ulceration or abscess, frequently pass- ing into fistula, often follows haemorrhoids, par- ticularly when inflammation occurs. When the inflammation is superficial, affecting chiefly the mucous membrane, it gives rise to ulcera- tion in one or more points, especially in the situation of the tumours ; and it may penetrate deeply, or be followed by small abscesses, either in these tumours or in their vicinity. When the inflammation is more deeply seated, impli- cating the cellular and adipose tissues, an ab- scess then forms very readily, and often rapidly. Pain, tension, and heat about the anus are then severe, and with the throbbings extend up the pelvis. When the abscess is anterior to the anus, and presses upon the urethra, and parts adjoining the neck of the bladder, the suffering is very great, and sometimes is attended by strangury or total retention of urine. The ab- scess, in the female, occasionally extends to one of the labia, or even breaks into the vagina, or passes into fistula in that or in an adjoining situation. Of this I have seen several instan- ces. (See art. Rectum.) [Such cases, according to Dr. Burke, are far from being uncommon, and are too often over- looked. To detect these small fistulae, the fin- ger ought to be cautiously introduced, and after a little exploration, a small depression, marking the fistulous orifice, may be discovered on each tumour thus affected. But should this attempt fail, the buttocks may be forcibly separated by an assistant, while the patient bears down; then, with a strong light and a probe of a small size, the sinus will be easily found. Dr. B. states that in a majority of cases but one tu- mour is fistulous.] 23. D. Hcemorrhoidal tenesmus, or spasmodic constriction of the sphincter, frequently with pro- trusion of the mucous coat of the rectum, is a com- mon complication of haemorrhoidal affections, particularly when the tumours are inflamed, or when there are fissures between them ( 33), will generally remove it. When it is connect- ed with inflammatory irritation, the means about to be stated () 42) are most appropriate. 37. D. Treatment of the Hoemorrhoidal Tu- mours.—a. In all cases the parts should be care- fully examined by the practitioner, since the accounts given by patients themselves are very fallacious. Besides, the particular kind of tu- mour must be ascertained before the means of cure can be appropriately directed. Whether the piles be internal or external, or both, the anus should be washed with cold water after HAEMORRHOIDS—Treatment. each evacuation ; or with yellow soap and wa- ter, as suggested, in the course of some excel- lent remarks on the treatment of the disease, by Mr. Mayo. If the piles be internal, this should be done before they are returned.. If they cannot be returned, or are permanently protruded, or altogether external, whatever may be their form, pressure is one of the best remedies that can be applied to them. After each evacuation, and having thoroughly cleans- ed the parts, a conical pad, or piece of ivory, made to slide along a bandage or handker- chief, should be passed between the nates, and fastened above to a cincture, or belt, worn around the loins, in the form of the T bandage. The pad may be provided with a concentric wire spring, the more internal coils of which rise in a conical form. This is the best exter- nal mode of employing pressure. When the tumours are internal, and protrude at stool, dragging the mucous coat with them, or when they consist chiefly of varicose veins, a short metallic bougie, of an oval form, with a short, slender neck, and a conical base to press upon the anus externally, may be attached to the bandage, carefully introduced into the rectum, and worn occasionally. Pressure will thus be made both above and within the sphincter, as well as without it. When introduced, the part of the bougie which rises above the sphincter being oval, varying in diameter with the pecu- liarities of the case, and being many times as thick as its slender neck grasped by this mus- cle. necessarily, from its shape, retains itself within the rectum, draws up with it the exter- nal tumours and prolapsed portion of the bow- el, and presses its conical base externally against the anus, and upon the tumours or en- larged veins external to the sphincter. This combination of the internal with the external method of making pressure on the anus was in- troduced by Mr. Mackenzie into practice, and is often extremely efficacious in the treatment of haemorrhoids, and of the prolapsus attending them. 38. Before having recourse to either of these, it will often be of service to wash out the rectum immediately after each evacuation, by injecting some cold or tepid water, with or without a few grains of sulphate of zinc dis- solved in it; and, if the parts be painful or ir- ritable, a little cold cream, or of a slightly ano- dyne or astringent ointment, or of any other most appropriate to the circumstances of the case, should be applied to the surface of the bougie, when about to introduce it. At the same time, the bowels ought to be kept gently open by any mild or cooling purgative that will not irritate the rectum. I have found equal parts of the compound infusions of gen- tian and of senna, with the soluble tartar, &c., taken at bedtime, the most beneficial, when the digestive organs were weak; and one or two tea-spoonfuls of either of the following electuaries, or of one of those in the Appendix (F. 82, 98), the most serviceable when pleth- ora or hepatic disorder was present, or even when there was a manifest tendency to them. No. 242. R Potass® Bitart, in Pulv. fj. ; Sulphuris prm- cipitat. 3ij.-iv. ; Confect. Senna) fij. ; Sirupi Aurantii vel Zingib. (f s. nt fiat Electuarium molle. No. 243. R Potass® Nitratis 3ij.; Confect. Sennae, et Si- rup. Zingiberis, aa Jjss.; Succi Spiss. Sambuci ?j. M Fiat Electuarium. 153 154 HAEMORRHOIDS—Treatment. 39. These electuaries may be variously mod- ified, according to circumstances ; and the con- fectio piperis nigri may be substituted for the sirup, or the inspissated juice of the sambu- cus, or a small quantity of it may be taken twice or thrice daily, when there is much re- laxation of parts, or in cold, languid, or leuco- phlegmatic habits. Aperient medicines, in haemorrhoidal cases, should always be taken at bedtime, in such doses as to operate only once, or, at most, twice in the morning. Subse- quent irritation of the bowels during the day will thus be prevented, especially if the rectum be washed out by a lavement after passing a motion. When it is necessary to have re- course to the short bougie described above (§ 37), it should then be introduced, its passage being facilitated by an anodyne or slightly as- tringent ointment or pomade. 40. b. When the tumours are internal and protrude only at stool, and when they continue, notwithstanding the use of the constitutional treatment advised above, aided by the modes of employing pressure just described, the re- moval of them by an operation may be enter- tained ; but it certainly ought not to be prac- tised, unless it be clearly ascertained that they belong to the first variety (§ 9), and never, if they present the varicose character (§ 12). Most surgical writers make no distinction between these tumours, and resort either to the liga- ture or to excision to remove them. Mr. Cope- land refers to several instances of dangerous, and even fatal results from having recourse to the ligature ; and yet Dr. J. Johnson, in an able review of the subject, states that he knows “ that Mr. Copeland’s practice is, and long has been, almost invariably to employ the ligature his success, by means of it, entirely depending upon his drawing the thread as tight as possible, so as completely to destroy the vi- tality of the tumour. This is certainly the only mode in which the ligature ought to be employed, and the one in which it has been generally recommended and practised since the days of Galen ; but Mr. Copeland only states the danger of this method in his work, and neither advises it nor points out the mode of performing it! Le Dran considers that, in addition to the pain, the ligature may cause inflammation extending along the rectum to the intestines ; and M. Montegre objects to it for the following reasons : 1st. The operation is often difficult, and always very painful. 2d. The tumours sometimes resist the ligature, and, instead of falling off, ulcerate. 3d. As they can only be tied in succession, the irrita- tion produced by the first operation increases the swelling and inflammation of those remain- ing. 4th. The ligature- may produce all the ef- fects of strangulation of the gut. Dr. J. John- son thinks that these objections are founded on the inefficient mode of applying the ligature, and that few or none of them are valid, provi- ded the thread is drawn to a proper degree of tightness at the beginning. I believe that even this more efficient mode is not secure from danger ; that, in addition to the evils enu- merated by Montegre (a), inflammation of the haemorrhoidal veins, extending even to the liv- er (b), locked jaw (c), retention of urine, and (d) contraction of the rectum have in some instances resulted. It were to be wished that those who have been most in the habit of re- sorting to it would state more fully than they have done the results, and the circumstances in which they confide chiefly in it. In the var- icose form of the complaint, it is a most dan- gerous mode of treatment. 41. c. Excision of the tumours is preferred by Le Dran, Abernethy, Montegre, Colles, and Calvert ; while Sir Astley Cooper and Mr. Howship are favourable to the ligature. Mr. Mayo advises this latter method for all in- ternal piles, his mode of operating being the most judicious that can be followed. Sir E. Home and Sir C. Bell recommend a combina- tion of both methods—the excision of the tu- mour immediately after the application of the ligature. There can be no doubt of the danger of excision, and that it is very liable to be fol- lowed by great haemorrhage, and by peritoneal inflammation, particularly when the tumours are formed by varicose veins. Numerous cases illustrative of the fatal or dangerous results of this practice are adduced by several of the au- thors referred to. When the piles are exter- nal, are covered by skin, and are formed as described when considering the first form of tumour (§ 9), excision is preferable. But I be- lieve, from considerable experience, that either operation will be very seldom required if the medical treatment be judiciously conducted. Neither the one nor the other should be resort- ed to without a careful examination of the pathological relations of the case, and of the form, state, and complications of the local af- fections ; nor without a preliminary treatment, consisting of one or two small cuppings over the sacrum, of a regulated state of the bowels, moderate diet, and of abstinence from ferment- ed or spirituous liquors. In nervous and irri- table persons either operation is hazardous, and should not be performed unless in urgent circumstances. Dr. Burne states that he has seen “ a person die of sympathetic adynamic fever in four days after the removal of piles by a most accomplished surgeon. The nervous system of this patient was disturbed prior to the operation, the shock of which excited high febrile movement and delirium, soon termina- ting in dissolution.” [The removal of haemorrhoidal tumours is not to be thought of, unless they become seriously injurious to the health, and threaten to under- mine the constitution. We find them, when neglected, as has been seen, sometimes result- ing in prolapsus, ulceration of the rectum, fis- tula in ano; and in females, fistula between the rectum and vagina; to swelled testicle; dis- eases of the bladder; constant tenesmus and uneasy sensations in the limbs; frequent and copious loss of blood, and its attendant states of anaemia and sinking; palpitations, lowness of spirits, &c. But notwithstanding these evils, great as they are, the surgeon, in view of the past results of surgical operations for the re- moval of these tumours, will hesitate much be- fore undertaking their cure, either by excision or ligature. We do not allude to those tem- porary evils, such as tenesmus, strangury, gas- tralgia, and nervous symptoms, which so fre- quently follow the operation, but phlebitis, te- tanus, excessive haemorrhage, and fatal collapse | from the shock of the operation itself. There I are others, also, of a more permanent charac- HEMORRHOIDS—Treatment. 155 ter, such as contraction or stricture of the I anus, extensive abscesses, obstinate fistula, | and, finally, a state of general plethora, from suddenly checking the frequent loss of blood in a system long habituated to it, and, conse- quently, to an accelerated process of sanguifica- tion. Dr. John Watson, of New-York, has very forcibly called the attention of the profession to the dangers attending the operations,* both of excision and the application of the ligature for the removal of haemorrhoidal tumours, and states that within eight years he had known of four fatal cases ; one after excision, and three after the application of ligature, but none by haemorrhage. One fatal case has also recently occurred in this city, after the operation by lig- ature. One fatal case occurred in the practice of the late Dr. Physick, of Philadelphia, from phlebitis, on application of the ligature. Two serious cases occurred in the practice of J. L. Petis, where, after the operation of tying, symp- toms occurred similar to those of strangulated hernia—nausea, vomiting, hiccough, and ab- dominal pains : one of these proved fatal. The late Dr. Bushe was of opinion that phlebitis was not one of the accidents likely to occur after these operations. “ Haemorrhoidal tu- mours,” says Dr. Watson (loc. cit.), “ are either external or internal. The first are readily managed, either by incision, excision, ligature, or caustic applications. The internal, however, are worthy of much more serious consideration. They rarely extend above the pouch of the rectum, and are, therefore, generally within reach. Hence the great success of operations upon them when properly performed, and where the patient escapes the first effects of the op- eration itself. But, in some cases, I have known them situated so high up within the rec- tum as to be beyond the reach of either knife or ligature. Tumours of this sort may, in the end, give rise to prolapsus of the mucous mem- brane, descend with the descending prolapsus, and finally come within the surgeon’s reach. So long, however, as they remain high up, be- yond the verge of the anus, although they may frequently bleed, or harass the patient and un- dermine his health, they are not to be inter- fered with, except by enemata, suppositories, and the administration of internal remedies. “ For these bleeding internal haemorrhoids, I have found more benefit in the use of injections of acetate of lead than in any other form of local application. I commonly employ this of the strength of a drachm to eight ounces of rain water, and never administer over two ounces of this solution at a time. I repeat the injection after each return of haemorrhage ; and, as this most commonly occurs during the effort to evacuate the bowels, I commonly ad- vise the patient to resort to the injection imme- diately after every stool, until the haemorrhage has ceased for a few days. The usual internal medicines are, the occasional administration of a blue pill, especially where there is reason to suspect any disturbance in the functions of the liver ; a dose of oil, or the extract of taraxacum, or some other mild laxative. But, for the mere evacuation of the bowels, and with the view of correcting an obstinately-constipated habit, I know of no article better than one or the other of the following confections: First. Common Rosin, well pulverized, fi.; Clarified Honey, fv. M. Second. Common Rosin, as before, fi. ; Balsam of Copaiva, ;ss.; Clarified Honey, fivss. M. “ The last of these, when it can be borne, is the most efficacious. But to many persons, and particularly delicate females, the balsam is so nauseous that they are unable to use it. The ordinary dose is from two to three drachms at bedtime. This dose is generally sufficient to produce one soft and consistent stool early on the following morning, without griping, unea- siness, or any of the usually disagreeable at- tendants of cathartic medicine. These meas- ures are to be assisted by the occasional use of the hip bath ; by cooling, anodyne, and emoll- ient clysters; by a course of regimen most suitable to -keep the bowels regular, without, however, stimulating them; and, above all, by carefully and gently reducing the prolapsus after every evacuation of the bowels, and guard- ing against all movements likely to produce it in the intervals.”* The late Dr. Physick, who was very success- ful in the treatment of piles, resorted to their excision by scissors, when external and cov- ered by skin; and to the wire ligature, when internal and enveloped with mucous membrane, in order to avoid danger from hannorrhage, which he believed was considerable. Dr. Har- ris, however, of Philadelphia, who has also had much experience in the treatment of the dis- ease, always practises excision, and states that, in his numerous operations, he has never encountered any of the accidents alleged to have followed this plan. Dr. Chapman strenu- ously opposes the ligature as a most dangerous and painful mode of treatment, and recom- mends excision, excepting in the varicose tu- mour. (Lecture on Hemorrhages, &c., Phil., 1844.) Dr. Houston, of Dublin, has lately called the attention of the profession to the use of nitric acid in haemorrhoidal affections. (See Braith- waite’s Retrospect, part vii., art. 62; part x., art. 64.1 He confines its use to the internal bleeding piles—that soft, red, strawberry-like elevation of the mucous membrane, called by some vascular tumour, which it removes by •producing a slough on its surface. The part to be touched must be free from cuticle, and wiped dry, or freed from all mucous or other adherent fluids. The acid is to be applied free- ly, and rubbed in with force enough to be press- ed into the pores of the surface. A slough fol- lows ; but often a second, or even a third appli- cation may be required before the disease is cured, especially where the tumours are old or firm in texture. Dr. Watson remarks that this remedy may prove useful when the disease lies near the surface of the mucous membrane, or is entirely confined to it; but that be should expect little benefit from it where the hemor- rhoidal tumours lie deep, and are enveloped in thickened and indurated mucous membrane and cellular tissue ; where the mucous coat of * [The reader may profitably consult, in relation to the surgical part of the treatment of these tumours, Dr. Wat- son’s paper in the New-York Jour, for July, 1844, and Dr. Bushe’s Treatise on the Malformations, Injuries, and Dis- I eases of the Rectum and Anus, New-York, 1837, 8vo.] * [The New-York Journal of Medicine and Surgery and the Collateral Sciences, vol. iii., N. Y., 1844.] 156 HAEMORRHOIDS—Treatment. the rectum is varicose and tumefied, the solid nitrate of silver may be often used with advan- tage ; but it must be employed very freely, and every day or two, for weeks together, in order to effect a permanent cure. Where we conclude to apply the nitric acid, it may be done in the following manner: the patient is directed to strain, so as to bring the tumours fully into view ; and while they are so down, let him either lean over the back of a chair or lie on the edge of a bed, on the side on which the disease exists. A piece of wood made into the shape of a spatula should then be dipped in the acid, and as much of it applied as will adhere to it, rubbing it on as above di- rected. When the membrane is changed to a grayish white colour, smear it with oil, and gently replace the prolapsed parts within the sphincter ; put the patient to bed, and adminis- ter an opiate. The pain, which is'often sharp and burning at first, soon subsides, and does not again return in the same form.] 42. E. Treatment of Inflamed Piles.—The ap- plication cf leeches to inflamed haemorrhoids is very often advised. Montegre disapproves of the practice, as it frequently draws the blood to the parts. I believe that cupping on the loins or on the perinaeum is more beneficial. As more or less strangulation produces or accompanies the inflammation, the tumours should be pushed within the sphincter, if this can be done without aggravating the affection ; and poultices or fomentations applied. When the inflammation is abated, Montegre advises injections of cold water; but care should be taken not to lacerate the tumours by the pipe of the syringe, as serious consequences may accrue, as in the cases recorded by Zacutus Lusitanus, Gassendi, and others. The exter- nal application of lint, moistened with a cooling and anodyne lotion, or frequently sponging the parts with it, will often afford relief. Equal parts of the solution of the acetate of lead, and of laudanum, diluted with rose water, will gen- erally answer the purpose. If this lotion is not of service, it may be relinquished for poultices or poppy fomentations. Incisions or punctures of the inflamed and protruded piles are advised by some surgeons. Montegre condemns the practice ; and Mr. Calvert states that he saw an instance of fatal haemorrhage from having had recourse to it. Much more dependance should be, therefore, placed upon local blood- lettings in the situations just mentioned, on low diet or abstinence, and on the refrigerants and cooling diaphoretics already recommended. If the inflammation terminate in suppuration or abscess, poultices or fomentations, and as early an external outlet to the matter as can be given it, are requisite. When tenesmus is present, cupping over the sacrum, ipecacuanha, with nitrate of potash and opium, in frequent doses, anodyne fomentations, and the treat- ment about to be prescribed for this symptom (() 46), are most serviceable. The bowels should be kept gently open by means of castor oil, the aperient electuaries, and other laxatives mentioned hereafter (<) 46, c.). 43. F Treatment of Ulcerations, Fissures, or Cracks.—a. When ulcerations form between the tumours, or on their surfaces, the parts should be carefully cleansed after each evacuation, and an ointment, with a small proportion of Peru- vian balsam, may be applied to it by a pledget of lint, or any other ointment of an astringent and anodyne kind may be tried. The balsams or terebinthinates should be given internally, in the form of pill, with magnesia, in quantity sufficient to keep the bowels gently open. 44. b. Fissures or cracks between the tu- mours are attended either by exquisite pain, or by spasmodic constriction of the sphincter. More frequently both these latter morbid states are present, and occasionally the patient is tolerably free from both. When the lesion is thus simple, the treatment recommended for ulceration will often be sufficient; the local application of biborate of soda, dissolved in honey, will also be of service as a substitute for an ointment; but when either pain or spasm of the sphincter is complained of, other means are required. In these cases, I have found the addition of the extract of belladonna to any of the ointments usually prescribed, give almost immediate relief. If a large proportion of the extract be employed, the effects ought to be carefully watched. Due attention to the func- tions of digestion and of excretion, and to existing constitutional symptoms, is always necessary. In less severe cases of this de- scription, the extract of hyoscyamus may be tried before having recourse to the belladonna. M. Boyer and most surgeons in this country have advised a complete division of the sphinc- ter ani muscle for the removal of this com- plaint. I have treated five cases of fissured anus since 1822, when the first came under my care. In all these the operation had been rec- ommended ; and yet they perfectly recovered in a short time, and, without a single exception, by means of a purely medical treatment. Strict injunctions as to diet and regimen; the daily evacuation of the bowels, and afterward wash- ing out the rectum by emollient injections; careful ablution of the external parts, and the application of an appropriate ointment or cerate with belladonna ; attention to the functions of the digestive and assimilating organs, and to constitutional symptoms, and the removal of general or local plethora, constituted the treat- ment. The belladonna was added to various kinds of ointment, according to the peculiari- ties of the case. In all it affected the pupils, and in two it produced its characteristic erup- tion on the skin. Several years after I first employed this medicine for fissure, with painful spasm of the sphincter, the account of M. Du- puytren’s treatment of this affection by the same means appeared in the medical journals of Paris. [In the treatment of this extremely painful affection, the patient should maintain the re- cumbent position, and confined to a low diet. Cathartics are to be carefully avoided, and irri- tation allayed by simple enemata of flax-seed tea. When the disease is mild, we have found the application of the unguentum acetatis plumbi prove sufficient for its healing; and if there be much spasm of the sphincter, the extract of belladonna will prove a powerful auxiliary: a drachm of this substance, with the same quan- tity of the acetate of lead, mixed with six drachms of lard, is the preparation of Dupuy- tren, which has been so extensively used in these cases. A very good practice is, to apply i the nitrate of silver to these fissures when HAEMORRHOIDS—Treatment. 157 superficial, and then introduce meshes of lint, besmeared with a mass consisting of one part of the extract of belladonna, and seven of sper- maceti ointment—a course of practice which has succeeded in cases where Dupuytren’s ointment has failed. The late Dr. Bushe, of this city, was in the habit, where other means failed, of dividing the stricture with the knife, a procedure, he states, “which never fails to give immediate relief, and to effect a rapid cure.”*—(Loc. cit.). This practice, however, originated with Boy- er, who regarded the fissures as the conse- quence of a spasmodic contraction of the sphincter ani. This, however, as M. Jobert has pointed out (Gaz. Med. de Paris), is more than questionable. The spasmodic contraction of the sphincter seems to be rather the effect than the cause of the ulcerated fissure of its mucous covering and of its surface. It is the irritation to which its superficial fibres are ex- posed that induces the spasmodic contraction of the muscles. It is of importance to attend to this circumstance, viz., whether the ulcera- tion is limited to the mucous lining of the gut, or whether it has extended to the fibres of the sphincter ani, in the management of the dis- ease. In the former case, it is rarely necessa- ry to have recourse to the scalpel; the ulcer- ated fissure will generally heal under the use of caustics, &c. But when once the fibres of the sphincter are involved, and the consequent spasmodic contractions of the muscles is in- duced, the application of any irritating sub- stance tends only to aggravate the suffering; and some suppose the only successful mode of treatment is probably to divide the muscles across. M. Jobert has, however, found that simple excision of the diseased part, with the knife or scissors, will relieve the spasmodic contraction of the sphincter, by bringing the fissure to the state of a simple wound, and thus cure the disease.—(Loc. cit.)) 45. G. Hcemorrhoidal Pains and Spasmodic Stricture of the Rectum, generally connected with fissure or ulceration at the bases of the tumours, must be treated in the manner just stated ($ 44). The pains are often intermit- tent, but very acute during their continuance. Sometimes they extend down to the feet and ankles, and even occasionally assume a neu- ralgic character in these or other parts of the lower extremities, or give rise to spasm in various parts, especially in nervous or hyster- ical females. Some interesting instances of such affections have been recorded by Sir B. C. Brodie, and have been observed by myself. In such cases, much benefit will generally ac- crue from taking the confectio piperis nigri twice or thrice daily, and from adopting the constitutional and local treatment just recom- mended. This medicine may also be conjoined with an anodyne, and the bowels regulated by the medicines already suggested. M. Monte- gre strongly advises having recourse to the “ douche ascendante or the forcible dashing of cold water against the anus, and to cold injec- tions. In order to render the evacuation more easy, he directs the lavement to be thrown up when the inclination to stool takes place. Emollient injections may also be tried, either to facilitate the discharge, or to cleanse the rectum afterward ; and suppositories with the ceratum plumbi compositum, and opium, or stramonium or belladonna, or any other nar- cotic, may be occasionally introduced into the rectum, and they will seldom fail of giving re- lief. Great care ought to be taken in the ad- ministration of narcotics in lavements, in the treatment of this or any other state of the com- plaint, as they are often rapidly absorbed into the circulation from the rectum and colon, and without having undergone any change. I have known half a grain of the belladonna in one case, and thirty drops of laudanum in another, produce the most serious effects. When, how- ever, either of these, or any other narcotic, is prescribed in an ointment, pomade, or supposi- tory, no unpleasant results will follow. 46. H. Tenesmus, Strangury, and Constipa- tion, often depend upon the same pathological states.—a. The tenesmus is generally owing to inflammatory irritation and congestion of the inner coats of the rectum, conjoined with spas- modic action of the muscular tunic. It will, with few exceptions, be removed by the means just directed (§ 42, 45). In less acute, or more obstinate cases, the belladonna plaster may be applied to the perimeum or sacrum. Five or six grains of the extract of poppies, or one or two drachms of the sirup, may also be occa- sionally thrown into the rectum, with any tepid emollient enema ; or a suppository of the kind just stated may sometimes be introduced.—L. If strangury or dysuria supervene, it is to be imputed to the extension of the affection of the rectum to the neck of the bladder, or to the prostate and urethra ; and it will generally be found that it will be removed or relieved by the treatment recommended for tenesmus.-r-c. Con- stipation also frequently proceeds from the same local changes as occasion tenesmus and stran- gury, and from tumours or enlarged and eor- gested vessels obstructing the canal of the in- testine. In either case, there is more or less obstacle to the passage of a consistent motion, and much pain attending it. If these syrnp toms be allowed to continue, the complaint will be aggravated; or they will give rise to still more serious changes. In removing them, the milder laxatives will be found more serviceable than active purgatives; but those which act , also upon the liver should be selected. Mer- curials aggravate, and even bring on tenesmus, * [In performing the operation, Dr. B. recommended that the patient should be placed opposite a window, on his side, an assistant being employed to separate the buttocks, and retain them so during the operation. The surgeon is then to insert the forefinger of the left hand, well oiled, into the anus, as far as the second joint, which is to serve as a conductor for the knife, which should have a blade two inches long and one eighth broad, with a blunt extrem- ity. Having passed the blade flatwise as high as the supe- rior border of the internal sphincter, he then turns its edge towards the fissure, provided it be on the side of the bowel, and divides both sphincters by cutting outward, gradually increasing the pressure so as to ensure the complete section of the external muscle. If a fissure exists on the opposite side. Dr. B. recommends to treat it in the same manner. If the seat of disease be the anterior or posterior portions of the intestine, the incision is to be made on the side, as the division of the sphincter, and not the fissure, is the ob- ject in view. After the hsemorrhage ceases, dossils of lint should be placed in each wound, and secured by a compress and T bandage. A full dose of morphine is to be given, and nothing but toast-water, broths, and gruel allowed for two or three days. The dossils of lint, compress, and ban- dage are then to be removed with great care, the bowels evacuated with an emollient lavement, and fresh dressings applied. This course is to be pursued daily, gradually di- minishing the si/e of the dossils of lint, until the wounds heal, which will be in about three weeks.—(Lnc. cit.)] 158 4LEMORRHOIDS—Bibliography and References. and therefore cannot be employed, with the exception of hydrargyrum cum creta. This may be taken in small doses at bedtime, with ipecacuanha and hyoscyamus, or with extract of taraxacum. Some one of the electuaries already prescribed (§ 38), or the decoction of taraxacum with the carbonate of soda, or the tartrate of potash with tincture of senna and sirup of roses, or of senna, may be given and continued for some time. A Seidlitz powder, taken about an hour before breakfast, is also one of the best aperients in haemorrhoidal cases. A frequent recourse to warm lave- ments is injurious in this complaint, as they relax the parts and solicit the circulation to them. M. Montegre, whose authority in this matter is very high, advises the injection of cold water in preference, as it strengthens the bowel; but he directs no more than will fill the rectum (about half a pint) to be thrown up. In the more severe states of the disease, especial- ly in cases of fissure, of spasm of the sphincter, and of painful evacuation, he considers the cold injection, every time that a motion is about to be passed, most beneficial. 47. I. Re-establishment of Suppressed Hemor- rhoids.—When the suppression or interruption of piles is followed by aggravation of some re- lated complaint, or injures the general health, or threatens some important organ, as the lungs, brain, liver, &c., there ought to be no hesitation as to having recourse to means cal- culated to reproduce them. A gentleman of about fifty, residing near Russell Square, sub- ject to returns of humoral asthma often pass- ing into bronchitis, as well as to frequent at- tacks of haemorrhoids, experienced great aggra- vation of the former in 1835, after the latter had disappeared for some time. I directed him to be cupped, but he neglected to adopt my ad- vice ; I therefore prescribed a full dose of cal- omel and aloes, and repeated it in a few hours, with the view of restoring the suppressed piles. This had the desired effect; but severe inflam- mation of the tumours and strangury superve- ned, followed by an abscess between the pros- tate and anus. This broke externally, and soon healed, and the patient has not been confined a day since. Another gentleman, between fifty and sixty, had experienced severe headaches from the non-appearance of the haemorrhoidal discharge. He was advised in 1829, when I saw him, to lose blood, to live abstemiously, and to relinquish malt liquors. The first only of these injunctions was complied with, and his complaints returned. The same advice was again given, and the purgatives formerly prescribed were changed to those which act most energetically on the rectum. The haem- orrhoids were reproduced, and the headaches disappeared. Such instances are, however, not at all uncommon. Unless in urgent ca- ses, it will be preferable to attempt the resto- ration of piles by the more gentle means at first, as the exhibition of those which are most irritating, before the action of milder remedies is ascertained, may excite inflammatory action of a very severe kind, and great distress, as in the case first adduced. A reference to the causes which commonly occasion the complaint will show the means most likely to reproduce it. The most appropriate, however, are, pedi- luvia or semicupia ; the hip-bath; the applica- tion of leeches to the anus ; the use of purga- tives which act especially on the rectum, as calomel and other mercurials in full doses ; al- oes, colocynth, rhubarb, sulphate of soda, &c. ; warm injections ; aloetic enemata, &c. 48. K. Of Regimen and Prophylaxis.—An ab- stemious regimen is required during the attack, and is even more necessary in the intervals ; for it is chiefly by diet and prudent conduct at these times that this complaint and its contin- gent ills are to be warded off. A temperate climate is best suited to persons liable to haem- orrhoids -, but sudden vicissitudes of weather are unfavourable, and should be guarded against by wearing flannel next the skin, and by warm clothing. Malt and spirituous liquors ought to be avoided, and temperance in food and drink should be observed. Too warm and soft beds are improper; and sitting on soft, warm cush- ions is still more so. Regularity in the hours of eating, sleeping, waking, and taking exer- cise is generally of service ; and when medi- cine is requisite, it should be such as will cor- rect morbid action, increase scanty secretion and excretion, particularly of the biliary and mucous surfaces, and preserve the bowels reg- ularly and gently open. Cold ablution of the anus after each motion, and, if haemorrhoidal tumours protrude, the careful sponging of them before they are returned, will not only remove disorder, but prevent its return, if continued without interruption in winter as well as in summer. Venereal excesses, the more violent mental emotions, and all the depressing pas- sions, are injurious. Exercise in the open air, especially on horseback, is always of service if taken regularly, although rough riding, espe- cially by those wdio are not accustomed to it, is often a cause of the complaint. (See, also, Rectum—Diseases of.) Bibliog. and Refer.—Hippocrates, Tlcpi AlpoppoiSov, Opp., p. 891, ed. Foes.—Celsus, L., vii., cap. 30.—Oaten, De Comp. Med., loc. ix., cap. 7.—Scribonius Largus, De Comp. Medicam, c. 91.—Paulus Mgineta, 1. vi., c. 79.—Ae- tius, Tetr. iii., serm. i., c. 46.—Oribasius, Synopsis, 1. ix., cap. 18, 42.—Avicenna, Canon., 1. iii., fen. x., tr. i., cap. 2. — H. Barlandus, Epist. de Aquarum destil. facultat. et Iliemorrh. Generibus, 8vo. Antwerp, 1536. — Ballonius, Consil., t. ii., p. 51 ; t. iii., p. 98.—Rhodius, Cent, ii., obs. 93.—Glisson, De Ventriculo et Intestinis, tr. ii., c. 11.— Amatus Lusitanus, Cent, vi., cur. 32Riedlin, Millenari- us, n. 401, n. 517, n. 742, n. 996.—J. C. Fromman, De Hsemorrhoidibus, 12mo. Noriberg, 1677.—Zacutus Lusita- nus, Med. Pr. Hist., 1. ii., obs. 26.—Lentin, Obs. Med., fascic. ii., p. 68.—Bonet, Sepulchr., 1. iii., sect, iii., obs. 27. —G. Baglivi, Opera omnia, 4to. Leyden, 1745, p. 826.— J. A. Gulich, Meditationes Theoret. Pract. de Furore ILem- or. Internarum. Lugd. Bat., 8vo, 1733.—Pelargus, Med. Jahrg., iii., p. 734; iv., p. 302.—F. Hoffmann, De Salu- britate Fluxus Hsemorrhoidalis. Hal., 1708 ; et De Immod. Hsemor. Fluxione. liaise, 1730.—Peschel, Epist. de Hic, a serpent); Ophiasis, Celsus ; Area, Auct. var.; Alopecia Areata, Sauvages ; Porrigo decalvans, Willan, Bateman ; Tricho- sis Area, Good ; Alopecia partialis, Alopecia circumscripta. 23. Charact.—Bald patches, often without de- cay or change of colour of the surrounding hair, the bared spots being often shining and white, fre- quently spreading or coalescing. 24. Partial alopecia is the consequence of various alterations of the secreting follicles of the hair, induced by impetigo, fevers, chronic eczema, sycosis, &c. The variety described by Willan, under the name of Porrigo decal- vans, is the most remarkable which comes un- der the present head. The scalp, or skin of the chin or cheeks of persons affected with it, presents one or more patches, frequently of a circular form, entirely devoid of hair, although surrounded by that of the natural growth. The skin of these patches is smooth, without red- ness, and often unusually white; and their areas extend gradually. When several exist near each other, they ultimately unite. A large portion of the scalp may be thus denuded of hair. Neither vesicles nor pustules, nor any other kind of eruption, can be detected in the surface of these patches. This affection oc- curs commonly in the hairy scalp, and in chil- dren ; but it is not infrequent in adults, and in the beard. In children it often assumes an ir- regular serpentine or winding form. I have seen it in them associated with various disor- ders of the digestive organs, and occasionally with those of the brain ; hut it has also been apparently independent of any internal affec- tion. Dr. Elliotson has seen it in a child with disease of the brain (Land. Med. Gaz., vol. vii., p. 639, and vol. viii., p. 30). The ca- ses which I have met with in adults were not connected with any other disorder. I agree with Good, Raver, and Todd in viewing it as a variety of alopecia, and entirely unconnected with porrigo. 25. A variety of partial alopecia has been no- ticed by MM. Mahon, Rayer, and myself, that differs from the preceding chiefly in the appear- ance of the affected surface, and in the pres- ence of a few altered and brittle hairs. In this latter respect it nearly approaches the morbid state of the hair already mentioned (<) 10). On one or more circular patches, the hair seems broken off to within a line or two of the skin. The surface of the patches is dry, appears rough to the eye, and feels more so to the touch. It is slightly bluish, and a fine, white powder can be detached from it. The affec- tion begins at a point, and spreads, similar spots forming in the vicinity of the one which first appeared. These may extend until nearly all the scalp becomes affected. ii. Diffused Alopecia.—Syn. Calvities, Dcpi- latio, Dcfiuvium Pilorum, Auct. var. ; Tricho- sis Atherix, Good 26. Charact.—The decay or fall, of the hair oc- curring in a diffused, or general manner; the hair HAIR—Loss of—Causes—History—Pathology. 163 becoming gradually thinner, commonly, at first, on the crown, or on the forehead and temples. 27. Decay of the hair in a gradual and diffu- sed manner may take place prematurely, and as a consequence of disorder of the digestive organs, or of the constitution, or of a local af- fection of the scalp extending to the pilous fol- licles. It is often an indication of premature exhaustion of organic nervous energy. Con- genital absence, or defective development of the hair of a permanent kind ($ 21), has been rare- ly observed. Instances of it have been record- ed by Heister, Dans, Wells, and Rayer. Premature loss of hair is not confined to the scalp, but often extends to the eyebrows, beard, and other parts of the body. It may be even general. Mr. South (Translation of Otto’s Pathology, p. 120) mentions a case most prob- ably of this kind. A total loss of hair, howev- er, is more common than general defective de- velopment of a permanent kind, and is met with chiefly in mature or far advanced age. J. P. Frank saw it in a young man ; and instan- ces of its sudden occurrence are recorded by Paulini and Heister, and in the Journal de Physique (t. xiv.), and in the Berlin Medical Transactions (t. iii., p. 372). Most commonly, the hair of the head, of the axillae, and pubes gradually and successively fall off. In rare in- stances, the hair has been renewed of a finer quality, as in the cases recorded by Lemery and Bonina (Journ. des Progres, &c., t. xiv., p. 244). A singular case of baldness, confined to one side of the body, is related by Ravaton. 28. Causes.—A. The remote causes of baldness are, whatever debilitates and exhausts the system, as profuse or prolonged discharges; dangerous haemorrhages ; masturbation, or im- moderate indulgence of the venereal appetite ; low, typhoid, or adynamic fevers ; care and dis- appointments ; the depressing passions and anxiety of mind; excessive application to study ; the contact of rancid, septic, or putrid animal matters with the scalp ; more rarely the syphilitic poison, and the frequent or prolonged use of mercury. It may also be caused by ex- posure to the sun’s rays; by the fumes of quicksilver, by the friction of a military cap or helmet; by eczema or other chronic eruptions of the scalp, and by the use of tobacco. It has been said to be endemic in some places. Leo Africanus has stated that baldness is common in Barbary; Tournefort, that it is almost universal in Mycone, one of the Cyclades ; and Sir R. Sibbald, that it was frequent in Shet- land in his time, owing to the fish diet of the inhabitants. That living chiefly on fish, and on poor, unwholesome food may aid in its produc- tion. is not improbable. The salts of sea-wa- ter left in the hair will sometimes cause it in- directly. Extreme distress of mind has pro- duced a general loss of hair within twenty-four hours ; but such instances are extremely rare. Since Hippocrates, it has been said that eu- nuchs do not become bald ; and Schenck re- marks that baldness does not commence until after the generative functions are exercised. It is certainly much less frequent in females than in males. 29. History and Pathology.—A. The fall of the hair may take place in a few days, or even in a shorter period ; or so slowly as to escape observation. The skin of the denuded part usually presents the ordinary appearance, especially in senile alopecia. In some cases it is pale, or of a dead, whitish colour, and furfura- ceous; and occasionally it is covered by scurf, or scales, and is distinctly inflamed. In the former case, its sensibility is not materially al- tered ; in the latter, there is heat, itching, or pricking. The hair is often more or less al- tered before it falls out, being thin, harsh, dry, weak, and stunted, or deprived of colour. This is most frequently the case when it proceeds from causes acting directly on the scalp, and from chronic eruptions of this part. 30. B. Loss of the hair proceeds from chan ges in the bulbs, 1st. From atrophy or -wasting of the follicles, as in senile alopecia, and in that state of the affection which is produced by ex- cessive venereal indulgences; 2d. From an impaired or suspended vital action of the pilous follicles, as in the alopecia that takes place sud- denly or rapidly from mental emotions, &c. ; in that which follows malignant adynamic or putrid fevers; and in that variety which has generally been known by the name of porrigo decalvans; and, 3d. From chronic inflammation, extending to the bulbs. Equally important with a knowledge of the particular condition of the follicles of bulbs to which the loss of hair is to be imputed is the investigation of the af- fections with which it is related, or upon which it is dependant. Although alopecia is often a strictly local and primary affection, proceeding directly from local causes ; yet it as frequently depends upon disorder of the digestive and as- similating organs, and upon the general state of the system. As Dr. T. J. Todd justly re- marks, it may arise not only from a change primarily induced in the follicles, but also from the extension of disease to them from the tis- sues in which they are situate. In this latter case, the alopecia may be also local, but it is consecutive, the follicles being altered by becom- ing involved in the inflammation constituting an adjacent cutaneous disease. The baldness following eczema, porrigo, impetigo, &c., is an illustration of this. 31. C. Alopecia is most frequently sympto- matic of debility or cachexia, produced by the exhausting causes enumerated above (§ 28). Af- ter fevers, the hair is generally exfoliated with tne cuticle, and sometimes even with the nails ; but as the follicles have their vital actions re- stored, the hair is reproduced. When, howev- er, the hair falls out in phthisis, diabetes, and other cachectic maladies, no attempt at resto- ration takes place. Alopecia may also be symp- tomatic of chronic inflammation of the digestive mucous surface ; indeed, this is a frequent cause of it. The connexion of this state of the digestive organs with chronic cutaneous eruptions is fully established and well known ; and the pilous follicles are sometimes the parts of the integuments affected thus sympathetical- ly ; the affection implicating them either prin- cipally or solely, or in conjunction witli oth- er parts of the skin. This dependance upon, or connexion with derangement of the digest- ive, and even of the biliary functions, should never be overlooked in practice ; for, although I cannot agree with Broussais and his follow- ers that the external change is produced by the internal inflammatory irritation, or that the internal complaint is so generally inflammatory 164 HAIR—Lobs of—Treatment—Trichomatose. in its nature as they would make it appear, yet I am convinced that there is a very close con- nexion often existing between the internal and external affection, both affections generally proceeding from, and being associated by the same pre-existent disorder; which disorder may generally be referred to the state of or- ganic nervous function or power. 32. Treatment.—A. In limited or partial alopecia, more particularly that variety usually called porrigo decalvans, and in all those cases that appear independently of inflammatory ac- tion, that depend upon the first and second pathological states enumerated above (<) 30), stimulation of the parts, by the decoction of walnut-tree leaves, or of the leaves of the so- lanum; by the infusion of rosemary, or of the lesser centaury, or of mustard-seed ; by various spirituous and aromatic washes ; by ointments containing the tincture of cantharides, or some essential oils; or by embrocations of thyme, lavender, the juice of onions, of garlic, &c., has been very generally recommended. M. Rayer, however, does not consider this practice very successful. Dr. Willis has seen the common mercurial ointment prove of service. An oint- ment, with the iodide of sulphur (9j. of iodide to 3vj. or jj. of ointment), may be rubbed on the part, night and morning. This ointment has been much employed by me in affections of the skin and scalp since 1824. The balsam of sulphur, applied to the scalp, is praised by Ruland ; a solution of the sulphate of copper in spirits, by some recent writers ; and blisters, by Arndt. I have seen a strong solution of the nitrate of silver, in some instances, and either an infusion of capsicum, or ointments with the tincture, in others, applied to the af- fected surface, and persisted in for some time, restore the hair. Dupuytren generally pre- scribed an ointment with a strong tincture of cantharides. I have, in several cases of bald- ness, of the kind under consideration, employ- ed an ointment containing the balsam of Peru with complete success. It has the effect of rendering the hair thick and persistent, and of promoting the growth of it in parts from which it had fallen out from impaired action of the follicles, The following is the formula that I have usually employed : No. 244. R Adipis Pr®paratie fjj. ; Cer® Alb® §ss.; lento igne simul liquefae, turn ab igne remove, et, nbi pri- mum lentescant, Balsami Peruviani veri 3ij.; Olei Lavan- dula TtLxij,, adjice, et assidue move donee refrixerint. 33. When alopecia proceeds from eczema, impetigo, feverg, &c., the treatment should be entirely directed to the removal of these erup- tions. When this is accomplished, and the skin remains dry, tense, or furfuraceous, the part should be shaved, and the surface anointed with the above ointment, or with some sub- stance of a similar nature, as an ointment with the oil of mace, &c. The tincture or infusion of tobacco, as recommended by Zacutus Lusi- tanus, and often empirically resorted to, will also be of service in this and in some other states of the disorder. In every form of the affection, the digestive, assimilating, and ex- creting functions should be regulated or assist- ed ; and associated internal congestions, or inflammatory irritations, removed by appropri- ate means. Alopecia, as well as premature grayness of the hair, is often caused by disor- der of these functions, and associated with these internal diseases; and neither the one nor the other can even be retarded in their prog- ress, unless the treatment be directed with a strict reference to these pathological connex- ions. Bibliog. and Refer.—Hippocrates, EmSr/paov, 1. vi., sect, vii., viii.—Galenus, De Med. Soc. I,oc., 1. i.; et Meth. M6d , xiv., 18.—Cehus, 1. vi., 4.—Paulus jEgin., 1. iii., o. 1. —Aitius, 1. vi., s. 65.—Actuarius, Meth. Med., 1. ii., cap. 5 ; 1. vi., cap. 1.—Oribasius, Synop., 1. viii., 22.—Mesue, L. ii., serm. i.—Avicenna, L. iv., fen. 7, tr. i., ch. 5.—Leo Africanus, Descriptio Afric®, 1. i., p. 85.—Fernelius, Oon- sil., i.—Joubert, De Affect. Pilorum et Cutis pnesertim Ca- pitis, 8vo. Lyon., 1577.—Ampsing, Hortus Affect. Cnpil- los et Pilos Corp. Hum. Infestantium, 4to. Rost., 1623.— Mercuriali, De Morb. Cutan., 1. i., cap. 3-5.—Merlet, Ergo A Salacitate Calvities. Paris, 1662.—Plempius, De Affect. Capillorum et Unguium. Lov., 1662.—J. Purlin, De Foe- minis ex Mensium Supp. Barliatis, 4to. Altd., 1664.— Za- cuius Lusitanus, Prax. Hist., 1. vii., obs. i. ; Prax. Admir., 1. ii., olis. 129.—E. Tyson, Philosoph. Trans., 1678.— Schenck, Obssrv. Med. Rar., 1. i., obs. 3.—Hagedorn, Hist. Med. Phys., cent, iii., p. 354.—Glisson, De Vent, et latest., tr. i., cap. 10.—RulanJ, Cent, viii., cur. 49, 65.—Heister, Misc. Nat. Cur., dec. i., an. ii., obs. 193.—Paulini, Cent. 111., obs. 60.— Riedlin, Lin. Med., 1695, p. 439; 1700, p. 341.—Lemery, Hist, de l’Acad. des Sciences, Ac., an. 1702, P- 29.—Alberti, De Canitie prematura. Halain may be either slight or intense, or characterized as heavy, dull, indis- tinct, diffused, numbing, compressive, constrict- ive, tensive, acute, burning, rending or burst- ing, or splitting, darting, lancinating, plunging, cutting, tearing, gnawing, boring, pulsating, or throbbing, &c. ; but whichever of these may exist, the mode of its accession and subsidence; its duration, remissions, and exacerbations; the circumstances alleviating or aggravating it; the extent and situation of it; and its con- nexion with affections of sight, with noises in the ears—the character of these noises—and with derangements of sensation, touch, and muscular action in any part of the body, ought to be carefully remarked. The state of the mental operations, of the articulation, and of sleep in respect both to its manner and dura- tion, should also receive attention. It is only from a careful estimate of these circumstan- ces—of all the functions depending upon the cerebro-spinal system in connexion with the state of the digestive, excreting, and circula- ting functions—that a correct opinion as to the nature of headache can be formed. There is no disorder which tries the science, experience, powers of observation, and acumen of the phy- sician more than this does ; and there is none that requires a more precise estimate of the pathological conditions on which it depends, as a basis for safe and successful indications of cure. From this it will appear that a compre- hensive division of the varieties of headache, HEADACHE—Nervous—Congestive, 169 without being either complicated or unnecessa- rily minute, is requisite to the due considera- tion of so important a subject as this. 7. Sauvages divides headache into three spe- cies : Cephalalgia, or acute headache; Cephalcea, or chronic headache ; and Hemicrania, or par- tial or local headache. Under the first he enu- merates the following varieties : the plethoric, catamenial, hcemorrhoida.l, dyspeptic, febrile, throb- bing, intermittent, puerperal, inflammatory, catar- rhal, nervous, hysterical, and the metallic. Under the second species he adduces the syphilitic, scor- butic, arthritic, remittent, melancholic, the Polish or plicose, and the serous. Under the third, pains of the eyes and sockets, in the frontal sinuses, and the catarrhal and hysterical, hcemorrhoidal, purulent, nephralgic. and the lunatic hcemicrania. It is obvious that this enumeration is deserving of attention only in as far as it shows the symp- tomatic states of the disease. Sagar adopts the division of Sauvages without any material alteration. J. Frank, also, follows it partially, and enumerates four species, viz., Cephalalgia, Cephalcea, Hemicrania, and Clavus. He consid- ers that headaches, in respect of their nature, may be farther divided into inflammatory, rheu- matic, gastric, arthritic, scorbutic, periodic, scrof- ulous, carcinomatous, syphilitic, and nervous. 8. Dr. Good has taken a very superficial view of the pathology of headache, and the surgical editor of his work has added nothing to the text. He divides headaches into the stupid, chronic, throbbing, and the sick, and megrim. Every practitioner of experience must have met with, if he have not actually experienced in his own person, headaches which at one and the same time possessed all the characters Dr. Good has enumerated as marking distinct spe- cies. Dr. Border has given a more correct division of the complaint, but it is deficient in some important particulars. The varieties, ac- cording to him, are, muscular, periosteal, congest- ive, organic, dyspeptic, and periodic headache. Dr. Weatherhead divides headaches into dys- peptic, nervous, plethoric, rheumatic, arthritic, and organic. The division adopted by Sauvages is complicated, and, notwithstanding its apparent minuteness, deficient. The arrangements of recent writers are even still more defective. 9. The several varieties of headache will be more advantageously considered according to the following arrangement: 1st. The nervous, from depression or exhaustion ; 2d. The con- gestive, from impeded circulation in the brain or its membranes ; 3d. The plethoric and in- flammatory, from general plethora, active de- termination of blood to the head, or inflamma- tory action ; 4th. The dyspeptic and bilious, from disorder of the stomach, liver, or bowels ; 5th. The cerebral, from organic change within the cranium ; 6th. The pericranial, from disease of the pericranium, or bones of the cranium ; 7th. The hemicranial or limited, confined to a spot, or neuralgic; 8th. The rheumatic and arthritic; 9th. The periodic; 10th. The hypochondriacal; and, 11th. The sympathetic, from disorder of the uterine and urinary organs. 10. i. Nervous Headache.—A. Causes.-—a. This variety is most frequent in females, in persons of the nervous temperament, and in those possessing high susceptibility and deli- cate constitutions. Venereal excesses, mas- turbation, intestinal worms, the abuse of calo- mel or other mercurials, and whatever depress- es or exhausts nervous or vital energy, predis- pose to it.—b. It is often excited by exposure to cold, or to cold and humidity conjoined ; by northerly or easterly winds ; by the more ex- treme electrical states of the air, or by sudden vicissitudes of these states ; by prolopged or excessive lactation ; by losses of blood, men- orrhagia, leucorrhcea, or other discharges ; by low diet and prolonged fasting ; by the depress- ing passions, alarm, fear, grief, and anxiety of mind ; by want of sleep, or inordinate mental or physical exertion; by the improper use of mercury or other depressants, as tobacco, dig- italis, &c. ; by various odours or mephitic va- pours or gases ; and by the impure air of crowd- ed or insufficiently ventilated rooms. Sleeping in apartments containing plants in flowrer, the fumes of burning charcoal, or of turpentine, and recently painted rooms, not infrequently cause it. The irritation of adjoining parts, as caries of the teeth and disease of their fangs, sometimes also occasion it, especially on the same side of the head as the seat of irritation. I have seen the most intense state of this af- fection produced by the injudicious application of cold to the head, by too copious depletion, by floodings, and by a residence in low, cold, and humid localities. Nervous headache is common to females during the catamenia, es- pecially when excessive or too frequent. It is often, also, indirectly caused by intoxicating liquors. Hf.inimann very justly notices it as a not infrequent attendant upon general anaemia resulting from disease or improper treatment. I believe that some degree of cerebral o.ruemia very often attends, if it does not produce this variety of headache. 11. B. Nervous headache is often sudden in its attack and termination ; is frequently acute, excruciating, lancinating, or darting; some- times constrictive, or attended by a sensation of the temples being pressed together; occa- sionally accompanied with vertigo, a feeling of sinking and dread of falling, or with great ner- vous agitation or restlessness, and sometimes confined or limited to a narrow space. The patient is incapable of thought and of physical and mental exertion. The sight is often dim or impaired, dark spots or meshes moving be- fore the eyes. In some instances, the eyes become sunk, and the countenance depressed or collapsed. The pulse is small, occasionally frequent, but generally languid, and always compressible. The pulsation of the carotids is small or weak. The head is cool, and the face more pallid than natural. The stomach is liable to disorder, especially to acidity and flatulence, and the bowels are often costive. This headache is frequently worse in the morn- ing and through the day, and abates in the even- ing. During severe attacks, wakefulness, diz- ziness, loss of memory, general susceptibility of the nervous system, &c., are usually com- plained of. 12. ii. Congestive Headache.—The state of the circulation within the head, the manner in which the blood is returned from the brain, the partial protection of the parts contained in the cranium from the physical influences exerted upon the rest of the general surface, and the periodical changes in the position of the head and in the exercise of the functions of the 170 HEADACHE—from Plethora, etc. brain, would seem, on a superficial view, to fa- vour the occurrence of congestion in this part. Yet, if these circumstances be more closely contemplated, there is at least equal evidence that they essentially tend to preserve the brain from passive congestion on the one hand, and inflammatory determination on the other, as well as from the more serious contingencies consequent upon that minute division of the extreme vessels required for the exercise of the various cerebral functions. The congestion oc- casioning this form of headache is seldom gen- eral, but commonly limited to, or seated chief- ly in one hemisphere or lobe of the brain, or one or more lobes, either in their vertical or basilar aspect. 13. A. Causes.—Congestive headache is pro- duced by pre-existent disorder, especially by repeated attacks of nervous or dyspeptic head- ache, and of active determination of blood to the brain. It often follows adynamic fevers, phrenitis, congestions of the lungs, and impe- ded circulation through the heart ; and it is not infrequently caused by the circumstances that sometimes give rise to nervous headache, particularly the depressing passions, cold and humidity, miasmata, noxious gases, mephitic vapours, and crowded rooms. The use of opium, belladonna, aconitum, and other narcot- ics, occasionally also produces it, especially in certain idiosyncracies, or in large doses. Tight neckcloths, stooping, and a too low position of the bead during sleep, also occasion it. The headaches following the inordinate use of in- toxicating liquors are to be referred to this and the preceding variety, rather than to disorder of the digestive organs or any other pathologi- cal state. Prolonged or intense mental occu- pation often gives rise to congestive headache; the repeated or continued determination of blood to the brain, thereby produced, passing into congestion, owing to exhaustion of ner- vous power ; and this state, if allowed to con- tinue, or frequently produced, often terminates in apoplexy or palsy. This variety is most frequently observed in persons advanced in life, and in those who have exhausted their vital energies and injured their constitutions by dissipation or intemperance. 14. B. The most characteristic symptoms of this variety are, the dull, gravative pain, and sense of weight in the head ; 'frequently stupor, heaviness, or giddiness ; dimness of sight; buzzing, ringing, or humming noises in the ears; and heaviness or pallor of the counte- nance. The pain is often referred to one part of the head chiefly, probably owing to the con- gestion being greater in one part than in an- other (<) 12). The patient experiences great increase of vertigo when looking up, or when stooping or looking down from an eminence; he sometimes complains of a sense of coldness in the head, of fatigue or prostration of strength, coldness of the extremities, and of susceptibil- ity of the nervous system. Sleep is often sound, heavy, or snoring; occasionally it is disturbed or restless, and attended by dreams, or by convulsive movements. The spirits are depressed, or almost hypochondriacal. The pulse is languid, weak, or small, occasionally accelerated. The bowels are torpid, and the biliary secretion deficient or morbid. The urine is loaded, and deposites a copious sediment. 15. iii. Headache from Plethora and in- creased Vascular Determination or Action. — A. The ‘predisposing causes of this variety are, the earlier and middle periods of life, the male sex, plethoric habits of body, sanguineous and irritable temperaments, full living, indo- lence, indulgence in bed, neglect of regular ex- ercise in the open air, and mental exertion.— B. The exciting causes are, all the circumstan- ces which either increase the vascular plethora resulting from the predisposing causes, or de- termine an increased flow of blood towards the head, especially neglect of accustomed depletions ; the suppression of discharges and eruptions, particularly of epistaxis, the cata- menia, and haemorrhoids ; exposure to the sun; intemperance in eating or drinking ; premature or inordinate mental culture, and exercise of the intellectual powers : every kind of mental excitement; fits of passion ; the supine pos- ture, with the head low; wearing strait corsets; too long hair, or the removal of it; overheated or overcrowded rooms or assemblies ; prolong- ed or unaccustomed continence, and the causes usually occasioning inflammation of the brain or of its membranes, or determination of blood to these parts. (See art. Brain, $ 182.) 16. C. The Symptoms in this variety suffi- ciently indicate the cause of the headache ; but they differ very much in different habits, tem- peraments, and ages.—a. In young persons the pulse is strong, or full, somewhat accelerated ; the head is hot, the countenance flushed, the eyes more or less suffused and heavy ; and the pain is rending, severe, sometimes pulsative or throbbing, occasionally with a beating noise in the ears, and felt chiefly in the forehead and temples. The bowels are costive ; and the patient is depressed, heavy, and indisposed to exertion. — h. In delicate or young persons, whose mental faculties have been prematurely exercised, or exerted to the neglect of the phys- ical powers, the slightest excitement and the most trifling causes will produce headache, with coldness of the extremities, and great susceptibility of the nervous system, especially of females. The principal flux of the circula- tion takes place to the head, and the functions of other parts are performed imperfectly.—c. In persons of the middle age, or beyond it, and especially in those who have lived fully or in- temperately, the headache is heavy, rending, or throbbing; often general, or referred chiefly to the occiput; attended with increased heat of the scalp, with distention of the veins about the temples, with fulness or redness of the eyes, and sometimes also of the whole counte- nance. The face is occasionally bloated, and its expression heavy ; the pulse is full, strong, and oppressed, or slower than the usual standard ; the bowels are torpid, the liver inactive, and the urine high-coloured or loaded. Sleep is heavy, but often disturbed. In some cases, however, with all, or nearly all these symp- toms, the patient is excited or restless, is watchful, or sleeps but little, or is irritable, and the pulse is slightly accelerated, the excre- tions being scanty. In the first and second classes of persons, this form of headache not infrequently precedes the inflammation of the brain and membranes, or effusion from the lat- ter : in the third class, it more frequently ush- ers in apoplexy or palsy. HEADACHE—Dyspeptic and Bilious. 171 17. iv. Dyspeptic and Bilious Headaches. —A. This variety of headache is very nearly allied to the nervous and congestive, and it has been confounded with these in the description of it given by Dr. Warren. From the circum- stance of sickness or vomiting being a frequent symptom, the term sick headache has been com- monly applied to it. But I am convinced that this symptom often depends upon the brain, and that many cases which have been viewed as merely instances of sick headache have ac- tually been cases in which the affection of the brain has been attended both by sickness and by headache (§ 2, et seq.). This form of disor- der frequently affects dyspeptic persons who have been longer than usual without food, or who have committed even slight errors of diet, and whose bowels are habitually sluggish. It may occur, as Dr. Burder remarks, \yithout any obvious susceptibility of the brain ; or in persons who can bear close application to study without inconvenience as respects the head, and yet who are liable to headache after taking certain articles of food, or mingling them in too great variety. 18. a. Dyspeptic headache, particularly when attended by nausea or vomiting, is observed chiefly in persons subject to mental or cerebral excitement, and in whom the gastric disorder, as well as the pain of the head, are only effects of that excitement. In these, the stomach is either irritable or weak, or even both, and unfit to perform its functions, as well as very liable to become farther disordered by slight causes. Stomach headache generally affects the fore- head or one temple, particularly the left; but it often extends over most of the head. When the left temple is chiefly affected, tenderness of the left eye is frequently, also, felt. The pain is dull, heavy, or oppressive, or acute, sharp, or darting. The mental faculties are some- what weakened, and exertion of the mind is irksome. Tenderness of the scalp is seldom present, unless in a slight degree, or in con- nexion with rheumatism. This variety of head- ache usually commences when the patient first wakes. It is then oppressive, heavy, or dif- fused. Nausea often supervenes, and some- times vomiting. When the pain is slight, it generally subsides after breakfast; but if retch- ing occurs, it continues longer, or until offend- ing matters are thrown off, and then becomes more limited or concentrated. The remains of an undigested meal, or merely an insipid fluid, mixed with frothy mucus, is at first eject- ed. But if the vomiting continue, bile is fre- quently discharged. In some instances, an acid or acrid fluid, or greenish bile, is vomited, when pain and all the symptoms disappear. If the attack be not arrested by suitable means, or by the spontaneous vomiting, the pain often increases as the day advances, until stimulating food or beverages taken into the stomach, or sleep, allay it; but it may return the following day. Dyspeptic headache, however, may take place much more slightly and transiently, or it may assume a more chronic or continued form. It may follow a principal meal, and cease in two or three hours ; or it may not occur until several hours after a meal. The pulse is lan- guid or feeble, seldom accelerated. The tongue is white, loaded, particularly towards the root; and its edges are slightly red, and often indent- ed by the teeth. The bowels are usually cos- tive. Vision is frequently indistinct; and cold- ness or slight numbness of the fingers is some- times complained of. 19. b. It has been supposed by Dr. Warren and Dr. Paris that, when the headache does not occur until several hours after a meal, and particularly when uneasiness or a sense of dis- tention is felt in the situation of the duodenum, it depends upon irritation of this viscus. The circumstance of an emetic often failing to afford relief in such cases, or to evacuate anything material from the stomach, while a dose of rhubarb and magnesia, or of any other purgative, generally removes both the headache and the uneasiness in the course of the duodenum, has been considered as proof of the dependance of the affection of the head upon disorder of this bowel. Without questioning the existence of functional disorder of the duodenum in these cases, the origin of the headache in that disor- der does not necessarily follow. Both affec- tions, most probably, depend upon the same pathological states; and it is, moreover, ex- tremely likely that the derangement of the duo- denum extends more or less to both the stom- ach and liver. The symptoms which the wri- ters just referred to consider characteristic of headache proceeding from disorder of the upper portion of the intestines—particularly chilliness of the body; coldness and dampness of the hands and feet; severe pain of the head, with a sense of coldness and tightness of the scalp ; slight giddiness, with weight, distention, and stiffness of the eyebjalls, and the appearance of brilliant ocular spectra ; and sometimes tin- gling and numbness of the fingers and hands —arise as much from disorder of the stomach or liver, or both, as from derangement of the duodenum and upper parts of the intestines. More dependance may, perhaps, be placed upon flatulency and the sensation of dryness and in- activity of the bowels noticed by Dr. Paris, and upon the presence of nausea without vom- iting ; but it is most probable that the altered sensibility referred to the head, equally with the symptoms just mentioned, depends prima- rily upon the state of orgame nervous influence. 20. B. Biliary derangement is generally con- nected with more or less disorder of the stom- ach and bowels; the affection of the one may have extended to the other, or all may have been simultaneously disturbed by causes affect- ing the nervous or the vascular systems. In either case, the disturbance is not infrequently, also, extended to the head, and partly mani- fested by pain in this situation, particularly in the forehead, eyebrows, and orbits.—a. The headache may proceed from an interrupted dis- charge of bile into the duodenum, and a conse- quent accumulation of it in the gall-bladder or hepatic ducts; the morbid impression thereby made upon the organic nervous system affect- ing the head, and often, also, other remote parts. When the headache arises from this state of disorder, vascular action is generally weak, languid, or depressed, the tongue loaded or white, the skin harsh or unhealthy in its hue, and the functions of digestion and fecation impaired. In these cases, flatulence, coldness of the extremities, and a sense of smarting in the eyes and eyelids, or pain in the eyeballs, are often, also, complained of. 172 HEADACHE—from Disease of the Periosteum, etc. 21. h. In some instances, headache proceeds from an exuberant secretion of bile, or from the irruption of morbid bile into the duodenum; but, in most of these, there are increased vas- cular action and heat of skin, with nausea and bilious vomitings. The face is flushed, the eyes suffused, and the pain is throbbing or rending. The evacuation of bile often gives relief, but the retchings sometimes keep up the secretion, or promote the discharge of it; and the digestive mucous surface, and the nerves supplying it, being thereby irritated, vascular action becomes excited, and the sensibility even of remote parts more or less altered : pains of the head, loins, and limbs are thus induced. 22. C. The Causes of dyspeptic and bilious headache have a very intimate relation to the predisposition or susceptibility of the nervous systems and digestive organs to excitation or irritation.—a. Such susceptibility very often exists in a high degree in persons of sedentary and studious habits. Intense application of the mind, the anxieties of parents, the eager pursuit of husiness or of gain, the speculations of merchants, the gambling transactions of the stock-markets and of club-rooms, &c., keep the mind in an almost constant state of excite- ment, determine an augmented flow of blood to the brain, and thereby increase the irritabil- ity of the stomach, and predispose both organs to be disordered by the slighter causes to which the latter is so much exposed. As vital power becomes weakened, the susceptibility of the cerebro-spinal nervous system is increased, and the sensibility of it more readily disturbed. The digestive and assimilative functions are also weakened, and more prone to disorder, which not infrequently affects the brain, espe- cially when its circulation has been excited, or kept in an almost constant state of erethism, by the circumstances just adverted to. Dys- peptic headache is most common in the young or middle-aged. The bilious variety is most prevalent during summer and autumn. 23. b. The exciting causes are, errors in diet, especially too great a variety or quantity of food ; indigestible, acrid, cloying, rich, or heavy articles; too long fasting; the excessive use of diluents or of stimulating or intoxicating beverages, particularly of spirituous liquors ; costiveness or constipation, and the irritation of morbid secretions and faecal matters retained in the bowels. In young persons, especially, headache and increased determination of blood to the head are frequent consequences of cos- tiveness, of collections of sordes or of fecal matters in the digestive canal, and of intestinal worms. 24. v. Headache from Organic Changes.— In the early stages, this form of headache can hardly be distinguished from the other varie- ties ; indeed, organic change not infrequently originates in some one of the pathological states of which headache is an occasional at- tendant. But, while in all these varieties the pain is only sometimes present, or is, at least, entirely absent for considerable periods, that produced by organic lesion is nearly constant or continued, or merely remits, without alto- gether disappearing. The alterations which are attended by headache are numerous; in- deed, all those enumerated in the articles Brain (§ 3-133) and Cranium may give rise to it.; but the most common are tumours of vari- ous kinds, hydatids, exostosis from the inner surfac'e of the cranium, ossific formations, soft- ening of the substance of the brain, suppuration, adhesions of the membranes ; tubercular, can- cerous, fungous, and malignant productions, &c. Besides these, aneurismal or ossified ar- teries, varicose or inflamed veins, obstructions in the sinuses and veins; concretions, albu- minous exudations, or purulent matters in these vessels (Lieutaud, Borsieri); enlargement of the pineal or pituitary glands, serous effusion, &c., have been observed. 25. The pain caused by any of these lesions is generally fixed, often referred to the same spot, continued, and deep-seated. It is inde- pendent of the other causes of headache, al- though aggravated by them, by mental applica- tion, by stooping, and by stimulants. Dr. Bur- der justly remarks that cheerful conversation that would chase away, or at least suspend the feeling of ordinary headache, often becomes in- supportable in this variety. When the disease is farther advanced, even a slight motion of the head, or rotating it, often gives rise to ex- treme suffering, and sometimes to vomiting. The affection of the stomach, dependant upon the cephalic lesion, frequently occurs without any obvious cause, or independently of appa- rent disorder of the stomach itself, or of any error in diet; and the pain of the head remains when the sickness ceases. Although the pain is generally constant, yet remissions are some- times felt, or even short intermissions, espe- cially early in the disease. This is even the case when the lesion is malignant or carci- nomatous, or consists of fungous tumours; and the pain is usually then lancinating, stounding, or darting, and referred to a particular spot. In the advanced stage of organic headache, spasmodic contractions of the limbs, vertigo, convulsions, paralysis, or idio-tism frequently supervene. When the lesion is of a malignant or contaminating nature, the surface generally assumes a pale straw-coloured hue, or is ob- viously cachectic. Neuralgic pains in the face, or in more remote parts, darting pains in the limbs, are also occasionally present in this variety. (See arts. Brain—Softening of, &c., and Palsy.) 26. vi. Headache from Disease of tiie Pe- riosteum and Cranial Bones.—This variety is not often met with. Cases of it have been recorded by Mr. Crampton, Sir E. Home, Dr. Abercrombie, and others; but the best de- scription of it is given by Dr. Border.—a. Af- fection of the ■periosteum is usually caused by exposure to cold, to currents of air, to humid- ity, and vicissitudes of temperature and weath- er. The pain is tensive, remitting, and in- creased by pressure, and by the action of the temporal or occipito-frontalis muscles. There are sometimes fever, and excited action of the vessels of the head, with increase of the heat of the scalp. A constrictive pain is caused or aggravated by going into a cold room, or by removing the usual covering froln the head. Dr. Border observes that this variety of head- ache occurs only in those who have suffered from continued cerebral excitement; and that it is commonly dependant upon a highly sus- ceptible, or preternaturally vascular condition of the brain or its membranes, such as is often HEADACHE—Rheumatic and Arthritic—Intermittent. induced by long-continued study, by mental ir- ritation, or by gastric or hepatic disorder con- nected with debility or exhaustion. If a per- son whose nervous or vital powers are thus impaired, and whose brain and membranes are rendered susceptible and vascular, is exposed to the exciting causes just mentioned, perios- teal cephalalgia of great severity or obstinacy is often produced, the external affection, with the consequent irritation and want of sleep, aggra- vating the morbid condition of the brain and membranes. The cases which I have seen have been chiefly in persons of the scrofulous diath- esis. 27. b. Cases of fixed pain of the head, and tenderness of a portion of the scalp, with thick- ening or swelling of the integuments, have been observed by the writers just mentioned, and by Mr. Pearson and Sir C. B. Brodie. I have seen instances of this affection originate in otitis: one of these was in a medical friend, who consulted also Dr. J. Johnson and Sir C. B. Brodie. The external disorder followed the use of the cold douche or shower-bath, recom- mended for the removal of increased vascular action and heat of the scalp indicative of cere- bral excitement. Division of the pericranium in these cases has generally shown thickening of the periosteum, and even disease of the bone in a few instances. 28. c. When headache is owing to a dis- eased state of the bones (see art. Cranium), there are constant pain and tenderness of a particular spot. Some of these cases originate, in syphilitic or mercurial cachexia. Others proceed from inflammation of the ear, and are connected with chronic discharges from this organ, or consist of caries of a portion of the petrous bone, or of the mastoid process. In the cases of this kind which I have seen, there was partial paralysis of the face, with exces- sive swelling around the ear, especially below it, and extending even to the eye. I attended one of these cases with Mr. Barnwell, and another was seen by Sir C. Bell and myself, and is noticed in his work on the nervous sys- tem. Similar instances are recorded, also, by J. Frank and others. 29. vii. Rheumatic and Arthritic Head- ache.—A. Rheumatic Headache is usually caused by exposure to cold, or to cold and humidity, or to currents of air; by uncovering the head when perspiring; by sleeping on a damp pil- low ; by the passage of air through a carriage window ; by sudden vicissitudes of tempera- ture or of weather, especially by easterly or northerly winds. But a predisposition arising out of the rheumatic diathesis, or of disorder of the digestive organs—particularly torpor of the liver, accumulations of bile in the bile pas- sages, and collections of sordes in the intesti- nal canal—is often necessary to the production of this affection of the head. 30. Rheumatic headache is often preceded by a sense of coldness over the head and face, especially on one side. It is seated chiefly in the aponeurosis of the occipito-frontalis and temporal muscles; but it is not always con- \ fined to this structure, it being sometimes as- sociated with increased vascular determination to the membranes of the brain. The pain is severe, heavy, distracting, or aching, and in its j uncomplicated state is attended by a sense of I coldness, by great tenderness of the scalp, by rheumatic pains extending down the neck, or in one side of the neck, or in one shoulder, or in the face ; sometimes by copious perspira- tions, and more rarely by rheumatic inflamma- tion of one or both eyes. It is generally ag- gravated in the evening, and alleviated in the morning, and by warmth. There is no in- crease of the temperature of the scalp, or aug- mented action of the arteries of the head, un- less the affection be complicated with excited vascular action in the internal membranes. If it be thus complicated, these symptoms are also present; and, as Dr. Elliotson justly ob- serves, there are likewise giddiness, drowsi- ness, and internal throbbings. This associated disorder is seldom ameliorated by warmth, and the face is often flushed, the eyes injected, and the vessels loaded. 31. B. Arthritic Headache is met with in per- sons who are subject to the irregular forms of gout; and, in those who have an hereditary or an acquired predisposition to this malady, it may be the first manifestation of the gouty af- fection. Of this I have seen more than one in- stance, both in males and in females about the change of life. It is not an unusual form of misplaced or of retrocedent gout, in persons who have had the disease in its more regular forms, but who neglect the air, exercise, and regimen necessary to the development of a regular paroxysm ; and it is often a dangerous affection. The pain is severe, and attended by a sense of fulness and of heat or burning in the head ; by remarkable tenderness, and by increased heat of the scalp ; by giddiness, dim- ness of sight, and fear of approaching insensi- bility, especially upon stooping; by sounds in the ears, great acuteness of hearing, and intol- erance of noises; by flushes of heat in the face ; by irritability of temper and restlessness; and by confusion of thought and loss of mem- ory. There are also flatulence and disordered digestion ; costiveness ; a morbid state of the stools, and of the biliary secretion ; and scanty, high-coloured urine, which deposites a copious reddish sediment. The tongue is generally loaded, and its papillae excited ; and the pulse is either natural, as to frequency, and full, or accelerated and hard, or oppressed. If this affection is not removed, it may pass into effu- sion, with comatose or apopletic symptoms. (See Gout—Irregular Forms of, IB ) 32. viii. Intermittent Headache.— Cepha- lalgia Periodica, Auctorum—Fehris Intermittens Cephalica larvata, J. Frank—usually presents the same characters as the functional varieties already described, especially the nervous and dyspeptic, and differs from them only in re- spect of periodicity. But it may be not merely functional ; for the pain caused by chronic in- flammation of the membranes, or even by or- ganic lesion within the cranium, may assume, at their early stages, an intermittent type. A strict investigation of the causes, and of the states of the various functions, is therefore requisite to a knowledge of the nature of the j affection. When the headache proceeds from terrestrial exhalations, or from cold, raw, east- erly or northerly winds, and attacks persons ; who have been affected with agues or rernit- ! tent fevers, it generally returns daily, either in i the morning or about noon ; but it may observe 173 174 HEADACHE—Neuralgic—Diagnosis. a tertian pr quartan form. It is often limited to a particular part of the head—frequently to the forehead, or to one brow, or to the brow and orbit—brow-ague. It is sometimes seated in one half of the head. The pain is occasion- ally so severe and so limited in extent as closely to resemble neuralgia. Indeed, inter- mittent headache and neuralgic affections al- most insensibly pass into each other, the parox- ysms of the latter being, however, much more intense and of shorter duration than those of the latter ; and they both frequently proceed from the same predisposing anil exciting caus- es, namely, disorder of the stomach, bowels, and biliary organs, and exposure to malaria, or to cold damp winds, &c. 33. ix. Hysterical and Sympathetic Head- ache.—The pain in the head is one of the nu- merous forms in which hysteria manifests it- self. It is generally limited to a small space, or to a single spot; and is often described as resembling a wedge or nail driven into the cra- nium or pressing upon the brain— Clavus, &c. It is commonly sympathetic of irritation of the uterine organs, and associated with irregularity of the uterine discharge ; with painful, scanty, or excessive menstruation, or with leucorrhcea; and with flatulent borborygmi, or with the glo- bus hystericus. I have seen it also connected with worms in the intestines, with the irrita- tion of calculi in the kidneys, and with tender- ness and other indications of inflammatory ir- ritation of parts of the spinal chord and mem- branes. Indeed, affections of the spine seldom exist without pain in the head, in some one of its forms, being occasionally felt. 34. x. Hypochondriacal Headache. — Pain of the head is often one of the most distressing symptoms of which hypochondriacal and mel- ancholic persons complain, and is exaggerated by them into the most intense suffering that can be imagined ; and yet, when their atten- tion is directed to other objects of interest, or when they are otherwise excited, this part of their miseries seems altogether forgotten, or for the time removed. Their minds brood upon the cause and consequences of the pains re- ferred to this situation, until they firmly be- lieve the very worst results. A patient, some time since, called upon me to know whether or not I considered the pain to depend upon or- ganic change ; and although my opinion was that this was not the source of the affection, yet several visits were afterward made to me with the same object. Another more recently came under my care, with the firm belief that the headache would terminate in insanity or idiotism. Such cases are, however, not rare ; and although the fears, which subsequently be- come the firm convictions of the patient, are fulfilled in some instances, or even impel them to suicide in others, yet recovery is not infre- quently effected by judicious treatment and management. The source and character of the pain in such cases are ascertained with difficulty, as the patients’ accounts are often exaggerated, but are most frequently depend- ant, as far as I have observed, upon the state of the nervous system, in connexion with chronic disorder of the digestive canal and bil- iary organs. The organic nervous energy is manifestly impaired, and all the functions which chiefly depend upon it. But I have seen cases furnishing evidence of congestion, or of chronic inflammatory action of the brain or of its membranes, and have found a treatment based on this view more or less beneficial. 35. xi. Of Hemicrania, and Partial and Neuralgic Headaches.—These can scarcely be considered as distinct varieties of head- ache, inasmuch as the pains proceeding from the pathological states which have been passed in review are very frequently limited in ex- tent, or confined to one side of the head, or af- fect it chiefly. This is especially the case with the dyspeptic, the bilious, the organic, the ner- vous, the rheumatic, the intermittent, and the hysterical varieties ; and it is still more so in respect of that, upon which a few observations remain to be made—the neuralgic.—A. This variety is characterized principally by the in- tensity of the pain, which is confined to a sin- gle spot, or extends in the course of a single nerve. The pain comes on in violent parox- ysms, is of short duration, and is followed by distinct, and often by considerable intermis- sions. There is generally increased sensibil- ity or tenderness of the scalp around the seat of suffering, and the digestive organs often betray disorder. The nervous system is sus- ceptible and weakened. The pulse is seldom materially disturbed. This is only one of the numerous situations in which Neuralgic Af- fections (see the article) manifest themselves. 36. B. Partial or limited Headache is often excited by local causes of irritation. Very se- vere pain in the situation of the frontal sinuses has been experienced, owing to the ova of in- sects having passed by the nostrils to this part. Ploucquet gives numerous references to cases where the larvae of insects had occasioned in- tense pain. A servant in my own family suf- fered from this cause, the larva being dischar- ged upon a violent fit of sneezing. Caries, or disease of the fangs of the teeth, is often the cause of partial headache, the pain being some- times confined to a single spot on the same side of the head as that in which the cause of irritation is seated. 37. xii. Diagnosis.—There is no class of af- fections which requires greater discrimination than this; and there is, perhaps, none which is esteemed more lightly by practitioners, or more empirically treated, the digestive organs being considered much too generally as the source of disorder. I believe that a careful investigation of the cases, and close observa- tion of the juvantia and laidentia. will show that a greater number of them depend upon chronic inflammation of the brain, or of its membranes, than is commonly supposed. The diagnostic symptoms of each variety have been enumerated in the description of it, but the following summary may be given at this place: («) Nervous headache is distinguished by absence of constitutional disorder, by susceptibility of the nervous system, by the feeling of constric- tion, and the limited extent of the pain, by the natural temperature of the head, &c. (<) 11) — (I)) The congestive is characterized by the numb, dull, or heavy, oppressive, and deep-seated pain ; by languor of the circulation ; by pallour or heaviness of the countenance; by dizziness, drowsiness, and want of animation ; by the coolness of the scalp, and sometimes by ful- ness of the eyes and a bloated state of the face HEADACHE—Prognosis—Treatment. 175 (§ 14).—(c) Plethoric and inflammatory headache is manifested by the general, severe, rending, and throbbing pain ; by nausea or vomiting; by fulness of the vessels, or flushing of the face and eyes ; by the full, hard, or oppressed pulse ; and by the increased temperature of the head ($ 16).—(d) The dyspeptic and bilious is evinced by dull, aching, or racking, or shooting pains, which move from one part to another, and are often attended by soreness of the scalp, by dis- order of the digestive organs, and flatulence ; by a loaded tongue, foul breath, and a morbid state of the secretions, especially the biliary (<) 18-21)—(e) The organic is distinguished by internal acute pain, which becomes more and more constant or prolonged ; by sudden retch- ings ; by a quick, irritable, or irregular pulse ; by the pain darting or shooting from one situ- ation ; by tenderness or soreness on pressure being felt, particularly when the bones are af- fected ; by alterations in the sensibility and motions of a limb or limbs; and by sympto- matic pains, spasmodic contractions, &c. (§ 25). —(/) Rheumatic and arthritic headaches are readily recognised from the diathesis of the patient, and from the causes and characters of these affections. The rheumatic is generally connected with rheumatism of an adjoining part (§ 30). The arthritic presents symptoms that cannot be mistaken, especially when viewed in connexion with the history of the case (6 31). The description of these, and of the other forms of headache, has been so fully given, that nothing farther respecting their diagnosis is requisite. 38. iii. Prognosis.—A favourable result may be anticipated of cases of the nervous, the dys- peptic. the bilious, the rheumatic, the aguish, and the hysterical headache. A guarded opin- ion should be given respecting the inflamma- tory, the arthritic, and the rheumatic when as- sociated with increased vascular action in the internal membranes (<) 30). When headache is accompanied with vomiting, without obvious disorder of the stomach having preceded the attack, an inflammatory affection of the brain should be suspected, and a prognosis conform- able with this view ought to be given. A still more unfavourable opinion should be enter- tained if the locomotive powers, if the memory, if the senses, or if utterance or articulation become impaired. If there be sufficient evi- dence of disease of the brain, or of its mem- branes, great danger exists, although a fatal termination may be long delayed, or even de- ferred for some years, as in cases of palsy. If the pericranium be affected, and especially if the bones of the cranium be diseased, a very guarded, if not a very unfavourable, prognosis is necessary. 39. xiv. Treatment.—It is evident that the indications for the cure of headaches should be inferred from the nature of each ; that reme- dies ought to be directed to their pathological conditions and relations, ascertained by a close examination of the states of the organic and locomotive functions, of the senses, and of the mental manifestations. And, although what has been advanced above may aid the inexpe- rienced, or furnish useful suggestions to many, yet the successful administration of remedies in these affections will entirely depend upon accuracy of observation, and upon pathological and therapeutical knowledge previously ac- quired.—A. Nervous Headache, proceeding from depression or exhaustion, obviously requires the nervous energies to be restored by tonics and stimulants. These medicines, however, should be administered with due caution at first; as the more active of them, or too large doses, may excite fever, or even occasion vas- cular determination to the head. They ought not to be given, or continued long, until faecal accumulations have been removed by mild or stomachic purgatives, which should afterward be prescribed occasionally, in conjunction with deobstruents, in order to preserve the excreting functions in a state of healthy activity. While the head ought not to be kept too warm, the impression of cold must be prevented, at least until the organic functions have acquired their usual tone. In most instances, the milder tonics may be given, with the alkaline carbon- ates, or the aromatic spirit of ammonia, and with carminatives. The diet should be light and nourishing, the occasional causes avoided, and gentle exercise in the open air daily taken. In slight cases, these means, and a due regula- tion of the digestive functions, will remove the disorder; but, if they fail, those about to be noticed should be resorted to. 40. Nervous headache may prove obstinate, or it may be unusually violent from the com- mencement, or gradually become so. If, in these cases, the symptoms, especially those connected with the organic functions, and with the senses and cerebral manifestations, evince neither vascular action nor organic lesion within the cranium tonics conjoined with ano- dynes, antispasmodics, or carminatives, ac- cording to the peculiarities of the case, should be resorted to. The preparations of cinchona, of valerian, of arnica, of asafcetida, and of am- monia ; camphor in full doses; the aethers ; the carbonate of iron, the nitrate of silver, &c., are then severally indicated, and may be given with opium, or with the acetate or hydrochlo- rate of morphia, or with hyoscyamus, or with belladonna, according to circumstances. If there be prolonged watchfulness, a suitable narcotic should be exhibited at, or shortly be- fore bedtime. I have found the following medicines of great benefit in some very severe cases of this kind, the pills (No. 245) having been taken, in addition to the mixture (No. 246), during the violence of the attack. An increased dose of the pills, or the anodyne draught, may also be given at night. Formula 24, 25, 36, 269, 367, 423, 539, 555, prescribed in the Ap- pendix, also, may prove useful in this variety of headache. Nn. 245. R Camphor® rasce gr. xij.-xviij.; Extract! Hy- oscyami 3ss.; Conserv. Rosarum q. s. ut fiant 1‘ilul® xij., quarum capiat duas. quarts vel quinta qn&que hnril No. 246. R Infusi Valerian® 3.x. ; Sod® Carbonatis K'r. xij. ; Spiritus Ammonia? foetid. 3j.; Tinctur® I.avand. Comp. Ttlxx. ; Tinct. Aurantii Co. 3j. M. Fiat Haustus, quartis, quintis. vel sextis horis sumendus. No. 247. R Quinime Sulphatis, Camphor® rase, 23 ST. x. ; Extr. Aloes purif. gr. xij. ; Extr. Hyoscyarni 3ss. ; Mucilag. Acacia; q. s. M. Fiant Pilul® xxiv., quarum ca- piat unam, vel duas, vel tres, bis terve in die. 41. B. Congestive Headache should be treated according to the age, habit of body, and consti- tutional power of the patient, and to the local as well as general state of the circulation. It should not be overlooked that vascular action in the brain, owing either to impaired vital HEADACHE—T reatment. 176 power of the capillaries, and of the organ gen- erally, or to impeded return of blood by the veins and sinuses, is insufficient for the due performance of the several functions of this part of the frame.—a. In delicate or irritable persons, stomachic or mild purgatives ; tepid or cold sponging the head with fluids contain- ing aromatic and fragrant substances, as laven- der or Cologne water; derivatives, especially warm or stimulating pediluvia; the internal exhibition of camphor, ammonia, valerian, gen- tle tonics, &c. ; light diet, and moderate exer- cise in the open air, will prove most service- able. Local blood-letting will seldom be re- quired, even in small quantity; blisters behind the ears wall be productive of benefit in some cases ; and the effusion of tepid water on the head in others. As the patient’s strength im- proves, cold spotlging the head, or the shower bath, and friction of the scalp, will be useful in preventing a return of the affection. Where there is much irritability, the combination of hyoscyamns, or of small doses of the powder 'or extract of belladonna, with the medicines just named, and strict attention to diet, air, and exercise, will generally be found of advan- tage. 42. b. When this form of headache affects persons whose vital powers have been exhaust- ed by dissipation and unrestrained indulgences, or those of a leucophlegmatic habit of body, the treatment should be still more restorative, tonic, or stjmulant than the foregoing ($ 41). Even local depletions will be injurious, and the cold affusion on the head will be of little ser- vice unless the affection has followed the use of narcotics, or when the head is hot. Cordial stomachic aperients, warm spiced wine, or cof- fee ; the preparations of ammonia, or of cam- phor, or of valerian, or of arnica, &c.; stimu- lating pediluvia ; and blisters beliind the ears, or on the temples, or even on the head, in ex- treme cases, are among the most appropriate remedies in cases of this kind. After these have relieved the more distressing symptoms, the complete removal of the disorder, and the prevention of a return of it, may be attempted by promoting the digestive, the assimilating, and the excreting functions ; by the use of ton- ics, of the preparations of bark or of iron ; and by mild chalybeate and aerated mineral waters. But, before these are prescribed, the secretions and excretions should be freely evacuated, and their morbid states corrected, by alteratives and mild purgatives (F. 205, 266, 430); and, during the course of restorative medicines, these should be frequently resorted to. The factitious mineral waters of Carlsbad, Marien- bad, or of Pyrmont or Spa, subsequently, may be cautiously tried ; but those of Seidschutz or Pullna should, in many cases, precede the use of these. 43. c. When congestive headache occurs in the plethoric, the indolent, and well fed; in persons about or past middle age, or who have experienced obstructions of the liver, or of any accustomed evacuation, the treatment should be very different from the above. General or local blood-letting, the affusion of cold water an the head, brisk cathartics, and derivation to the extremities by warm and stimulating pedi- luvia or manuluvia, are chiefly to be depended upon. But these will fail of being permanent- ly useful, unless the diet of the patient be re- stricted, and regular exercise be taken in the open air. The secretions and excretions ought, also, to be freely and regularly promoted. A daily recourse to the shower bath will prove of great service. 44. d. When this form of headache proceeds from prolonged or intense mental application or exertion, not only should the above means be adopted, according to the age, strength, habit of body, and modes of living of the pa- tient, but entire relaxation of the mind, change of air, travelling, the amusements of watering places, sea voyaging, early hours, light reading, and horse exercise should be enjoyed, as cir- cumstances may permit. At the same time, the mineral waters most suited to the peculi- arities of the case may be taken, especially those that are deobstruent, aperient, and gently tonic ; and, while the functions of digestion and assimilation are promoted by restoratives, and by breathing an open, dry air, the secre- ting and excreting actions of the abdominal viscera should receive strict attention. 45. C. Plethoric and Inflammatory Headache requires the adoption of the means just enu- merated 43), but in a much more active man- ner. The regimen ought to be strictly anti- phlogistic, and permanent derivation or coun- ter-irritation established by means of issues or setons in the nape of the neck, or of the tartar emetic ointment, or of croton oil, applied in this situation and in its vicinity. The bowels ought, also, to be copiously and frequently act- ed upon. When this form of headache follows the disappearance of accustomed discharges or eruptions, or of haemorrhages, this treatment should be most strictly enforced, and the use of external as well as internal derivatives stren- uously persisted in. (See Brain—Congestion of, § 139, and Inflammation of, <) 191.) 46. I). Dyspeptic and Bilious Headaches.—a. The former will be remedied by the means ad- vised in the article on Indigestion. I may, however, state in this place, that when this headache is attended by nausea, and when it is clearly ascertained that the sickness does not proceed from inflammatory action within the cranium, an ipecacuanha emetic, vomiting being promoted by drinking chamomile tea or warm water, will generally give relief. After the stomach is evacuated, and the nausea is gone, a mild purgative, as the compound rhubarb pill; or the sulphate of magnesia, with carbonate of magnesia and a carminative spirit or tincture in an aromatic water ; or rhubarb, with mag- nesia or an alkaline carbonate, and any aro- matic or carminative medicine, will give far- ther relief by changing the state of the secre- tions in the stomach and upper part of the in- testines, and by promoting the excreting func- tions of the latter and of the large bowels. 11 nausea be not present, these purgatives should be given forthwith, and repeated until the bow- els are freely evacuated. Suitable light diet, exercise in the open air, and an occasional re- course to these or similar aperients will pre- vent a return of the affection. I have found the following most serviceable, when given with this intention, in moderate doses. In lar- ger doses, they will also remove the complaint. No. 248. It Pulveris Rhei Jss.; Extr. Fellis Dovini. Extr. Aloes purificati, aa 3j.; Saponis Duri gr. xv. ; Pulv. Ipe- HEADACHE—Treatment. 177 cacuanh®, Pulveris Capsici,aa gr. xij. ; Balsami Peruviani, Olei Carui, aa gutt. viij. Contunile bene simul, et massam divide in Pilulas xxxvj., quarum capiat unam vei duas, cum prandio, vel hora somni. No. 249. ft Infusi Gentiante Comp., Infusi Sennce Comp., aa fiij. ; Sod® Carbon. 3ij. (vel Magnesiae Sulphatis 3yj.) ; Tinct. Jalap. 3jss. ; Tinct. Senn®, et Tinct. Cardamom. Comp., 5a 3iijss. M. Fiat Mist., cujus capiat Coch. iij. ampla horft somni, vel Coch. ir. primo mane. 47. b. When bilious headache seems to depend upon the congestion or accumulation of bile in the biliary passages, then chologogues, partic- ularly calomel or blue pill, should be given, and followed, after a few hours, by a stomachic purgative, which should be repeated until a full effect is produced. In these cases, it will oft- en be necessary to repeat the mercurial, as well as the purgative, oftener than once; the infusion of senna, or equal parts of it and of a tonic infusion, being given with an alkaline car- bonate, or with a neutral salt and the extract of taraxacum, or the bitartrate of potash in large doses, with the confection of senna and this extract. When the headache seems to proceed from an exuberance of acrid bile, then demulcents, with cooling aperients, or with al- kaline carbonates, saline medicines in a state of effervescence, and warm mucilaginous dilu- ents, are generally useful. In cases of this kind, it is necessary to dilute the acrid secre- tions, to evacuate them from the bowels, and to protect the digestive mucous surface from their irritating operation. When the acridity of the bile is the consequence merely of its re- tention and accumulation in the biliary appa- ratus, then these means will be sufficient to re- move disorder; but when it depends upon the exuberance in the blood of the elements whence bile is formed, or upon a morbid action in the liver, a vegetable or farinaceous diet, bland flu- ids, the alkaline carbonates and refrigerants in camphor mixture, regular exercise, especially of the muscles of the upper extremities and of the trunk, are then required. If the action of the liver is not improved by these means, re- course should be had to mercurial alteratives or aperients ; and if it be connected with vas- cular excitement of, or determination to the organ, local depletions, antimonial prepara- tions, diaphoretics and diuretics, external de- rivatives, and the antiphlogistic regimen, should be prescribed. In every case, fecal accumula- tions and morbid secretions should be regular- ly evacuated by the means already advised. 48. E. Organic or Cerebral Headache.—When the patient complains of increased pain in the head on moving it, of spasms or pains in the limbs, or of impaired sensibility of motion of them, of sickness, and of any of the character- istic symptoms of this variety (§ 25), deple- tions, general or local, according to the peculi- arities of the case ; deobstruent purgatives, in- ternal and external derivatives, blisters applied on the nape or behind the ears, and kept long discharging, setons or issues, low diet, mental and bodily repose, and local or general refriger- ants, or diaphoretics, as circumstances indi- cate, then constitute the principal means of af- fording relief. After these have removed vas- cular excitement, small doses of the bichloride of mercury, or of the iodide of mercury, or of the iodide of potassium, or of the ioduretted solution of the iodide of potassium, or of the arsenical solution, may be prescribed, and con- tinued until the effects are ascertained 5 but external derivation should be also persisted in. (See, also, articles Bkain, § 211, 222, and Palsy.) 49. F. Pericranial Headache.—When the af- fection proceeds from disease of the pericrani- um or of the cranial bones (<) 26), the treatment is essentially the same as that just advised ($ 48); but it may be modified to meet various peculiarities and changes. If the affection is syphilitic, the bichloride of mercury, or the io- dide of mercury, or the other preparations of iodine above mentioned, may be employed. If the periosteum or the bone be diseased, an in- cision should be made down to the affected part, and a free discharge afterward maintain- ed, as successfully practised by Mr. Pearson and Sir B. C. Brodie. If this affection have proceeded from inflammation of the ear, the discharge from the external meatus of the or- gan should be allowed a free egress. (See Ear —Inflammation of, <) 26-29.) 50. G. Rheumatic and Arthritic Headaches should be treated with strict reference to the diathesis or constitutional disorder.—a. If rheu- matic headache is not associated with inflamma- tory action of the membranes, the head should be kept warm, and the secretions and excre- tions freely promoted and evacuated. After biliary and fecal accumulations have been car- ried off, camphor, ammonia, and colchicum may be given in conjunction; or one or more of these may be taken, with bark or any other tonic, or with magnesia, or with the subcar- bonate of soda or potash, especially when the urine deposites a copious sediment or is acid. If severe symptomatic fever or signs of inflam- matory action in the cerebral membranes ac- company the rheumatic affection of the head, local depletions, antimonials, active cathartics, and derivatives should be prescribed, and col- chicum freely exhibited. But when these symp- toms are absent, either of the following medi- cines will generally give relief, a full dose of calomel, or of blue pill with James’s powder, or some antimonial, having been taken at bed- time, and a stomachic purgative the following morning, and repeated according to circum- stances : No. 250. ft Camphor® rasae, Quinin® Sulphatis, Pulveris Radicis Colchici, ail gr. xviij. ; Extracti Hyoscyami 3ss„; Conserv. Rosar. q. s. M. Fiant Pilul® xxiv., quarum ca- piat duas, bis terve in die.—Vel. No. 251. ft Sods Carbon. 3j. ; Tinct. Colchici Comp. 3ss.; Tinct. Cardamom. Co. 3j. ; Decocti Cinchonas (vel Infusi Cascarill®) Jx.; Tinct. Lavandul. Comp. Tttxij. M. Fiat Haustus, ter in die sumendus. 51. h. Arthritic headache sometimes requires local depletions from the nape of the neck and from behind the ears, especially in plethoric or robust persons ; but a great quantity of blood should not be taken away. The lower extrem- ities ought to be put in warm water containing flour of mustard and salt; and if the headache is not very much relieved by these means, mustard poultices may be applied to the feet. Colchicum should also be prescribed,, with aperi- ent or purgative medicines, and with magnesia, or the alkaline carbonates, as recommended in the article Gout (§ 55, 82, et seq.). In these cases, the colchicum, when given in small or suitable doses, and continued for some time, in order to ensure its action on the liver and on the kidneys, seems to favour the elimination of the superabundant urea from the blood; a 178 great excess of this substance in the circula- tion being generally connected with the pro- duction of the gouty affection, in all its modes of manifestation. As urea is the sum or ulti- mate product of assimilation, or results from a combination of the effoete elements of human organization, and as it is liable to accumulate in the blood when the functions of excretion are impaired, owing to weakened organic ner- vous power (see art. Gout, § 40-42), so it is not improbable that, when it is thus superabun- dant, it becomes an excitant not only of mor- bid or altered sensibility, but also of increased vascular action, and of local determination— that, in short, it is the matcries morbi of the an- cients, and one of the forms which effcete and excrementitious elements in the blood assume ; and that it constitutes a part of the morbid con- dition of which I have shown gout to be the chief manifestation. This view is supported by the experiments of Prout, Chelius, and oth- ers, showing the superabundance of urea, and its combinations in the urine, when the actions of the kidneys are freely exerted, towards the decline of the gouty attack. 52. H. It is unnecessary to enter into the treatment of the other symptomatic varieties of headache, inasmuch as the means of cure for them are essentially the same as are fully sta- ted in the articles on those diseases of which headache is a frequent symptom.—a. When the pain is intermittent, independent of organic lesion, and one of the forms which masked ague assumes, then a full dose of calomel with James’s powder, or of any other mercurial al- terative, at bedtime, a brisk cathartic draught early the following morning, and, after the op- eration of these, the sulphate of quinine with camphor, or the preparations of bark and ser- pentaria, will remove the affection.—b. If the headache be hysterical, the means already ad- vised for nervous headache (40) will generally remedy it. If, however, the pain be sympto- matic of disorder of the uterine or of the urinary functions, the means of cure must be directed to the restoration of these functions to the healthy state, as shown in the articles on Men- struation, Urine, and Uterus ; and to the re- moval of vascular plethora by evacuations and derivatives, especially when the affection de- pends upon this state of the circulation, or ari- ses from suppressed or diminished secretion or excretion. (See Treatment of Plethoric Head- ache, 45.)—c. The headache attending hypo- chondriacal affections is frequently relieved by the means advised for dyspeptic and bilious headaches (<) 46); but the treatment may be conducted in all respects as directed in the ar- ticle on Hypochondriasis.—d. Local or neural- gic headaches (l) 35) require the removal of the cause of irritation, when it can be accomplish- ed, and generally the means already advised for the nervous and congestive varieties (<) 40- 44); sometimes a constant and energetic ac- tion to be exerted upon the intestinal canal; frequently the exhibition of tonics, stimulants, and narcotics, or anodynes; occasionally ex- ternal irritants or vesicatories, as moxas, cro- ton oil applied to the surface, the tartar emetic ointmpnt, issues, blisters, &c. ; in some instan- ces the application of narcotics, as veratria, &c., to the part affected, or of the acetate of morphia to the skin denuded of its cuticle, and HEADACHE—Remedies recommended by Authors. the other means mentioned in the article on Neuralgic Affections. 53. xv. Brief Account of Remedies recom- mended by Authors.—A. Evacuants.—a. Emet- ics have been advised for headaches by us Aurelianus, Horstius, Ruland, Riedlin, and Frank, and are often of great benefit when the pain proceeds from injurious ingesta, from the accumulation of bile in the biliary passages, or from impeded circulation in the vena porta. —b. Purgatives are not less useful, and have been very generally, but often empirically, pre- scribed for headaches. Selig trusted chiefly to them for the removal of the intermittent form of the affection. Considerable judgment is, however, requisite jn the selection of medi- cines of this class, and in the combination of them with other substances, so as to secure all the advantages they are calculated to afford. ARETiEus, and many others of the ancients, employed hellebore. When the pain arises from accumulations of bile, or from obstructions to the excretion of this fluid, then calomel, con- joined with some other purgative, and occa- sionally, also, with antimony, or with ipecacu- anha, is most appropriate. In the nervous, the congestive, the dyspeptic, the periodic, and in the hypochondriacal forms of headache, the stomachic purgatives prescribed above ($ 46), or the combination of a purgative with a tonic, carminative, or aromatic, &c. (F. 215, 266, 379), will be found most serviceable.—c. Vascular de- pletions are requisite in plethoric and inflamma- tory headaches. Bleeding from the arm, some- times from a vein in the foot, or cupping on the nape, are the most eligible modes. CasLius Aurelianus, and Velschius preferred cupping on the head itself. I have repeatedly directed it to be performed on the occiput, be- hind the ears, or on the temples ; and, when a small quantity of blood is to be taken away, these are often preferable situations. Leeches may be applied in circumstances similar to those requiring cupping. Artcriotomy has re- ceived the sanction of Arethsus, SchencK, Wepfer, Willis, Zacutus, Lusitanus, and of many recent writers ; but I believe that it pos- sesses no advantages above the other modes of vascular depletion, even in the most inflam- matory form of the complaint.—d. Sudorifics are most beneficial in the febrile, inflammatory, rheumatic, and periodic states of the affection. In the last of these, they have been prescribed by Morgagni. The selection of sudorifics or diaphoretics should be guided by the state of the general circulation and of vascular action in the head. When either the former or the latter is excited, the potassio-tartrate of antimo- ny, in frequent doses, or James’s powder, and the more refrigerant diaphoretics, are most ap- propriate ; but when the head is cool, and the pain is connected with rheumatism, depression of vital power, and suppressed cutaneous func- tion, the warm or vapour bath, camphor, the mis- tura guaiaci, or weak infusions of serpen/aria, or of arnica, or of briony, will be more benefi- cial than antimonials, unless these latter be conjoined with opiates and restoratives. 54. B. Stimulants and Antispasrnodics.—These are serviceable chiefly in the nervous, the rheu- matic, the hypochondriacal, and the neuralgic forms of headache, and sometimes in the inter- mittent, the congestive, the dyspeptic, and liys- HEADACHE—Remedies recommended by Authors. 179 terical. The medicines of this kind most com- monly prescribed are, the preparations of cam- phor and ammonia, the compound tincture and fez- tid spirits of ammonia, the cethers, castor, musk, serpentaria, tincture of lavender, &c. Besides these, preparations of arnica have been recom- mended by Selig, Dumangin, and J. Frank; cajeput oil,* by Thunberg ; a strong infusion of coffee, by Baglivi and Percival ; an infusion of verbena, betonica officinalis, and semina coriandri, by J. Frank ; and the ledum palustre by Lin- naeus. Valerian has been praised by Strand- berg and Fordyce. I have found the infusion, with the ammoniated tincture of valerian, or the foetid spirit of ammonia, of great benefit in the headaches just mentioned. Black pepper has been recommended by Lange in the dyspeptic variety ; and its active principle, piperine, has been employed in the intermittent form of the affection. Guaiacum has been prescribed by J. Frank in rheumatic and arthritic headaches. It is of service in combination with colchicum and magnesia, or with an alkali. Green tea and coffee are very commonly resorted to in the above forms of headache as domestic rem- edies. 55. C. Tonics.—a. The preparations of bark are generally beneficial in the periodic and non- inflammatory kinds of this complaint. The sul- phate of quinine is now generally preferred ; but, in many cases, tbe decoction of cinchona, with the compound tincture, and an alkaline subcar- bonate, will be more efficacious.—b. Absinthium was most frequently employed by the older writers. Riverius conjoined it, or other bit- ters, with purgatives ; a practice deserving of more general adoption.—c. The cascarilla bark was used for nervous and dyspeptic headaches by Riedlin, and is excelled only by cinchona. •—d. The hydrochlorate of ammonia is also of ser- vice in the nervous and intermittent varieties. —e. The arsenical solution was praised by Dar- win. I have prescribed it, and taken it myself, for headache, with marked benefit.—f. The chloride of barium was recommended by Hufe- land, for the pains proceeding from, or con- nected with scroftdous disease.—g. The prep- arations of iodine are, however, more deserving of adoption, when the complaint is thus asso- ciated, and when it depends upon organic le- sion. They may be given with any of the nar- cotics about to be mentioned. I have lately proved their efficacy in the rheumatic variety of headache arising from the gonorrhoeal infec- tion. The iodide of potassium is preferable in this latter form, and, indeed, in several others. —h. The extract of nux vomica is mentioned by Horn, and may be given in small doses, as a tonic, in the nervous, the rheumatic, and the hypochondriacal varieties ; but its effects must be carefully watched. It is preferable to the active principle, strychnine, which should be prescribed only in very minute doses. [The carbonate of iron, in large doses, will often cure these periodic and kinds of headache. The valerianate of quinine, a remedy lately introduced, promises more ben- efit in this and other intermittent forms of dis- ease than any other with which we have been hitherto acquainted ] 56. D. Narcotics and Anodynes have been em- ployed in several of the varieties of headache, both externally and internally.—a. Opium, in various forms, has been directed by Whytt, Mursinna, J. Frank, W. Stokes, and many others ; especially in the nervous, the rheu- matic, and intermittent kinds of the complaint. The acetate and hydrochlorate of morphia are now generally used ; but they, as well as other prep- arations of opium, should be conjoined with camphor, or with an aromatic, in order to en- sure their good effects.—b. Aconitum, in the form principally of extract, was praised by Stoerck and Vogel, and was once much em- ployed in rheumatic and chronic headaches. It is certainly often beneficial in these as well as in the nervous varieties ; but it should be given in small doses, and its effects carefully observed. Aconitine, the active principle, is to be preferred as an external application, in the neuralgic or rheumatic states of the complaint; but even in these it requires the utmost cau- tion. The powder of the root or of the leaves may sometimes be ordered with advantage. I was lately consulted in a case where the incau- tious employment of aconitine caused an apo- plectic seizure and hemiplegia. — c. Belladonna has been used in somewhat similar cases to those for which the aconitum has been exhibit- ed. The extract, or the powder of the root or of the leaves, may be given, either alone or with camphor, or an aromatic. I prescribed it in a case of hypochondriacal headache with much benefit. — d. Hyoscyamus has likewise been recommended by Stoerck, Renard, and others. I have found it of great use when combined as just stated, or when conjoined with ipecacuanha and some stimulating anti- spasmodic, and given in a decided dose.—e. Co- nium was directed by Letts om ; the distilled laurel-water, by J. Frank ; and the hydrocyanic acid, by Goon. Digitalis is considered by Frank as very beneficial in the headache pro- ceeding from scrofulous disease.—f. Stramoni- um has been prescribed by several writers. I have seen it given with benefit. 57. E. Alteratives are required whenever the affection of the head appears to depend upon a morbid state of the secretions, upon impaired action of the chief excreting viscera, or upon an impure state of the circulating fluids.—a. Of these, mercurials are the most active, and most generally used, both internally and externally, for this complaint. Calomel was prescribed largely by Wepfer, Velschius, Bang, &c. It is most serviceable- when the headache depends upon accumulations or obstructions of the bile, and a torpid state of the bowels, and when con- joined with, or followed by other purgatives. In the rheumatic form it is advantageously con- joined with antimony and opium. The blue pill may be prescribed on similar occasions, and in the same manner. The bichloride of mercury was preferred by Lentin, De Moneta, Van Swieten, and Gmelin, especially in the head- aches depending upon organic lesions within the cranium, or upon disease of the bones. In these, as well as in some other cases, it may be prescribed in a tonic tincture or decoction. The iodide of mercury may be used in similar circumstances. Mercurials were pushed to salivation by Willis, Lentin, Nuck, Bang, Dar- win, and Blane ; but this effect is rarely re * Thunberg prescribed the cajeput oil externally ; but I have ordered it to be taken internally, and with great benefit. 180 HEADACHE—Remedies recommended bv Authors. quired unless when the pain resists all other means, or proceeds from a syphilitic taint.—b. Alkalies, particularly the subcarbonates of soda or of potash (Thilenius), the solution of pot- ash, or Branoisii’s alkaline solution, are often of service, when given in tonic or aperient in- fusions or mixtures, and aided by the decoc- tion or extract of taraxacum.—c. An infusion of two or three drachms of the clematis vitalba, in a pint of boiling water, was recommended by Stoerck and Muller, to be taken in the twen- ty-four hours.—d. The decoctions of sarsaparil- la are more deserving of adoption, and may be made the vehicles for the exhibition of other medicines which produce an alterative effect, as the bichloride of mercury, the iodide of po- tassium, the alkalies, the extract of taraxacum, &c.—e. The alkaline chlorides may be also tried. —f. The precipitated sulphur will be found ben- eficial in the rheumatic form of the complaint, if taken daily in sufficient quantity to exert a gentle action on the bowels.—g. The prepara- tions of colchicum, when given in small doses, and conjoined with magnesia, or with sarsapa- rilla and the alkalies, also exert an alterative operation, as explained above (§ 52), and are of great use in the arthritic and rheumatic forms of the affection.—h. Various mineral springs are extremely serviceable : but they require to be appropriately prescribed. Those containing iron, fixed air, lime, or the alkaline carbonates, are most suited to the nervous, neuralgic, rheumatic, and dyspeptic varieties ; those holding sulphur, &c., in the rheumatic, arthritic, bilious, hypochondriacal, &c. ; and those containing the purgative salts, in the bil- ious, arthritic, hypochondriacal, &c. 58. F. Derivatives—whether those which ex- ert an immediate and brief effect, or those which act more slowly but permanently—are of great benefit in several forms of headache. —a. To the former class purgatives may be said to belong ; as they not only increase secretion and excretion, but also determine the fluids to the digestive canal.—b. Masticatories were em- ployed for headaches by Celsus, Forestus, Muralt, and many others ; but they have now fallen into disuse. Nevertheless, they are frequently of service.—c. The same remark applies to sternutatories, which have been recommended by the same writers, and have experienced the same fate. The benefit derived from various cephalic snuffs is undoubt- ed, even in cases that have resisted other means, and has led to their adoption as empir- ical remedies, in irregular and domestic prac- tice. They are beneficial in exciting the olfac- tory nerves, and thereby the cerebral functions, and in procuring a defluxion from the Schnei- derian membrane.—d. Warm pediluvia and man- uluvia are often resorted to, especially when the extremities are cold, or when the pain de- pends upon determination of blood to the head. In these circumstances, the addition of mus- tard and of salt to the water will be of service. —e. Sinapisms and stinging with nettles, or ur- tications, were employed by the ancients in the treatment of headache. Celsus. and others directed sinapisms to the head, over the seat of pain ; but Themison contended for their application to the lower extremities.—/. Blisters on the nape, sometimes on the extrem- ities, are now more generally prescribed.—g. Setons and issues in these situations, or in the arm, are commonly recommended in the more obstinate cases of this complaint, and when the pain is suspected to arise from organic le- sion. They are praised by Riverius, Zacutus, Lusitanus, Holler, Fabricius Hildanus, Heis- ter, Purmann, and De Haen. I have pre- scribed them in several cases with benefit.—h. The tartarizcd antimonial ointment has also been of advantage when applied on the scalp or nape of the neck, and its effects on the in- teguments fully procured. 59. G. Topical Means.—a. The application of cold to the head or temples, in various modes, has been advised by most writers, when the pain proceeds from determination of blood to, or inflammatory action of the brain or mem- branes. A recourse to the affusion of cold or tepid water on the head, and the repetition of either, according to the grade of vascular ac- tion in it, are often preferable to the continued application of great cold, which is sometimes productive of mischief. Cold sponging, cold lotions, or epithems, wetting the forehead and temples with aether, or with aromatic waters, &c., and the shower bath, are severally of ben- efit, especially in the plethoric or inflammatory states of the affection ; but the douche, or affu- sion, should be preferred in the congestive form, especially when caused by narnotics.— b. Warm applications and warm coverings on the head have been sanctioned by Celsus, Lange, and many others. In nervous and rheumatic headaches especially, they are frequently of great service. Alexander Trallianus pre- scribed them in the form of emollient fomenta- tions. Diemerbroeck and Marcus directed fo- mentations with aromatic herbs ; and J. Frank warm epithems, moistened with a decoction of verbena and bctonica officinalis. Hot sinapisms applied over the affected part have been re- sorted to by .some of the ancients (§ 58).—c. Blisters on the head are occasionally of service, especially in the congestive and rheumatic va- rieties of headache ; but they require much dis- crimination. They have been applied to the scalp by Riverius, Schrader, Bang, Pouteau, Aubert, Monro, and others ; but, unless in some cases of the varieties just stated, they are more useful behind the ears, where they may be kept open for some time, or often re- peated.—d Stimulating liniments (F. 299, 311), rubbed assiduously on the scalp, are sometimes of service when cautiously prescribed, in ner- vous, rheumatic, and neuralgic headaches, or hemicrania. Liniments, also, containing ace- tate of morphia, or the extract of belladonna, or of aconitum, or of hyoscyamus, or of stramonium, or of opium, have been advised by several wri- ters to be rubbed upon the scalp, in obstinate cases of this kind. I have found them of ser- vice in several instances, although it was doubt- ful whether they or a full dose of acetate of morphia, given with aromatic spirits, that was also prescribed in some of the cases, had pro- duced the effect. Very recently, ointments, containing veratria, aconitine, or other acro-nar- cotic substances, have been directed to be sim- ilarly applied in these affections. I have seen benefit derived from them in two or three in- stances ; but I have known others where they either failed in giving relief, or seemed to be injurious. The propriety of having recourse HEADACHE—Bibliography and References. 181 to them is often doubtful. — e. The tartarized antimonial ointment may be used in the varieties of headache just mentioned, or even where or- ganic lesion within the cranium is suspected ; but the effects of it, as well as of liniments, onght to be carefully watched.—f. Frictions of the scalp have been advised by Gilbert and others, and have been of advantage when reg- ularly and assiduously practised.—g. Compres- sion of the carotids, although suggested by Se- eapion and Parry, is undeserving of farther notice. The same remark is applicable to strait cinctures of the head, advised by some writers. —h. The actual cautery, applied to the seat of pain, has been recommended by Hippocrates, Celsus, Aretceus, Velschius, Aulagnier, Valentin, and by other ancient and nhodern writers. It is, however, reprobated by us Aurelianus, and is now rarely had recourse to.—i. The application of moxas—a modification of this practice—has been long adopted in East- ern countries, and has been advised by Pas- cal, Saissy, Larrey, J. Frank, and others. Wepfer advises the moxas to be placed in the course of the coronal suture ; Pouteau, on the vertex ; and Velschius, on the temples.—k. In- cisions of the scalp, in the seat of pain, have been directed by Le Bruyn, Severinus, Gra- teloup, Tissot, and Sumeire. They are more serviceable in disease of the pericranium, or of the bones of the cranium. Issues in the scalp have been sanctioned by Purmann and many others. I have seen benefit accrue from them in two instances.—/. Electricity and gal- vanism have been recommended by many in headaches ; but they produce merely a tempo- rary benefit, and are not always safe.—m. Tre- phining the cranium has been favourably no- ticed by Baglivi, Morgagni, Meekren, Mar- chetti, Vogel, Schmucker, and Good, and ac- tually practised by some of them. It is only when the pain is very violent, confined to a single spot, has followed an external injury, and resists all other means, that the practice can be entertained. Mr. S. Cooper states that he has seen two cases in which the patients lost their lives by this treatment.—n. The ex- traction of carious teeth should not be neglected in hemicrania, or local pain of the head from this cause. In a case where this object could not be accomplished, and in another where it was objected to, I directed a strong solution of the acetate of morphia, to which aromatic spir- its were largely added, to be rubbed upon the seat of pain, and complete relief was obtained. The application of creosote to the tooth, or of camphor, acetate of morphia, and capsicum conjoined, has also been of service. [Granville's lotion, applied to the temples, or the scalp itself, is one of the best applica- tions we have ever employed for the relief of headache, especially of the nervous kind, or that connected with an anaemic state of the system, as in chlorotic females. In nervous headache from exhaustion, as well as general anaemia, the extract of aconite, in doses of from a half to a grain, every two or three hours, will often prove very useful. See Mease On Sick Head- ache, and Burgess On Nervous Headache from Exhaustion.] 60. In the sketch here given, I have men- tioned only such means as seem deserving of a trial, or are calculated to be of service in | some one or other of the numerous forms and circumstances in which headache is presented to the practitioner. I have furnished sugges- tions merely, but these will be useful even te the most experienced. The advantage to be derived from them will entirely depend upon the pathological acumen by which their appli cation to particular cases may be guided. Bibi ioo. and Refeb.—Hippocrates, ITc/>( vovaiov, ii., v. Opp., p. 462 ; iii., v., Opp., p. 489.—Celsus, ]. iv., c. 2.— Aretaus, Curat. Chron., 1. i., c. 2.—Themis on, apud Cali urn Aurelianum, Morb. Chron., 1. i., c. 1.—Orihasius, Sy nops.. 1. viii.., c. 18, 20.—Aetius, Tetrab. ii., serm. ii., c. 40, 41.—Alexander Trallianus, 1. i., c. 16, 17.—Paulus JEgi neta, 1. iii., c. 4.—Serapion, Tr. i., c. 6.—Avenzoar, L. i., tr. 3.—Mesue, De iEgrit. Capitis, 1. ii., fen. i.—Avicenna, Canon., 1. iii., fen. i., tract. 2, c. 1, 9.—D. Johnson, Prao tica Medicina: De A5gritudinibus Capitis, 4to. London, 1502.—Polidamus, De Capitis Doloribus, in Libris de Med- ica, 8vo. Basil, 1540.—S. Portius, Encomion de Cap. Do- loribus, 4to. Flor., 1551.—J. Cahagnesi, Brevis facilisque Method. Curand. Cap. Affect. Cadomi, 8vo, 1618.— Wep- fer, Observ., p. 81 .—Rhodius, Cent, i., obs. 69.—Schenck, 1. i., obs. 86.—J. A. Vander Linden, De Hemicrania Men- strua Hist. Lugd., 1660.—Diemerbroeck, Observ. et Curat. Cent., No. 70.—Amatus Lusitanus, Cent, i., cur. 4.—Bo- rellus, Cent, i., obs. 38.—Bellini, De Morbis Capitis, p. 575. —Paullini, Cent, iii., obs. 12, 55.—Ilorstius, Opera, vol. 111., p. 18.—Zacutus Lusitanus, De Med. Princ. Hist., 1. i., n. 5.—Rolfinck, Ordo et Method. Cognoscendi et Curandi Dolorem Capitis. Jena;, 1671. T. L. Morgan, On the Path, and Treatment of Headaches, Edin. Med. and Surg. Journ., vol. xxiv., p. 1 and 240.— Willis, De Anima Brut. Path., c. i.,ii.,pars ii.,c. 2.—J. Lommius, Observ. Med., 1. 11., n. 57.—Riverius, Observ., cent, i., 37.—Hollerius, Ob- serv. ad Calcem de Morb. Intends, No. 1.—Riedlin, Millo- narius, n. 27, 237, 532, 796.—Thonerus, Observ., 1. ii., n. 2. —Zwinger, Theatrum Vita; Humana;, p. 350, 520, 528.—Ru- land. Cur. Emp., cent, vii., 79; cent, x., 77.—Velschius, Episagm. 11, et Heoatost., t. ii., p. 67.—Purmann, Chirur- gia Curiosa, p. 43.—Selig, Observat., n. 54.—Bonet, Se- pulchretum, 1. i., sect, i., obs. 87, 88, 114.—Blankard, Col- lect. Med. Phys., cent, iii., n. 46 ; cent, v., 57.—Severinus, De Efficaci Med., pars ii., c. 5.—Schrader, De Doloribus. Helmet., 1688.—T. Mayerne, Prax. Med., 1. i., c. viii., p. 76.—Bartholin, Acta Hafn.,t. iii., obs. 66; et Epist., t. iii., p. 222.—Lange, Miscell. Verijtates, t. i., p. 69, 112.—Bag- livi, De Capitis Affect. Opera, p. 76.—F. Hoffmann, De Dolore Cephalico, obs. 3, 9 ; Opera, ii., p. 253.—Gilihert, Adversaria Pract., p. 224.— Vallisneri, Opera, vol. iii., p. 269-280.—Juncker, De Doloribus Capitis, Scandalo Medi- corum difficulter re movendo. Hal a;, 1741.—Morgagni, De Caus. et Sed. Morb., Ep. i., art. ii.—Thevenot, Voyages, t. 1., c. 27.—Meekren, Observ. Med. Chirurg., c. 9.—J. J. Wepfer, Observ. Medico-Pract. de Affect. Capitis, et ex- tern. Zur., 8vo, 1745.—Stoerck, Libel, de Hyosciamo, &c., p. 28.—J. Fordyce, Hist. Febr. Mil. et de Hemicrania, 8vo. Lond., 1758.—Heinimann, Museum der Heilkunde, b. iv., p. 171.—Pouteau, CEuvres Diverses, t. ii., iii.—Marchetti, Obs. 36, 38.—Hill, Cases in Surgery, p. 52.—Z. Vogel, Chirurg. u. Med. Beobachtungen, p. 410 —Lieutaud, Hist. Anat. Med., 1. iii., observ. 58, et seq.—Burserius, Institut. Med., par. iii., p. 9, 15, 18.—M. Stoll, Rat. Med., par. iii., p. 231.—Linnaus, Diss. Ledum Palustre. Ups., 1775; et in Amcen. Acad., vol. viii., p. 285.—Whytt, Works by his Son, p. 620.—Ranol, Act. Reg. Soc. Med. Havn., vol. iii., p. 348; et vol. iv., p. 80.—Bang, in Ibid., vol. i., p. 287; et vol. ii., p. 81, 268.—Anderson, in Trans, of Roy. Soc. of Edin., vol. ii.— Vicq d'Azyr, An JEther Hemicraniae Ner- vosael Paris, 1778.—Sumeire, Journ. de Med., t. lvi., p. 240.—Aubert, in Ibid., t. lxxx., p. 11.-—Pascal, in Ibid., t. lxi., p. 269.—Grateloup, in Ibid., t. lvi., p. 435.—Renard, in Ibid., t. xxviii., p. 347.:—Dumangin, in Ibid., t. lvii., p. 550.—J. Fothergill, On Sick Headache, in Med. Observ. et Inq., vol. vi., p. 103; and Works, 4to, p. 597.—T. Fowler, Med. Reports on Arsenic in Ague, Periodic Headaches, &c., 8vo. Lond., 1786.—Henry, Memoirs of the Med. Soc. of London, vol. i., p. 294.— Lettsom, in Ibid., vol. iii., art. 5, —Parry, in Ibid., vol. iii., art. viii., p. 77.-—Kilgour, Edin. Med. Comment., vol. viii., p. 7, 15.—A. Monro, Treatises on the Brain, &C.— G. Blane, Trans, of a Soc. for Improve- ment of Med. Knowledge, vol. ii., p. 192.—Darwin, Zoono- mia, ause of deaf- ness is chronic inflammation of the mucous r embraie which lines the tympanic cavity, and that by fat the gi tater ma- jority of cases commonly called nervovs deafness ought more properly to be attributed to this cause).—Joseph Will- iams, Treatise on the Ear, &c., Ed. Prize Essay, 1840.— James Yearsley, Deafness successfully Treated through the Passages leading from the Throat to the Ear, 3d ed. Lond., 1841, 12mo.— William Kramer, Nature and Treat- ment of the Diseases of the Ear, translated from the Ger- man by James Risdon Bennett, M.D., Am. Ed. Philad., 1838, 8vo.— William Dufton, The Nature and Treatment of Deafness and Diseases of the Ear, and the Treatment of the Deaf and Dumb. Lond., 1844, 12mo.—S. Saisy, On the Ear, translated by N. R. Smith.—/. H. Curtis, An Es- say on the Deaf and Dumb, showing the Necessity of Med- ical Treatment in early Infancy, with Observations on Con- genital Deafness, with Plates, 1 vol., 8vo.—Brit, and Foreign Med. Rev., No. 20.—Med. Chir. Rev., Nos. 76, 81, 87.] HEART AND PERICARDIUM—Diseases of the.—Syn. Kapdla, Xeap, Xf/p, Gr. Cor, Lat. Das Herz, Germ. Cceur, Fr. Cuore, Ital. r.epiKapdiov, Gr. Pericardium (from nept, around, and icapdla, the heart). Pericarde, Fr. Der Hertzbeutel, Germ. Pericardia, Ital. 1. I. Introductory Remarks. —The prog- ress that has been made in the knowledge of the diseases of the heart may be dated from the appearance of the writings of Hartenfels, Bonet, Vieusseux, Lancisi, and Barbeyrac, toward the close of the seventeenth, and at the commencement of the eighteenth century. Lancisi first directed attention to lesions of the valves, and to hypertrophy of the heart, as causes of sudden death. Morgagni, Senac, Meckel, Juncker, and Spaventi farther ad- vanced our knowledge of these diseases ; but, from the middle of the last century, when the work of the last-named writer appeared, until the beginning of the present, when Corvisart wrote, this department of pathology was com- pletely neglected. With Corvisart the recent progress that has been made in it may be said to have commenced. His work was soon fol- lowed by that of A. Burns, by the engravings of Baillie, and by the fragment of Farre, in this country; and by the w'orks of J. C. War- ren, in North America; of Testa, in Italy ; of Kreysig, in Germany; and of Bertin and Laennec, in France. Still more recently, the publications of Louis, Andral Williams, El- liotson, Hope, Stokes, Watoon, Latham, Cor- rigan, Bouillaud, and the contributions of many others, have farther enriched this de- partment of our science. 2. i. Of certain Topics relative to the Structure and Actions of the Heart in Health, &c.—a. The layers of muscular fibres, and their various and tortuous directions, in the different compart- ments of the heart, require not particular notice here. According to M. Gerdv, these layers amount to six in the left ventricle, and only to three in the right; in both auricles, there are two in each. The muscular tissue of the right auricle is less abundant than that of the left, and leaves minute intervals betweeen its fibres, allowing the external and internal membranes to come in almost immediate contact. To this circumstance M. Bouillaud imputes the fre- quent association of inflammations of these membranes. The muscular fibres of the heart are more distinct in the foetus than in the adult; this organ only participates in the general pale- ness of muscles at that epoch, although it is deeper coloured than they. It is also entirely without fat at this period. In corpulent per- sons, the external layers of muscular fibres, especially at the base, are covered with fat, which sometimes presents a watery or gelati- nous appearance in the cachectic or leucophleg- matic. In old age, the texture of the heart be- comes soft and flaccid, and the parietes of the cavities thin. The cavities themselves enlarge, especially the right; and the surface of the or- gan is charged with fat. The chorda tendinece, the whitish zones at the base of the valves forming the contour of the orifices, and the in- terior of the valves themselves, are principally- formed of fibres or albugineous tissue, which often becomes, especially in the latter situa- tion, the seat of serious lesions, particularly in persons far advanced in life. 3. b. The internal surfaces of the heart, as well as the parts just named, are covered by a transparent, pellucid, and whitish membrane, resembling the most attenuated serous mem- branes. It is more delicate in the right than in the left cavities ; and the least so in the au- riculo-ventricular and arterial orifices. It is readily stained by the colouring matter of the blood, owing to imbibition during certain states of this fluid. It is perfectly smooth and pol- ished ; but in the situation of the orifices, where it is thickest, it often becomes rough or uneven, from chronic inflammation, which most frequently occurs in these parts, and.in the valves. It is connected to the fibrous and muscular tissues by a fine cellular substance, which often is thickened or otherwise altered by disease. This membrane has been appro- priately called the Endocardium (from evdov,, within, and uapdla, the heart) by MM. Barbier and Bouillaud. It adheres so firmly to the adjoining tissues that it can be detached only in small pieces ; but, in certain diseases, it can be removed in large shreds. At the base of the valves, where the two layers of this membrane separate to receive the tendinous rings border- ing the orifices, the endocardium and pericardium are nearly in contact with each other, or are connected merely by a fine layer of cellular tissue. This state of structure, and its con- nexion with the enclosed fibrous tissue, explain both the frequent co-existence of internal and. external inflammation of the heart, and the in- timate connexion often existing between these inflammations and rheumatism. — c. Of the pericardium it is unnecessary to say more than 194 HEART—Actions—Weight and Dimensions. >hat it is a serous membrane, forming, as in all other situations, a shut cavity, reflected over the heart and origin of the large vessels, and over the fibrous bag enclosing this organ. Its free surface is polished, smooth, and bedewed with an exhalation preventing friction, and the production of any sound ; but when it is dis- eased, morbid sounds, as well as other phe- nomena, result. 4. d. The nerves of the heart have been a subject of interest with pathologists. They are ’erived chiefly from the ganglia of the great sympathetic, a few only coming from the pneu- mo-gastric, but these latter seem rather to in- osculate or communicate with the plexuses of the former than to directly supply the texture of the organ. The cardiac ganglion seems more particularly to preside over the actions of the heart, or to re-enforce with additional energy whatever it may receive from other sources, especially from the centre of the gan- glial system, and the other ganglia in the neck and chest. These nerves supply the substance of the heart in two ways : 1st. There are nu- merous branches which proceed from plexuses directly to the muscular texture, and which, dipping between the fibres, give off minute fibrillse to the muscular fibres next to them in their descent into the substance of the heart; 2d. A large portion of the cardiac nerves form a reticulum around the coronary arteries. A part of these follow the arteries to their distri- butions ; but before these arteries are ramified minutely, a part of the nerves surrounding them is detached to adjoining tissues, so that all the nerves reticulated around the coronary arteries do not accompany them to their ulti- mate distributions or terminations. 5. A. The Actions of the Heart may reason- ably be referred chiefly to the influence which the ganglial nervous system bestows on the muscular structure of the organ. Hauler at- tributed them to irritability, or a peculiar power inherent in the muscular fibres themselves. But I have contended in several publications, since 1820, that the ganglial system is the source of irritability ; and the same view has been more recently adopted, and ably support- ed by Dr. Fletcher. The experiments of Willis, Home, W. Philip, Clift, Brachet, and others show that the actions of the heart are independent of the cerebro-spinal nervous power, although they are influenced by it. In experiments which I performed, in 1818, on several species of fish, the heart continued to contract not only after the destruction of the cerebro-spinal axis, but even for some time after it was removed from the body. Cases, also, have been observed by Lallemand, Law- rence, and others of the absence of both the brain and the spinal chord, and yet the circula- tion continued for a considerable time after birth. An instance very nearly of this kind has very recently been observed by my late col- league Dr. Sweatman. Humboldt found that the contractions of the heart, even after the re- moval of it from the chest, were more frequent and forcible, upon the application of the galvanic current to one of the cardiac nerves ; and Home and Weinhold obtained nearly similar results from their experiments. In 1820, I repeated these experiments, and the phenomena were the same as observed by these physiologists. The more recent researches of M. Brachet show the justness of my views as to the de- pendance of the heart’s action upon the gan glial system, and which were published twelve years before the appearance of his work upon this system. In my publications on this sub- ject, it has been farther contended that irrita- bility does not exist as an independent princi- ple, but as one of the vital manifestations of this system, exerted through the medium of muscular or fibrous tissues. 6. B. Such, therefore, being the source of the heart’s action, the chief scat of action re- quires some notice. I believe that too much importance has been attached to the auricles in estimating the motions of the heart, and that the contractile force of these compart- ments is much less than is supposed. From some experiments I performed about twenty years ago, I concluded that the actions of the heart should be referred chiefly to the ventri- cles, and agreed with Hamberger in allowing them a dilating power, but considered that Dr. Carson pushed this opinion too far. I farther observed that, if the dilatation of the ventricles were a result of a relaxation of their parietes merely, the cavities would not be so quickly and perfectly filled by the mechanical pressure of the blood as they are ; and dilata- tion would be only the consequence of this pressure, and be proportionate to it. But such is not the case ; for, on close observation, the dilatation always appears as the cause of the flow of blood. The opinion of M. Bouillard nearly agrees with the above inferences, pub- lished by me in 1824. He, however, considers the injecting powers of the auricles to contrib- ute to the dilatation of the ventricles, and at- taches too much importance to the elasticity of their muscular parietes in aiding this action. If the contractions of the auricles were as en- ergetic as commonly believed, a valvular ap- paratus would have existed between them and the roots of the large veins. The actions of the ventricles should, therefore, be viewed in the double light of energetic contraction and ac- tive dilatation: by means of the former, the blood is propelled along the arteries; and, by aid of the latter, it is drawn into the ventricles, as well as into the auricles, a current from the smaller veins being thus kept up towards the heart. (See Notes and App. to M. Richerand’s Elements of Physiology, &c., by the author.) 7. ii. Of the Weight and Dimensions of the Heart in Health and Disease.—A. It is obvious that no precise idea can be formed as to atrophy and enlargement of this organ without having previously determined the dimensions and weight of it in health. This M. Bouillaud has endeavoured to ascertain. The following results are abstracts of his researches, and are given in the French weights and measures. He considers that the common opinion of the closed hand being the size of the heart of the same person is very nearly the truth ; and that the opinions of Cruveiliiier and Lobstein as to the weight and size of the healthy organ are neither precise nor correct. In fourteen cases, (a) The heart's medium weight was 8 oz. 3 dr. (9 oz. 4 dr.), the greatest being 11 oz.. and the least 6 oz. 2 dr. ; but its weight varies with the size of the person: it also is less in females than in males. The heart cannot be said to HEART—Sounds of. 195 have arrived at its full development until 24 or 25 years of age.—(b) The medium circumference of the heart, at the base of the ventricles, was 8 inches 9 lines ; the least being 8 inches, the greatest being 10 inches 6 lines.—(c) The me- dium thickness of the walls of the left ventricle was 6} lines; the maximum being 8, and the minimum 5 lines. The medium thickness of the parictes of the right ventricle was 21 lines ; the maximum being 3£, the minimum l£ line. The interventricular partition was 7 lines in thick- ness. The medium thickness of the parietes of the left auricle was 1£ line ; that of the right, 1 line.—(d) M. Bouillaud confirms the state- ment of Legallois, that the medium capacity of the right ventricle is somewhat greater than that of the left, and that of the right auricle greater than that of the left.—(e) The circum- ference of the left auriculo-ventricular orifice is about 3 inches 6 lines; that of the right, 3 inch- es 10 lines ; that of the ventriculo-aortic orifice, 2 inches lines ; and that of the ventriculo- pulmonary orifice, 2 inches 7f lines. 8. B. Of seven cases of atrophy of the heart, (a) the medium weight was 175 grammes (or scruples = 7 oz. 2 dr. Eng.), the maximum being 200, the minimum 135 grammes.—(b) compartments of the organ, in a state of atrophy, generally preserve their rela- tive dimensions. Sometimes, however, the parietes of the ventricles retain their usual thickness, chiefly from contracting on them- selves and diminishing their capacity. In atrophy, also, the mean weight of the organ may be much lessened, while the dimensions of the whole, or of certaA compartments of it, may not be sensibly, or may be only slightly diminished. 9. C. In hypertrophy of the heart, (a) The mean weight of thirteen cases was 473 grammes (scruples) 5 grains ; the maximum being 688, the minimum 338 grammes. — (b) The mean circumference of the organ was 11 inches 10| lines ; the maximum being, 12 inches, and the minimum 8 inches 10 lines.—(e) The mean thickness of the left ventricle was 10j lines ; the maximum being 1 inch 1 line, the minimum 7 lines.—(d) The mean thickness of the right was 3| lines; the maximum being 4J, the minimum 3 lines. The mean thickness of the left and right auricles was 2i lines, and 2\ lines respect- ively, that of the interventricular partition be- ing 9\ lines.—(c) The capacity of the left ven- tricle was generally more or less increased ; that of the right was also increased in one third of the cases. In three instances, the ca- pacity of the ventricles was diminished.—(/) The circumference of the left auriculo-ventricular orifice was increased in three cases, in one of them to 4 inches 3 lines ; that of the right was augmented in five instances, in one of winch it reached. 5 inches 9 lines ; and that of the ven- triculo-pulmonary orifice wras increased also in five, and reached in one 3 inches 6 lines. 10. iii. Of the Sounds of the Heart.—In the article on Auscultation, I stated the received opinions as to the sounds of this organ, and remarked that the subject required farther in- vestigation. Since that time, several able in- quirers have entered upon it, and may be said to have settled the question. Harvey and Haller described the contractions of the auri- >s as preceding those of the ventricles. This, the true view of the matter, was departed from by Laennec, who conceived that the contrac- tions of the auricles followed those of the ven- tricles. The researches of Turner, Corrigan, Williams, Hope, and Bouillauo have shown the inaccuracy of Laennec’s opinion. Dr. Will- iams, especially, has assiduously investigated this subject; and as his inferences have been, upon the whole, confirmed by the Committees of the British Association, I shall follow him chiefly in the few remarks which remain to be made respecting it. 1st. The contraction of the ventricles, following immediately that of the auricles, is accompanied by the first, or dull sound. This systole, by straightening the an- terior convexity of the ventricles, brings the apex of the heart into forcible contact with the ribs, and thus produces the impulse or shock. The systole, by throwing an additional quantity of blood into the arteries, causes the arterial pulse, which is synchronous with the systole in arteries near the heart; but, in those more distant, succeeds it at an interval occupied by the transmission of the wave through the blood along the elastic tubes from the heart. 2d. The systole of the ventricles is immediately followed by the diastole, which is attended by the second or short sound. 3d. There is after- ward an interval of rest, at the conclusion of which the auricles contract, and the series of motions is repeated as before. The points which here remain to be settled are, (a) the way in which the systole of the ventricles pro- duces the first sound ; and (&) how the diastole causes the second. 11. The first sound was ascribed, by Mr. Carlile, to the rush of blood into the great arteries ; by M. Rounet and others, to the closing of the auriculo-ventricular valves ; by Dr. Hope, to the collision of the particles of fluid in the ventricles ; and by Dr. Williams, to the muscular contraction itself. The second, or short sound, was ascribed, by Dr. Hope, to the impulse of the blood from the auricles re- filling the ventricles; by Elliott, Carswell, Rouanet, Carlile, Bouillaud, and others, to the suction of the ventricles causing the eleva- tion of the sigmoid valves, and to the reaction of the arterial columns of blood against these valves. The experiments performed by Dr. Williams, assisted by Dr. Hope and several other able physiologists, in order to determine these points, proved that the first sound is pro- duced by the muscular contraction of the ven- tricles ; and that the second sound is caused by the reaction of the arterial columns of blood tightening the semi-lunar valves at the dias- toles of the ventricles. Dr. Williams, Dr. Hope, and M. Bouillaud concur in consider- ing the impulse or stroke of the heart to be ef- fected by the apex alone; while the experi- ments of the Dublin Committee seem to show that the body of the ventricle is also concerned in producing it. The London Committee ad- mit that the first sound is caused by muscular tension, but think that the impulse may be an accessory. In other respects they all tolerably agree. 12. iv. The morbid Actions and Sounds of the Heart have been very fully considered in the article Auscultation (<) 25). Little, therefore, remains to be noticed respecting them at this place beyond a brief mention of the views ot 196 HEART—Sounds of. some writers of eminence that have appeared since that article was published.—A. As may be expected, a priori, the duration of the sys- tole seems often to be prolonged by the dif- ficulty experienced by the blood in passing through the morbid arterial orifices. Contin- ued and violent palpitations, particularly in cases of hypertrophy, tend eventually, accord- ing to the observations of M. Bouillaud, to produce marked prominence of the praecordial region. I have remarked this, also, in cases of sub-acute and chronic pericarditis. In a case of pericarditis complicated with rheuma- tism of the joints, in a child seven years of age, who was long under my care, this promi- nence and the palpitations were remarkable; but, after a time, these disappeared, and the lower half of the sternum, with the cartilages of the ribs, became drawn inward, and towards the spine, to such an extent as to form a very remarkable cavity in the praecordial region. This occurrence was so singular, that I caused the patient to be shown to several of my col- leagues at the Middlesex Hospital. It appear- ed to have arisen from adhesion of the pericar- dium to the heart, and from the subsequent atrophy of the latter. 13. B. The intensity of the sounds, as well as of the impulse of the heart, varies remarkably. In some instances the sounds are feeble, and heard with difficulty; while in others they are heard at a distance of two or three feet. Al- though the impulse against the ribs does not produce either of the natural sounds, yet, in violent action of the heart, the more sudden and abrupt strokes cause a sound, constituting the termination of the first sound in these cases, and which seems nearer the ear, and more like a knock than what is heard in the ordinary action of the heart. The sounds may assume a dry or hard character, which Bouil- laud imputes, but I think incorrectly, to hyper- trophy and rigidity of the mitral valve ; or they may be large, hoarse, or rough, owing, as he thinks, to a fungoid or infiltrated condition of the valves, which are then soft and flaccid. The saw sound sometimes has a peculiar hiss- ing character, and at others a thick or rough tone; but all these are merely modifications of the bellows sound, and are very commonly connected with narrowing of the orifices of the compartments. Laennec considered them to proceed from spasm; of the existence of which, however, we have no satisfactory proof. A sound, which varies in tone from the cooing of a dove to the chirping of birds, or the sibi- lous noise of bronchitis, is more rarely heard: I have heard it only twice. It has also been noticed by M. Bouillaud, Rouanet, and, I be- lieve, by Dr. Watson. It seems connected with narrowing of the orifices. I heard it in a case of rheumatic pericarditis in a child. The bellows, or blowing sound, M. Bouillaud asserts, has been heard in upward of a hundred cases, where contraction of the orifices, with indura- tion of the valves, was established by dissec- tion ; while M. Piorry states that his experi- ence is at variance with this result. An able reviewer (Brit, and For. Med. Rev., No. 2, p. 451) very justly remarks, that, although cases of well-marked contraction, with ossifications, &c., do present themselves, unaccompanied by any such abnormal sounds, such occurrences are extremely rare, and form only the excep- tion, and not the rule, as M. Piorky would have them to do. It should also be kept in mind that the morbid sounds may be produced by a refluent, as well as by an onward motion of the blood, as M. Filhos has contended. 14. M. Bouillaud considers that the bellows sound may proceed from, 1. Narrowing of the orifices, with induration of the valves; 2. Small- ness of the aortic orifice, although the valves are quite healthy ; 3. Polypous exudations, re- sulting from acute inflammation of the endo- cardium ; 4. Irregularity or roughness of the surface of the valves, or vegetations, or calca- reous incrustations on them; 5. Infiltration of the valves from inflammation ; 6. Adhesions of the auriculo-ventricular valves to the adja- cent parietes ; 7. Dilatation of one or more of the heart’s orifices, with consequent inefficien- cy of the valves ; 8. Hypertrophy, with dilata- tion of the left ventricles, although unattended by narrowing of the orifices ; 9. Chlorosis, anaemia, and nervous affections of the heart, in some instances ; 10. Extreme debility from haemorrhage, or other depressing causes. It has been supposed that the bellows sound, which is not constant, or is only occasional, in the last three circumstances may arise from spasm. M. Bouillaud believes it to depend in these on a narrowing of the orifices, to adapt themselves to the diminished quantity of blood circulating through them. He farther consid- ers that all the above cases are reducible to one common principle, namely, increased fric- tion produced in some of them by the direct, in others by the refluent, current of the blood; but most frequently from the former cause. From this it is evident—and most experienced practitioners must have arrived at the same conclusions, from their own observations—that it is impossible to decide, from the bellows sound alone, in which of the orifices, if in any, the lesion is seated. The co-existence of this sound with the systole or diastole, and the sit- uation in which it is loudest, may assist the observer, but still no accurate conclusion can be formed as to its precise cause. When the sawing or rasping sound is heard, the alteration may be considered to partake more or less of an osseous nature. [We have already referred (art. Ausculta- tion) to the late researches of Andral, by which it appears that an abnormal sound of the heart often exists independently of organic structure, and caused solely by modifications in the composition of the vital fluid—in other words, to changes in the relative proportion of the elements of the blood. Considering the proportion of red globules in healthy blood to he as 127 in 1000 parts, he has shown that the following modifications are caDable of produ- cing the bruit de souffiet, or bellows sound. First. When the globules have diminished suf- ficiently to be below the cipher 80, this sound always exists in the heart and large arter- ies. Second. The bellows sound may be heard when the amount of globules ranges from 80 to 100, and occasionally when it reaches above 100 ; but never after it attains the physiological mean 127. Andral has observed this sound, under these circumstances, in putrid and erup- tive fevers, pneumonia, rheumatism, and in numerous chronic diseases. Also, it is met HEART—Diseases of—General View of. 197 with often in pregnant women, in whom there is generally found to be a deficiency in the globular element of the blood. (Hcematolog., Am. Ed., Phil., 1844.)] 15. C. The sounds produced occasionally by the surfaces of the vsticardium in a state of dis- ease were overlooked by Laennec, and have only recently received attention. It is chiefly to Collin, Reynaud, Honore, Stokes, Will- iams, Mayne, and Bouillaud that we are in- debted for observations respecting them. M. Bouillaud divides these sounds into three va- rieties : 1st. The rubbing sound resembles that caused by rubbing together two pieces of silk, or of parchment. It is to be distinguished from a similar sound produced by the pleura, by its being double and synchronous with the heart’s action. It is most obvious in the systole, and is diffused over a considerable surface. 2d. The creaking sound is altogether similar to the creaking of leather, or of shoes, or of a saddle. M. Bouillaud remarked it once ; M. Andral only once; and Dr. Williams in three cases. M. Collin and others have also heard it. I have met with it in two instances : one of them a boy, about ten years of age; the other a young lady of about twenty, who, in 1833, came from Brompton to consult me. She had, several months previously, experienced an at- tack of aeute pericarditis ; and, while descri- bing her symptoms to me, she herself likened the morbid sound she heard in the prsecordial region to the creaking of new shoes. I heard it distinctly with the unassisted ear. 3d. The scraping sound is such as may be expected to be produced by rubbing a rough and hard car- tilaginous or osseous body against the pericar- dium. Its synchronism with the motions of the heart distinguishes it from similar morbid sounds originating in the pleura. M. Bouil- laud states that the first two sounds occur only in acute pericarditis. In the two instan- ces I met with there had existed the acute form of this disease ; but it had long before subsided, leaving after it organic lesion, or, at most, a chronic state of inflammation. The friction or rubbing sound, in its faintest states, occurs in the early stages of acute pericarditis, and while the membrane is dry. The creaking or leathery sound seems to arise from thicken- ing or condensation of the sub-serous and se- rous tissues of the pericardium, especially of the portion reflected over the heart; and the formation of a dense and elastic false mem- brane, with, perhaps, more or less adhesion of the opposite surfaces. The scraping or grating sound is caused by lesions which occur only in the more protracted cases of chronic pericardi- tis. When the bellows sound is heard in peri- carditis, it does not necessarily depend upon this disease, but rather upon the co-existence of inflammatory action in the internal mem- brane of the heart, or the extension of it to the fibrous structure of the orifices or of the valves, and the consequent contraction or other lesions thereby occasioned. 16. v. Percussion of the Cardiac Region is best performed with the index finger of the unemployed hand as the medium, or plessime- ter. In the healthy state, the extent of the dull sound generally varies from an inch and a half to two inches square, which answers pre- cisely to the extent to which the heart is dis- engaged from the lungs. The extent of the dulness increases very much in hypertrophy of the organ with or without dilatation of the cav- ities, in simple dilatations, and in congestions of them occurring in various diseases. It is not unusual to find the dulness, in these cir- cumstances, extending to five or six inches square. (See art. Auscultation.) Bibliog. and Refer.—W. Harvey, De Motu Cordis et Sang. Circulatione, 4to. Frank., 1628. — J. Smith, King Solomon’s Portraiture of Old Age, 8vo. Lond., 1666.—R. Lower, Tractat. de Corde, item de Motu et Colore Sangui- nis, 8vo. Lond., 1669.—It. de Vieussens, Nouvelles Decou- vertes sur le Cceur, 12mo. Toulouse, 1706; et Traitfe Nouv. de la Structure du Cosur, 4to. Toul., 1715.— W. Wood, A Mechanical Essay on the Heart, 4to. London, 1729.—P. Chirac, De Motu Cordis Adversaria Analytica, 12mo. Paris, 1744. — Author, in Lond. Med. Repos, for May, 1822; and Notes and App. to Richerand’s Elements of Phys., &c., p. 611, et seg. Lond., 1824 and 1829.— Vaust, in Journ. Univers. des Sciences Med., t. xxvii., p. 164.— Gendrin, Archives G6n6r. de M6d., t. xvi., p. 123.— W. Stokes, in Dubl. Journ. of Med. Sciences, vol. iii., p. 50 ; vol. iv., p. 29.—Turner, Trans, of Med. and Chirurg. Soc. of Edin., vol. iii., p. 205.—Spittal, in Edin. Med. and Surg. Journ., July, 1826, p. 132.—Corrigan, Trans, of King’s and Queen’s Coll, of Phys. Dubl., vol. i., N. S., p. 151.—D. Williams, in Edin. Med. and Surg. Journ., Oct., 1829.— Pigeaux, Archives Gen6r. de Mid., Juil. et Nov., 1832.— Magendie, Lect. in Lancet, Feb., 1835.—Bryan, in Ibid., Sept., 1833.—Rouanet, Journ. Hebdom., No. 97. —Bouillaud, in Ibid., 1834.—T. Davies, Lect. on Dis. of the Lungs and Heart, p. 369.—Carlile. Dubl. Journ. of Med. Science, vol. iv., p. 84.—C. I. B. Williams, The Pathology and Diagno- sis of Dis. of the Chest, &c., 3d edit. Lond., 1835, p. 163. —Report of the Dublin Committee on the Motions and Sounds of the Heart, in Dubl. Journ. of Med. Scien., Sept., 1825, and Med. Gazette, vol. xvi., p. 777.—Corrigan, in Dubl. Journ. of Med. Science, vol. ix., p. 173.— P. 31. La- tham, Lectures on Subjects connected with Clinical Medi- cine. Lond., 8vo, 1836 (An interesting work).—J. Bouil- laud, Traite Clinique des Mai. du Cceur, 8vo. Paris, 1835, reviewed in British and For. Review, No. 2, p. 425.—(See, also, Bibliog. and Refer, of art. Auscultation.) [Am. Bibliog. and Refer.—/. A. Swett, Review of Hope, On Diseases of the Heart, in New-York Journ. of Med., vol. ii., p. 417.—C. W. Pennack and E. M. 31oore, Report of Experiments on the Action of the Heart. Phila- delphia, 1840, and in Am Ed. of Hope, On the Heart.— Meredith Clymer, Am. Ed. of Williams, On Diseases of the Respiratory Organs. Phil., 1845.—T. Stewardson, Am. Edition of Elliotson’s Principles and Practice of Medicine Phil., 1844.—Medical Examiner, No. 44.] II. A general View of Diseases of the Heart. —Syn. Kapdlag voaot, Gr. ; Cordis Morbi, Lat. ; Herzkranlcheiten, Germ. ; Maladies du Cceur, Fr.; Malattie del Cuore, Ital.; Diseas- es of the Heart, Heart Diseases. 17. As the various maladies of the heart fre- quently proceed from the same causes, often are met with in similar states of complication or association, admit often of the same prog- nosis, and even frequently require the same modes of treatment, I shall, in order chiefly to prevent repetitions, take a general view of them before I proceed to consider their specific forms. 18. i. The Causes of Diseases of the Heart are even more diversified than was supposed by Corvisart and some other writers.—A. The Predisposing Causes are nearly the same as those concerned in producing inflammatory and nervous diseases in other organs ; but the un- ceasing actions and the intimate sympathies of this viscus not only increase the general pre- disposition, but also serve to impart a peculiar character to the effects more immediately pro- duced on it by numerous physical agents and moral influences. The irritable, nervous, and sanguineous temperaments ; a plethoric habit of body ; the rheumatic and gouty diathesis ; depression of mind ; and the puerperal states, favour more or less the occurrence of diseases 198 HEART—Diseases of—General View of. tions or discharges, and interrupted or impe- ded action of any of the principal assimilating and excreting organs. That the blood may be- come morbid, owing either to the imperfect as- similation and the injurious nature of the in- gesta, or to the accumulation in it of the ulti- mate products and effete principles of assimila tion requiring to be eliminated by the energet- ic action of the emunctories; and that this state of the blood may excite disease in some part of the heart’s internal surface, seem more than probable. The changes in the circulating fluids, moreover, taking place in the course of fevers, or in connexion with the exanthemata, erysipelas, gout, &c., may also occasion dis- ease of this organ ; and it is not unreasonable to infer that, when this connexion is observed, as much is often owing to the morbid condition of the blood as to that of the living solids. 5th. In cases of suppression of gout or rheumatism, or the retropulsion of the exanthemata and of other acute cutaneous eruptions, it may be ad- mitted that, while the constitutional disturb- ance upon which the local or external affec- tion depends remains unabated, the suppression of the latter will very probably be followed by some prominent affection or localization of morbid action in an internal organ, especially if the powers of life are inadequate to throw it off upon some external part; and as, in these diseases, the circulating fluids are more or less altered, and the actions of the heart already much disturbed, one or other of the tissues or compartments of this organ will be quite as likely to become the seat of the superinduced malady as any other internal part; and even more so, as respects the rheumatism, owing to the predisposition arising out of identity or sim- ilarity of structure. 6th. One affection of the heart, functional or structural, may occasion another, or an additional lesion. Thus, vio- lent palpitations sometimes rupture a muscu- lar column, or tendon of the valves, or even the parietes of the heart itself; and narrowing of an orifice occasions dilatation of the cavity behind it, &c. 21. While Corvisart and Schina have at- tached the greatest share of importance to mor- al causes in the production of cardiac diseas- es, and undervalued the influence of physical agents, M. Bouillaud has over-estimated the latter at the expense of the former ; and they, as well as all other writers, have either entire- ly overlooked, or have scarcely adverted to several of the antecedent changes or pathologi- cal states to which I have imputed so much in the causation of these maladies. 22. ii. Of the Seat and Anatomical Characters of Diseases of the Heart.—A. It is extremely rare, as M. Bouillaud remarks, to find the heart altogether diseased : most commonly a compartment only, or a portion of it merely, or even one of the tissues constituting it, is af- fected. Sometimes one or more valves or ori- fices are primarily altered ; and in other cases, either the internal or external membrane or the muscular structure is changed. In one in- stance, a cavity is dilated and its walls thin- ned ; in another, it is of natural capacity, but its parietes are remarkably thickened ; and in others, the compartments individually present various lesions, as softening, hardening, &c. 23. B. The intimate nature of the heart’s le- of the heart. Lancisi, Albertini, Senac, Mor- gagni, Corvisart, Bouillaud, and others have remarked an hereditary predisposition to these diseases, independently even of either of the diathesis just particularized. Besides these, susceptibility of the nervous system, whether original or acquired; and pre-existent disorder, especially debility in its various forms ; impair- ed digestive, excreting, and assimilating pow- ers ; morbid states of the blood, affections of the lungs and liver, and irritations of the ute- rus and spinal chord, predispose more or less to these maladies. 19. B. The Exciting Causes maybe arranged into, 1st. The Mechanical and Traumatic ; 2d. The Physical; 3d. The Moral; and, 4th. The Pathological.—a. Under the first of these may be arranged blows, falls, wounds, and external inju- ries directly or mediately affecting the organ ; compression of the ribs or sternum, or of the hypochondria, by resting against a desk, and by strait lacing ; and over-distention of the stom- ach by food or drink.—b. Among the physical causes may be enumerated, great muscular ex- ertion, especially while the breath is retained ; long journeys on foot, and fatigue; running against the wind, or ascending eminences or stairs ; reading or speaking aloud, and singing, especially if long continued, or when impas- sioned ; blowing wind instruments ; straining at stool; advanced pregnancy; excessive ve- nereal indulgences ; the abuse of spirituous or fermented liquors ; arsenical preparations in poisonous doses, or employed too long or in too large doses as a medicine ; the injudicious use of other acrid substancesexposure to cold, or to cold and humidity conjoined, and to currents of cold air; wearing damp linen or clothes, or sleeping in damp beds or sheets ; and drinking cold fluids or eating ices when the body is perspiring.—c. The moral causes comprise all the depressing and exciting affec- tions of mind, especially when excessive, but more particularly the former. Sudden shocks, fright, terror, violent fits of anger, anxiety, grief, sadness, nostalgia, amorous affections—all not merely affect the functions of the heart in a very remarkable manner, but sometimes, also, alter its structure. 20. d. The pathological causes are still more influential than the causes already enumerated, and act in different ways. 1st. Some of them embarrass the actions of the heart, by impeding the functions of the diaphragm and lungs; a flatulent distention of the stomach or colon, en- largement of the liver or of the spleen, and ef- fusions of fluid in the large cavities. 2. Others obstruct the circulation through the lungs, and consequently cause congestion or distention of the heart’s cavities ; as asthma, hooping-cough, pneumonia, bronchitis, convulsions, &c. 3d. Certain pathological states extend to the heart or pericardium from other parts, owing either to proximity of situation, or to their structure being of the same kind as that of the parts pre- viously affected. Thus, inflammation of the external or internal membrane, or other dis- eases of the heart, appear in the course, or af- ter the subsidence of pneumonia, of pleuritis, of rheumatism, &c. 4th. Some of these causes are connected with excessive vascular pletho- ra, with or without a morbid condition of the circulating fluids ; as the suppression of erup- HEART—Diseases of—Characters and Diagnosis. 199 cions is not always evident, even on the most sninute examination. That they are frequent- ly inflammatory, or of that kind usually so de- nominated, cannot admit of a doubt; and that they still more frequently are the consequen- ces of inflammation in some one or other of its grades, modified, however, by the tissue in which it is seated, by the state of vital power attending it, and by the condition of the circu- lating fluids, is no less true, although less man- ifest than the former proposition. Inflamma- tion affecting a serous surface gives rise to re- sults varying with its intensity, and with the state of the constitution, in respect both of or- ganic nervous energy and of vascular tone. When the latter remain unimpaired, the pro- duction of coagulable lymph is a common re- sult ; but the lymph, being secreted in a fluid state, will often, when the internal membrane of the heart is inflamed, be washed into the current of the circulation before it can be coag- ulated, and no very manifest evidence of the disease may be detected after death, although it has existed in its most intense form, or even has been the cause of death. When the. in- flammatory action is co-existent with depress- ed vital power and a morbid state of the blood, the fluid secreted by the inflamed surface is in- capable of coagulating, and it readily mixes with and contaminates the vital current; the seat of disease presenting, after death, but lit- tle change beyond dark discoloration and soft- ening. In respect both of the internal surface and of the substance of the heart, lesion of the capillary action and tone, as well as of vital co- hesion, may have existed during life, and yet escape detection after death; and certain of the changes sometimes observed—especially alterations of colour, fibrinous coagula attach- ed to the valves, &c., and slight effusion into the pericardium—have either taken place short- ly before, or at the period of dissolution, or even soon after this issue. 24. Although most of the affections and le- sions of the heart are to be imputed chiefly to inflammatory action and its consequences, va- ried by the conditions alluded to, yet they are not altogether of this nature, or do not always originate in this way. We have seen above (§ 5) that this organ derives its energies chief- ly from the ganglial nervous system : it must, therefore, follow that extreme depression or exhaustion of this system must be attended by a marked alteration of the functions of the heart; indeed, the evident imperfection of the actions of the latter is one of the principal in- dications we possess of the exhaustion of the former. And if this alteration or imperfection of action continues long, or returns frequently, lesion of structure, especially dilatation, soften- ing, thinning, atrophy, &c., of the parietes of one or more of the compartments of the organ, &c., must ultimately take place. Nor is this the only mischief; for, along with it, alteration of the circulating fluid often exists—this latter still farther impairing nervous or vital power— and, in connexion with both these pathological conditions, inflammatory action, or an altered state of vascular action, constituting one of the morbid conditions usually so denominated, oc- casionally, also, takes place in the internal sur- face of the heart, or in some other of its con- stituent tissues, giving rise to the farther chan- ges already alluded to in general terms, and hereafter to be more particularly noticed. 25. iii. The general Characters and Diagnosis of Diseases of the Heart naturally divide them- selves into, 1st. The Local Signs; and, 2d. The General Symptoms, or sympathetic phenomena. The former have been generally termed phys- ical ; the latter, physiological and rational; hut the one class should always be considered in connexion with the other in the course of prac- tice.—A. The local signs are ascertained by auscultation, percussion, inspection, and palpita- tion. Of the former of these means sufficient notice has been taken. (See arts. Ausculta- tion and Chest.) The latter requires equal care with the former ; and the sensations com- municated to the hand of the examiner, as well as those excited in the patient by the examina- tion, should be attentively ascertained and es- timated. The indications furnished by these means are diversified according to the nature of the diseases which furnish them ; but they can be known only by listening to the extent, seat, and nature of the sounds given out by the organ or elicited by percussion ; by ob- serving the form and motions of the prascordial and adjoining regions ; by feeling the motions, tremours, or thrills often existing in these situ- ations ; and by ascertaining the sensations of the patient upon pressing between the ribs, or on the praecordia, or upward upon the dia- phragm, and under the anterior margin of the left floating ribs. 26. B. The general symptoms, or sympathet- ic phenomena, are ascertained from attentive observation of the several related functions. The very intimate relation of the heart to all the principal viscera, but especially to the blood and circulating vessels, to the organic or gan- glial nervous system, and to the respiratory or- gans, and the influence which these exert upon this organ, and which it exerts upon them, sev- erally and conjointly, require to be kept in view. The manner, also, in which the brain, the liv- er, and other digestive organs are often affect- ed by diseases of the heart, may likewise be made a source of information. Most of the con- nexions which have been traced between affec- tions of distant organs and the heart have been imputed to augmented or impaired actions of the latter — most frequently to hypertrophy. But there is sufficient evidence to prove that interrupted circulation, caused by alterations of the valves or of the orifices, is much more con- cerned in the production of sympathetic dis- turbance, and even of structural lesion, of re- mote as well as associated parts, than hyper- trophy or excited action. An impeded passage of blood from the auricles occasions congestion of the venous system ; serous effusion into shut cavities, and cellular or parenchymatous struc- tures ; haemorrhages from mucous surfaces or into the substance of organs; and not infre- quently congestions or enlargements of the liver or spleen. When hypertrophy exists, it is generally caused by the increased action re- quired to overcome an obstacle situated at the outlet from the hypertrophied compartment; yet still the obstacle is but imperfectly over- come, and the force of the current of blood be- yond the seat of obstruction is even less than in health. The necessity, therefore, of ascer- taining the pathological states of remote as 200 HEART—Diseases of—their Nature and Arrangement. well as of collatitious parts, in connexion with the actions and sounds of the heart, in order to arrive at correct conclusions as to the diseases of the latter, is manifest. The relations of morbid actions must be duly estimated, with- out assigning a preponderating or an exclusive share to one or two conditions, and overlook- ing all the rest. No partial or empirical views should be entertained; and far less ought a charlatan parade of examination be pursued and acted upon, to the neglect of physiological inquiry and of rational deductions. There is as much empiricism at the present day in the modes of investigating and observing diseases as in those of curing them; but there is this difference, that the empiricism of the former kind is much more ad captandum than the lat- ter, and generally more fussy, and often more offensive. 27. iv. Of the Nature and Arrangement of Dis- eases of the Heart.—A. The nature of these dis- eases has been partially noticed when viewing the alterations of structure attending or conse- quent upon them (§ 23, 24). Of the intimate nature of these maladies we know nothing more than is intimated by function or action, or is made apparent on close inspection.—a. When disordered action is suddenly excited by men- tal emotions, or by affections of related parts, and as suddenly ceases, leaving the organ in the integrity of its functions, we infer that the disturbance is seated in, or extends to that part of the organic nervous system which ac- tuates it; and this view is confirmed by the juvantia and Icedentia, and often by the appear- ances observed after death in persons who had been thus affected, and who had died of other diseases. In these cases, the disorder must, in the present state of our knowledge, be view- ed as purely functional, or nervous, or dynamico- vital, as termed by various writers ; and it may, without much stretch of ingenuity, be chiefly referred either to impaired action or to excessive action. In these affections, the ner- vous system of organic life—particularly that part of it supplying the heart—is primarily dis- ordered, and continues the only or chief seat of the disturbance for some time. But if either affection be excessive or enduring, then alter- ation of structure may result, and assume one or other of the forms about to be noticed. 28. b. Diseases of a most serious nature often attack the heart, in which, conjointly with more or less disturbance of the organic nervous influence, the vessels supplying one or more of the constituent tissues of the organ exert a morbid action, and give rise to various changes of structure, according to the grade of vital power, and to the state of the blood. These diseases frequently take place less obviously, or much more insidiously, than the foregoing, although often, also, in a severe and acute form; and they are always dangerous. The rapidity of their course, as well as the chan- ges they produce, depends upon the intensity of the morbid vascular action, and the consti- tutional states just mentioned. From the cir- cumstance of this action being attended by injection and development of the vessels, par- ticularly of the capillaries, and giving rise to changes usually observed to follow inflamma- tion in other parts similarly constituted, it has been denominated inflammatory. By this term, however, it is not intended to be implied that the morbid vascular action altogether consists either of diminution or of augmentation of the vital properties of the vessels ; but that, as I have contended in the articles Disease (6 87) and Inflammation, it is rather an alteration, a perversion of these properties that constitutes inflammation, and not a change simply dynamic ; this change, whatever direction it may take, forming only one of the elements of the morbid state. Beyond this, wre can hardly advance in our analysis of the nature of inflammatory dis- eases of the heart; but we may infer, with some truth, that, when the organic nervous or vital powers are unimpaired, and the blood un- contaminated, the morbid vascular action will partake more or less of the excited or sthenic condition, will exert a formative process, and will most probably form lymph, which will co- agulate if allowed to remain for any time in contact with the part which produced it; or occasion thickening, or a condensation of the affected parts; or give rise to other changes varying with the grades of action ; and we may farther conclude, with equal justice, that, when the vital powers are depressed or ex- hausted, or the blood altered or contaminated, the local morbid action will be asthenic, will be incapable of developing the changes just specified, and, in their place, will produce, ac- cording to its seat, a sanious or sero-sanguine- ous fluid from the surfaces, that will farther contaminate the blood, if the internal membrane be implicated, or give rise to softening, discol- oration, &c., of the substance of the organ, if this part become affected. 29. c. Under the above two heads may be comprised those affections of the heart which may be said to be primary, as respects this or- gan, although they are often associated with, or even preceded by disorder of other viscera, as well as by alteration of vital power and of the circulating fluids. But there is another class of cardiac diseases which present differ- ent characters, and consist, in a great degree, of change of structure, often associated, how- ever, with disorder of the organic nervous in- fluence, and sometimes, also, with more or less marked alteration of vascular action in one or more of the constituent tissues, or com- partments, of the heart. They may be said to proceed from the morbid conditions already discussed, especially when these exist in sub- acute, or in slight or chronic forms. That this is the case, will become apparent when 1 come to describe them individually. It will then be fully shown that impaired or irregu- larly exerted nervous influence, and morbid vascular action, in one or more of the constitu- ent structures of the organ, h’ve, together or singly, altered their nutrition, or impaired the vital cohesion of the molecules of which they are formed ; and that the consequences of al- tered nutrition and impaired vital cohesion chiefly consist of the increased or diminished thickness and density, the augmented redness and elasticity, the softness, the dilatations, &c., of the parieties of the cavities ; and of the fungous or polypous excrescences, the cartila- ginous and osseous formations, and the differ- ent morbid productions, &c., found in the heart and pericardium. 30. B. Conformably with the above view of HEART—Diseases of—their Complications—Prognosis 201 the nature of affections of the heart, I shall divide them into, 1st. Disorders which are mere- ly nervous, or functional, and chiefly dependant upon the state or distribution of the ganglial ner- vous influence, particularly in respect of this or- gan ; and under this head will be comprised, (a) Impaired and irregular actions of the heart; and, (b) Excessive action of the heart. 2d. Diseases in which, conjointly with more or less disturbance of the organic nervous influence distributed to this organ, the blood-vessels of one or more of its constituent tissues manifest a per- verted or morbid action. Under this division will be considered, (a) Inflammation of the endo- cardium or internal membrane of the heart; (b) Inflammation of the pericardium ; and, (c) In- flammation of the substance of the heart, or car- ditis. 3d. Organic or consecutive lesions of the heart, resulting from, and often associated with one or more of the above pathological conditions. Under this head will be discussed, (a) Atrophy of the heart; (l) (Edema of the organ; (c) Softening and hardening of the structure; (d) Adventitious productions in the heart; (e) Changes of the di- mensions of the orifices and valves ; (/) Changes in the dimensions of the cavities of the heart; (g) Hypertrophy of one or more of the compartments ; (h) Rupture and wounds of the heart, &c., &c. 31. v. Of the Course, Termination, and Dura- tion of Cardiac Disease.—Affections of the heart may be acute, sub-acute, or chronic.—A. Those which are nervous or functional are most fre- quently chronic, remittent, or even periodic; yet they are sometimes acute, and of very short duration, as in cases of cardiac syncope, &c. ; and frequently terminate without any le- sion of structure, although they occasionally induce it.—B. Inflammations of one or more of the constituent tissues of the heart may as- sume any grade of intensity, and pursue, ac- cordingly, an acute or chronic course, or even any of the intermediate or sub-acute states. The chronic form may be consequent upon the acute ; or it, as well as the sub-acute, may ap- pear primarily, especially when the inflamma- tory action is limited in extent, or is confined to a single constituent tissue of the organ. Although they may terminate in resolution, yet they most commonly give rise to organic changes, among which must be ranked the ef- fusions of fluid, &c., frequently met with in the pericardium. The more intense states of in- flammation of either of the surfaces, or of the substance of the organ, may terminate fatally in two or three days, while the less severe or chronic states may continue months, or even years ; but wThen they become thus prolonged, it is generally owing to their having passed into organic change, or to a temporary subsi- dence of the morbid action, and to returns or exacerbations of it, under moral or physical influences.—C. Organic lesions of the heart are extremely uncertain as respects their course, duration, and termination. Even when most manifest and extensive, their symptoms and progress are by no means uniform ; the most distressing phenomena, as in inflammations of the organ, often varying, disappearing, return- ing, or pursuing very different courses in sep- arate cases, or even in the same person at different periods. They frequently, also, pre- sent more or less evident remissions and exa- cerbations, or even a marked periodicity. This circumstance probably induced Coe vis art, and especially Rostan, to refer many cases of ner- vous asthma to organic disease of the heart. But this circumstance is explained by the fact already adverted to—that change of structure, even when most prominent, is only one of the elements of the cardiac malady, the organic nervous energy of the organ being also always more or less affected; and we know that in- termittence, or periodicity, is characteristic of affections of the nervous system. The exa- cerbations or violent paroxysms which patients with organic lesions of the heart experience, is not, however, altogether owing to periodicity of the morbid action, but is often excited by mental emotions, by errors in diet, by over- distention of the stomach or colon, by neglect of the excreting functions, and by exposure to atmospheric vicissitudes. 32. vi. The Complications of Diseases of the Heart are important objects of consideration, in respect both of the associations of these dis- eases with one another, and of their connexion with other maladies.—A. Nervous affections of the heart are often attendant upon disorders of the digestive organs, on flatulency, on con- gestions of the liver, and on disorder of the respiratory functions. They are frequently, also, observed in the course of chlorosis, hys- teria, and anaemia; and are often excited by affections of the womb, and by the puerperal states. Indeed, the numerous pathological causes (§ 20) of cardiac diseases form, also, complications with them.—B. Acute or chronic inflammation of the internal membrane of the heart sometimes extends to the pericardium ; and inflammation commencing in the latter surface very frequently reaches the former. This association of inflammation of both sur- faces, or extension of the morbid action from the one to the other, especially from the exter- nal to the internal membrane, is to be explain- ed by the proximity of the one to the other in certain parts of the organ, and by the circum- stance of the connecting cellular substance being frequently implicated, especially when the pericardium is inflamed. This fact, which is much insisted upon by Bouillaud, has been taught in my lectures since 1825.—C. Inflam- mations of these membranes are also often complicated with, or consequent upon acute articular rheumatism, or inflammation of the pleura or lungs. This association is met with in a very large proportion of cases of these diseases.—D. The complication of organic le- sions of the heart with those of the large ves- sels, and particularly those of the aorta, are well known ; and of softening, dilatation, &c., with adynamic fevers, scurvy, purpura, &c., has been often remarked. The connexion ex- isting between obstructions at the orifices of the heart, and commencement of the large ves- sels, and hypertrophy ; and between these and diseases in the lungs and brain, especially apo- plexy, palsy, pulmonary haemorrhage, effusion into the cavities of the chest, anasarca, &c., will be more fully shown in the sequel. 33. vii. The Prognosis of Cardiac Diseases.— Senac and Corvisart entertained the most un- favourable opinion as to the result in diseases of the heart. The latter writer even affixed I the epigraph, “ Hceret lateri lethalis arundoto 202 HEART—Diseases of—their Prognosis and Treatment. the title-page of his work. At the present day, more favourable ideas are entertained on this subject, although the opinion of Corvisart will still hold with respect to some of the organic changes of the organ.—-a. The nervous affections of the heart will frequently yield to treatment, unless they be very violent, when an unfavour- able, or, at least, a guarded prognosis should be given.—b. Inflammations of the membranes, and even of the substance of the heart, if they come early under treatment, will often terminate fa- vourably; yet they ought, nevertheless, to be viewed as very dangerous maladies, as re- spects both the organic lesions they may cause, and the contingency of an immediate or sudden dissolution.—c. Most of the organic lesions of the organ are incurable; and yet the patient may live many years, when judiciously man- aged. Of this kind are, induration of the valves, narrowing of the orifices, chronic pericarditis, hypertrophy, &c. The unceasing functions of the heart, and their extreme importance to the economy, however, render diseases of it more dangerous than those of almost any other or- gan. But the advances that have been recent- ly made in their diagnosis have given greater precision to the treatment, and have, conse- quently, afforded a greater degree of success than formerly. 34. viii. The Treatment of Cardiac Affections.— A. The nervous affections of the heart, especial- ly those associated with disorder of the digest- ive and assimilative organs, or characterized by irregular or excessive action, have been too generally, and most injuriously treated by vas- cular depletions and purgatives. I have seen even the complication of palpitation with chlo- rosis treated by depletions, and a complete state of anaemia result. In cases of this kind, a judicious selection of tonics, chalybeates, an- odynes, and stomachic aperients, appropriately to the peculiarities of each, aided by light, nu- tritious diet, by gentle exercise in an open dry air, and sometimes by tonic and alterative min- eral waters, will generally remove the com- plaint. 35. B. The inflammatory diseases of the heart require more or less copious and repeated de- pletions ; in the acute stage, the most decided adoption of them, as well as of other antiphlogis- tic means. M. Bouillaud has strongly insist- ed upon the propriety of prescribing repeated blood-lettings ; but although the depletions he recommends are considered large in France, they are not larger than those usually directed in this country for the same diseases. The exhibition of calomel and opium, or of calomel, antimony, and opium, in repeated doses, to pro- mote the resolution of the inflammatory action, or to prevent it from passing into the chronic state, or from terminating in effusion, or to limit the effusion of lymph, or to prevent the organization of what may have been effused, and promote its absorption, is the next most important means, and should always follow im- mediately after a decided vascular depletion, in the manner described in the article Blood (§ 64-68). This practice, somewhat modified from that adopted by British medical practi- tioners in warm climates, was first brought into use in this country by Dr Hamilton, of Lynn Regis (Medical Commentaries, &c., vol. ix., p. 191. Lond., 1785). His paper on this subject—the most valuable in modern medical literature—contains all the modifications that have been attempted in this practice by Dr. Armstrong and other more recent writers, with the view of appearing original. It has been erroneously stated, by several who have adopted this treatment, that Dr. Hamilton al- ways prescribed these medicines until the gums were affected by them ; and it has been claim- ed as a point of originality that they have em- ployed the same means, so as not to produce, or short of producing this effect. In some complaints, however, and even in some of those under consideration, this effect is neces- sary to the successful operation of these sub- stances. That Dr. Hamilton, however, thought it unnecessary to employ them, in certain dis- eases, as rheumatism, &c., so as to affect the mouth, is shown by his remarks respecting their operation (Opus citat., p. 200). He there states that, when they act upon the skin or bowels, re- lief will accrue from them without the mouth becoming affected; and that, when the skin is dry, hot, or contracted, emetic tartar should be added to the calomel and opium, in order to determine to this surface. 36. When inflammations of the heart come under treatment at a more advanced stage, or when they have assumed a more chronic form, vascular depletions must be prescribed with greater caution, and the calomel and opium should be given until either the gums become affected or a slight ptyalism be produced. If the action of the heart be irregular or excited, a small quantity of camphor may be added to each dose of these medicines ; and if the pulse be hard and regular, a repetition of the blood- letting, and a combination of James’s powder, or of tartar emetic, or of ipecacuanha, with the calomel and opium, will act beneficially, both upon the circulation and upon the emunctories. The bowels should be kept freely open, and the action of aperients promoted by enemata. 37. Although it is necessary to have recourse to copious depletions in the acute or early stage of inflammations of the heart, yet their effects should be carefully watched; and they ought to be still more cautiously employed in chronic or advanced cases ; for there are very few in- flammatory diseases in which they may prove more beneficial than in these, if they be resort- ed to at the proper time, and in sufficient quan- tity ; or in which they may be more injurious, if too long delayed, or too sparingly employed, or carried too far. When prescribed in a tim- id manner, and if a decided use of calomel and opium, sometimes with antimony, colchicum, or other adjuvants, be not adopted, an acute inflammation, which would otherwise have en- tirely subsided, either passes into a chronic state, or gives rise to organic changes imbit- tering the shortened period of future existence. Yet, while thus prompted to decision, it must never be overlooked, that in most cases of in- flammation affecting this viscus, the organic nervous energy is more or less impaired or ir- regularly determined; and that the most decisive measures should, therefore, be directed with the utmost circumspection. The other means which may be brought in aid of those already noticed are comparatively of so little impor- tance, and require to be so varied according to the forms and stages of the disease, that no men- HEART—Functional Disorders of the. 203 tion need be made of them until the specific af- ‘ections of the organ come under consideration. 38. C. The organic lesions of the heart re- quire a much more prudent recourse to deple- tions than the diseases just dismissed, inas- much as the nervous influence, especially that actuating the organ, is much more impaired in the -former maladies than in the latter. In cases of dilatation of one or more of the cavi- ties, even a moderate depletion may be followed by a fatal result; and when there is hypertrophy the heart requires all the energy it possesses to overcome the obstacle in the way of the cir- culation. The small but repeated depletions, and the antiphlogistic regimen recommended by Valsalva and Albertini, and so generally adopted in organic diseases of the heart, may be carried too far, as Corvisart has judicious- ly shown. They may be even most injurious. There are few means which are universally or even generally applicable to these lesions, ex- cepting mental and physical quietude, and at- tention to the digestive and excreting functions. Vital energy seldom admits, in them, of being lowered ; and whatever acts in this manner should be employed with discrimination, or ap- propriately to those states which seem special- ly to require it. In them, also, moral training, attention to diet, living in an equable tempera- ment, and in a healthy and airy situation, a gently open state of the bowels, and a due se- cretion of bile, and the careful avoidance of whatever excites or aggravates the disorder of the heart, are among the most generally appli- cable means of treatment. Numerous other measures may be employed, but they are ap- plicable only to particular lesions, and there- fore will be mentioned where the treatment of these lesions is particularly discussed. Bibliog. and Refer.—Galen, De Locis Affect., 1. v., c. 2.—Aiitius, Tetrab. i., sect, iv., c. 77.—Avicenna, Canon., tract, iii., fen. ii., tract, i., c. 2.—B. Montagnana, Cons, de AJgritud. Cordis, in Op. Sel., fol. Ven., 1497.—C. Vega, De Cord, et Thoracis Affect., in Arte Med., fol. Lugd. Bat., 1564.—C. Bruno, De Corde et ejus Vitiis.,4to. Bas., 1580. —E. Rudius, De Nat. et Morbosa Cord. Constitutions, 4lo. Venet., 1600.— A. Albertini, De Affect. Cordis Libn Tres., 4to. Venet., 1618.—C. Tardy, Traitd de la Monarchie du Coeur en l’Homme., 4to. Paris, 1656.—A. Bulgetius, De Affect. Cordis., 4to. Pat., 1657.—Sennertus, Praxis, 1. ii., par. iii., c. 3.—A. Kramer, Diss. de Morbis qui Cor et Res- pirat. Organa infestant., 4to. Vien., 1716.—M. Martinez, Observat. Rarae de Corde, 4to. Madr., 1723.—J. M. Lan- cisi, De Motu Cordis et Aneurisrnatibus, fol. Rom®, 1728. —M. Berbeyrac, Nouv. Dissert, sur les Maladies de la Poi- trine et du Coeur, 12mo. Amst., 1741.—J. Senac, Traitd de la Structure de Cceur, et de ses Maladies, 2 tomes, 4to. Paris, 1749.—J. F. Meckel, Sur les Mai. du Cceur, in Mfem. de l’Acad. de Berlin, 4to. Berl., 1759.—A. Matanus, De Aneurismaticis Prrecordiorum Morbis, 4to. Libum., 1761. —H. Mason, Lectures upon the Heart, Ac., 8vo. Read., 1763.— C. F. Juncker, Diss. Cordis Morb. proprios in Tabu- la exhibens, 4to. Halae, 1763.—A. le Camus, Maladies du District du Cmur, 12mo. Paris, 1772.—Spaventi. Diss. de Frequentioribus Cordis Morbis, 4to. Vien., 1772.—J. J. Neifeld, Ratio Medendi Morbos Circuli Sanguinei, 8vo. Breslau, 1773.—F. Petraglia, De Cordis Affectionibus Syn- tagma, 8vo. Romae, 1778.—C. F. Michaelis, Aneurism. Cord. Disq., in Doering, Tract., vol. i.—J. G. Walther, in Nouv. Mem. de l’Acad. des Sc. A Berlin, 4to. Berlin, 1785. —Odier, Manuel de Mddecine Pratique, p. 151, 336.—J. C. Reil, Dissert. Anal, ad Hist. Cordis Pathologicam, 4to. Halie, 1790.—A. Portal, Anatomie Mddicale, t. iii., 8vo. Paris, 1804.—Cabirau-Cabannes, Apercu sur quelques Af- fect. Organiques du Cceur, &c., 8vo. * Paris, 1805.—J. N. Corvisart, Essai sur les Maladies du Cceur et des gros Vais- seaux, 8vo. Paris, 1806, 3d ed., 1818, translated by Heb, 8vo. Lond., 1813.—M. A. Petit, Essai sur la Medecine du Coeur, 8vo. Lyon., 1806.—Contelle, Essais sur quelques Causes de Mai. du Cceur, 8vo. Paris, 1808.—A. Burns, Observations on some of the most, frequent Diseases of the Heart, 8vo. Edin., 1809.—P. J. Pelletan, in Clinique Chi- rurg., 8vo. Paris, 1810. — A. Testa, Delle Malattie del Cuore, 3 vols., 8vo. Bologn., 1811.—J. Gates, On Diseases of the Heart, 8vo. Philadelphia, 1812.—Le Gallots et Me- rat, in Diet, des Sciences Mdd., t. v., 8vo. Paris, 1813.- F. L. Kreysig, Die Krankheiten des Herzens. &c., 4 bde., 8vo. Berlin, 1814-17.—L. P. Lukomski, De Statu Militurr Morbis Cordis gignendis ldonea. Wien., 1815. — J. H James, in Trans, of Med. and Ohirnrg. Society, voi. viii., p. 434.—J. C. Wctzler, Ueber Krankh. des Herzens, in Bey- trhge zur Medicin, b. i.—H. Reeder, A Pract. Treatise on Dis. of the Heart, 8vo. Lond., 1821.—Beclard, et Charnel, Diet, de M6d., t. v., 8vo. Paris, 1822. — M. Fodc e, in Journ. Complement, du Diet, des Sc. M6d., t. xxxii. et xxxiv. ; et J. Johnson's Med. Chirurg. Rev., vol. ii.,p. 417 —Hufeland, in Nouv. Journ. de Med., t. xiv., p. 204.—J. Johnson, in Trans, of Med. and Chirurg. Soc., vol. xiii., p. 212 ; and Med..-Chirurg. Rev., Nos. 38, 39, No. 43, p\231, —J. Abercrombie, Trans, of M(id.-Chirurg. Soc. of Edin., vol. i., part i. Edin., 1824.— Wishart, in Ibid., vol. iii., p, 195.— R. J. Bertin, Traite des Maladies du Cceur, 8vo Paris, 1824.—H. Burger, Diagnost. der Hertzkrankheiten, 8vo. Berlin, 1825.—C. H. Parry, Collect, from his unpub Writings, &c-, vol. ii., 8vo. Loud., 1825.—G. Andral, Clin, ique MAdicale, &c., t. iii. Paris, 1826, translated by G. Spillan, part ii., p. 217. Lond., 1835 ; et Precis d’Anat. Pathologique, t. ii., 8vo. Paris, 1829.—F Hawkins, Rheu matism and some Diseases of the Heart considered, 8vo. Lond., 1826.—R. Adams, in Dubl. IIosp. Reports, vol. iv., p. 353.—J. Brown, Medical Essays on Fever, Diseases of the Heart, &c.,8vo. Lond., 1828.—P. M. Latham, in Lon- don Med. Gazette, vol. iii., p. 2, et pass.—American Journ. of Med. Sci., vol. vi., p. 129.—J. Elliotson, On the Recent Improvements in distinguishing Diseases of the Heart, fol. Lond., 1830.—J. Bomllaud, Diet, de Mcd. et Chirurg. Prat., t. 7.—J. Hope, Treatise on Diseases of the Heart, &c., 8vo. Lond., 1832; and Cyclop, of Pract. Med., vol. ii.— T. Da- vies, Lectures on the Diseases of the Lungs and Heart, 8vo. Lond., 1835.—J. Bouillaud, Traitd Clinique des Maladies du Cceur, 2 tomes, 8vo. Paris, 1835. III. Of Nervous or Functional Affections of the Heart. i. Of Impaired or Irregular Action.—Clas- sif.—I. Class, III. Order {Author). 39. DefiN.—The action of the heart more or less weakened or irregular, with faintness or de- gression, and often with disorder of the digestive organs. 40. The functions of the heart may be imper- fectly performed in two principal ways: 1st. They may be simply weakened, but in every grade, until they become extinct, and yet struc- tural lesion may not be detected to account for the circumstance ; 2d. They may be impaired or enfeebled, with more or less irregularity of the contractions, and yet no organic change may exist, the impaired and irregular action occur- ring only temporarily. One of the most famil- iar forms in which this affection presents it- self is that of fainting or syncope. But in this the heart is not always primarily affected.—A. Simply Enfeebled Action of the Heart, depending upon deficient energy of the cardiac ganglia, may proceed from whatever depresses the or- ganic nervous influence, or from inanition or anaemia. It may also be sympathetic, or the result of a derivation of the vital influence to different organs, as during certain periods of impregnation. The causes, pathological states, the diagnosis and treatment of this af- fection, are fully described under the article Fainting. 41. B. Enfeebled and Irregular Action of the Heart is a common affection in its slighter grades. The pulsations may be unequal in fre- quency and power, or they may be intermittent, reiterated, or fluttering. This state of action, although attending various dangerous diseases of the organ, may be entirely nervous, or con- nected with depressed organic nervous power and enfeebled function of the stomach-and liv- er. In this latter case, especially, it is often induced by flatulence, particularly when the flatus rises into the cesophagus and is retained 204 HEART—Functional Disorders of—Palpitation—Causes. continuance ; and the first sound is farther aug- mented by the impulse or shock against the ribs occasioning a distinct knock, which may be sometimes heard at a short distance from the patient. are also occasionally attended by a slight bellows sound, which always disap- pears when the heart resumes its natural ac- tion. Nervous palpitations are often accom- panied with uneasiness and slight anxiety at the pracordia; and sometimes, also, with a sense of sinking, or faintness, with which they not infrequently alternate. 45. B. The Causes differ much in their na- tures, or modes of operation, and modify, ac- cordingly, the characters of this affection. The nervous and irritable temperaments, early age, debility, in whatever way induced, venereal ex- cesses, and mental exertion, remarkably pre- dispose to this disorder. The exciting causes are, 1st. The more active mental emotions, as fright, anger, joy, &c. ; also sadness, anxiety, melancholy, nostalgia, longings after objects of affection, excitements of the imagination, &c.; 2d. The abuse of spirituous liquors and mus- cular exertions, or whatever accelerates the return of blood to the right side of the heart, and over-distends the large veins and auricles ; 3d. Excessive or debilitating discharges ; the abstraction of a natural or necessary stimulus ; sexual excesses, or manustupratio, this last be- ing the most common and influential of the ex- citing causes ; 4th. Inanition from deprivation of the necessary nourishment, or from impair- ed assimilation, or from excessive waste of the secretions, or circulating fluids, as in the palpitations associated with chlorosis and anae- mia, or consequent upon depletions ; 5th. Pres- sure on the large vessels, occasioned by strait lacing, by pregnancy, by abdominal tumours, effusion, &c. ; 6th. Enfeebled action of the di- gestive functions, particularly when attended by flatulency and torpor of the liver, or consti- pation of the bowels ; 7th. The irritation of worms in the intestinal canal, in connexion with debility, &c. ; 8th. Hysteria in several of its Protaean forms, especially when the uterine functions are disordered, and the catamenia ei- ther excessive or obstructed ; 9th. Irritation of the spinal chord, or of its nerves, or excite- ment of the uterus or ovaria acting upon the heart, either directly by the great sympathetic nervous system, or mediately through the spi- nal chord, the irritation propagated to this lat- ter being reflected from it along the branches eommdnicating between it and the cardiac and other sympathetic ganglia. 46. Although these may be considered the principal causes, yet others sometimes pioduce functional palpitation, especially several an'ict- dent disorders and organic lesions; as, a. Ady- namic and nervous fevers ; b. General pletho- ra by overloading the auricles and large ves- sels ; c. Irregular or misplaced gout, occasion- ing irritation of the cardiac nerves, or conges- tion of the large vessels or cavities of the vis- cus ; d. Obesity, particularly in connexion with plethora ; e. Obstructed circulation through the lungs, owing to diseases of their structure, or to effusions of fluid pressing upon them, or oth- er causes preventing their expansion ; /. En- largements of the abdominal or pelvic viscera, or effusions into the peritoneum, preventing the easy descent of the diaphragm, or pressing there by spasm of the canal. It also may pro- ceed from mental emotions, or from whatever overloads the cavities of the heart, or inter- rupts the return of blood from the lungs, or causes congestion of the left auricle and pul- monary veins. 42. C. Treatment.—Unless it is attended with a sense of sinking, or oppression, or anx- iety at the praecordia, this affection requires only attention to the digestive, assimilating, and excreting functions, and to diet and regi- men. But if these symptoms are present, re- storatives, especially camphor, the preparations of ammonia, the aethers, carminatives, and ton- ics conjoined with either of these will often be necessary. Much advantage will also result from taking a digestive pill (F. 507, 562) at dinner or bedtime. A small or moderate blood- letting is not infrequently prescribed in cases of this kind with the view of removing con- gestion of the heart or large vessels. When the patient is plethoric, or when the irregular- ity is consequent upon the suppression of an accustomed evacuation, or of congestion of the portal system, this practice is judicious, if cau- tiously resorted to. In the latter circumstan- ces, the application of a few leeches around the anus will often be of service. The bowels ought also to be freely acted upon by deobstru- ent and mild purgatives. In these cases, al- though there may be vascular plethora, or lo- cal congestion, nervous or vital power is, at the same time, more or less impaired, and therefore the means of restoration just mentioned should also be employed. The treatment about to be advised for palpitations (§ 50) is often, also, ap- propriate in this affection. When enfeebled and impaired action of the heart occurs in gouty persons, or appears as misplaced or retrocedent Gout, the means advised under such circum- stances in that article (§ 83, 89) should be pre- scribed. ii. Excited Action of the Heart.—Syn. Kap- :kuypog, Hippocrates, Galen; Cordis Palpi- tatio, seu Pulsatio, Palmus (nafywf, a beating or palpitation); Cardiopalmus, Swediaur ; Tremor Cordis, Palpitatio, Cullen, et Auct. var.; Palmus Cordis, Young ; Clonus Palpi- tatio, M. Good ; Palpitation, Palpitation du Cceur, Fr.; Das Herzklopfen, Germ.; Palpi- tazione, Ital. ; Palpitation, Palpitation of the Heart. Classif.—2. Class, 3. Order (Cullen). 4. Class, 3. Order (Good). II. Class, I. Or- der (Author). 43. Defin.— Strong, frequent, or tumultuous action, with an increase of the impulse and natural sounds of Pc ’xart, so as to be sensible, and often distressing to the patient, without appreciable le- sion of the structure of the organ. 44. A. Peipitations are either nervous or func- tional, or symptomatic of some one of the more serious diseases of the heart hereafter to be considered. The former only of these fall un der discussion at this place. Nervous palpita- tions may be either primary, and depending upon excitement of the nerves of the heart, without manifest disorder of other viscera, as in attacks induced by moral emotions, or sym- pathetic of affections of remote or related organs. They are often sudden in their accessions, but more rarely so in their subsidence. The sounds of the organ are generally increased during their HEART—Functional Disorders of—Diagnosis—Treatment. 205 ®pon that part connected with the pericardium as enlarged or engorged liver or spleen, preg- nancy, ascites, &c. [To these may be added a diminution of the blood, characterized by a diminution in the pro- portion of the globules. This deficiency in one of the most important elements of the blood indicates a feebleness of constitution, which must generally be remedied by pure air, nutri- tious food, and the ferruginous preparations. Andral supposes that it is by diminishing the globules that bleeding and low diet produce such great disturbance of the nervous functions and lead to palpitations of the heart, although he does not maintain that all the neuroses are characterized by such a condition of the blood. These palpitations, in anaemic and chlorotic in- dividuals, from impoverishment of the blood, are often confounded with palpitations from an organic cause, and will often require all the judgment and acumen of the most experienced observer to discriminate between them.] 47. D. Course and Duration of Nervous Pal- pitation.— a. This affection varies somewhat, according to the cause which produced it.—a. W hen it proceeds from mental emotions, it is oft- en violent, but of very short duration.—(3. When it arises from manustupratio, it is not so exces- sive, but it is more prolonged, or remittent or recurrent.—y. Palpitations sympathetic of dys- pepsia are seldom severe, unless in persons of the nervous or irritable temperaments, nor of long duration ; but they are readily excited, particularly by a full meal, or by indigestible, or flatulent, or fluid food. In such cases the action of the heart is irregular, as well as ex- cessive, tumultuous or fluttering, and attended by anxiety, sometimes by pain, and by acceler- ated breathing or dyspnoea.—6. When this af- fection proceeds from misplaced or retrocedent gout, it is generally severe; more, however, from the attendant sensations than from the violence of the palpitations. The action of the heart is excessive, most irregular, or tumultu- ous, and attended by distressing anxiety, or sense of sinking or of anguish at the praecordia, often extending to the epigastrium, and by ex- treme restlessness, and a feeling of impending dissolution.—e. Palpitation is very often an at- tendant of hysteria, and in this case is excited or aggravated by the globus hystericus, or by the borborygmi or intestinal flatulence, char- acterizing the latter affection. A feeling of strangulation frequently accompanies this form of palpitation ; and, in two or three instances, I have observed an almost sudden swelling of the thyroid gland to take place, this part re- turning to, or nearly to its former state very soon after the attack. In more than one of these cases there was evidence of co-existent irritation or excitement of the uterine organs. Hysterical palpitation sometimes alternates with faintness, or is connected with excessive menstruation. It occasionally, also, follows abortions, floodings, &c.—h. The Duration of palpitation is most indefinite. It may continue only a few minutes, or many days. It may be remittent, intermittent, or even periodic ; but its course is more generally irregular. 48. E. Diagnosis.—It is often easy to dis- tinguish nervous palpitation from that symp- tomatic of organic lesion ; but quite as often -he diagnosis is very difficult. That it should be made with accuracy is most important, as respects both the treatment and the immediate happiness of the patient; for many distress themselves and aggravate their complaints with fears of an organic malady, while they are af- fected only with functional disorder. When nervous palpitations are prolonged, remittent, or return frequently, and are severe, the diag nosis is generally difficult; if attempted during their continuance, it is still more so; and if deferred until the period of intermission, it is often not much less difficult; for some organic lesions occasionally present periods in which the symptoms are remarkably ameliorated. Yet an attentive examination of the whole chest by percussion, auscultation, by the eye, and by the touch, will generally determine the question with great accuracy, and show that, in this af- fection, the heart is not enlarged, and that the blood circulates freely through its various ori- fices. The extended dulness on percussion, the morbid or adventitious sounds, the more or less constant dyspntea, the venous congestions, the bloated state of the countenance, the drop- sical effusions, &c., sufficiently mark organic lesion of this organ, especially if it have be- come far advanced. Sometimes, however, great nervous sensibility, or an hysterical af- fection, may be attendant upon some degree of alteration of structure, the palpitation recurring in severe paroxysms after slight mental emo- tions, or other causes affecting the nervous system, and leaving the patient comparatively easy, and with few precise or well-marked symptoms in the intervals. This is not infre- quently observed in persons who have been sub- jects of inflammation of one or more of the con- stituent tissues of the heart, that has left be- hind it slight structural change in connexion with an irritable state of the organ, and great susceptibility of the nervous system. 49. In addition to these considerations, the following circumstances may be adduced as distinctive of a functional disorder : 1st. The general prevalence of nervous symptoms, and the recurrence of the attack from causes acting on the nervous systems ; 2d. The return of the affection when the patient is quiet, and the re- lief following gentle or moderate exercise in the open air, and the means used to improve the digestive functions and to restore the ner- vous energy ; 3d. The prolonged and complete intermissions during an improved state of the general health, and the exacerbations conse- quent upon whatever depresses or exhausts or- ganic nervous power, especially upon the op- eration of any of the causes enumerated above (§ 45, 46); and, 4th. The absence of the phys- ical signs characterizing any of the inflamma- tory and structural diseases about to be cor sidered. 50. F. Treatment.—a. The means for this affection should have a very sti.cf ref- erence to the causes which produced n, and especially to the pathological state of which it is sympathetic. If it be independent of vascu- lar plethora, or of disease of remote organs; if it be primary, and the consequence of enfeebled or exhausted nervous influence, or of inanition anamia, chlorosis, &c., chalybeates, tonics, ana restoratives, regular exercise in the open a; , change of air to the seaside, the use of the te- pid or cold bath, sea-bathing, light and nutri 206 tious food, an infusion of green tea,* early hours, and healthy employment, the bowels be- ing regulated, or preserved open by an occa- sional dose of a mild stomachic purgative, or by a tonic, carminative, and purgative conjoin- ed, are the most appropriate remedies. For persons who are of an irritable or nervous tem- perament, or who cannot bear the immediate use of chalybeates, the stomachic bitters, or vegetable tonics, with the alkaline carbonates, or the preparations of ammonia, will be most serviceable; and afterward quinine with sul- phuric acid, and aether, or with camphor, or the decoction of bark with the hydrochloric acid and chloric aether; and, lastly, the metal- lic salts, especially the sulphate of zinc, or of iron, or the nitrate of silver, may be prescribed. I have for many years employed the nitrate of silver, triturated with the extract of hyoscya- mus, with great benefit in this affection, as well as the sulphate of zinc similarly combined. The various strengthening mineral waters, and amusements in the open air, will also prove beneficial. 51. b. When palpitation proceeds from mas- turbation—a more prevalent vice than is gen- erally supposed—the preparations of iron, with camphor; the tincture of the sesqui-chloride of iron ; the tonic infusions or decoctions, with the alkaline carbonates, with the solution of potash, or with Brandish’s alkaline solu- tion ; soda water or Seltzer w’ater as a com- mon beverage ; early rising, and regular exer- cise in the open air, will be found the most use- ful means of cure ; but they will all fail if the cause still continues.—c. Palpitation in con- nexion with plethora requires a moderate blood- letting, which may be repeated in some instan- ces ; a restricted and chiefly farinaceous diet, and the daily use of stomachic or mild purga- tives, early rising, and regular exercise. This form of the affection is not uncommon during the early months of pregnancy, and may be treated by the means just named.—d. When this affection is symptomatic of dyspepsia, the treatment must depend upon the state of the vascular system. If this system be plethoric, then the remedies now specified should be pre- scribed, the excreting functions freely acted upon, and the biliary secretions promoted. (See Indigestion.)—e. The palpitations arising from gout are generally relieved by camphor con- joined with acetate or hydrochlorate of mor- phia, or with hyoscyamus, and by a copious ac- tion of the bowels procured by warm stomach- ic-purgatives, with which magnesia or the al- kaline subcarbonates may be conjoined. In this, as well as in the dyspeptic form of palpi- tation, I have seen much benefit accrue from the hydrocyanic acid, given three times a day in a tonic infusion, an absorbent and carmina- HEAill--Functional Disorders of—Treatment. tive tincture being added ; but the bowel* should previously be well evacuated. (See art Gout, <$ 86.) 52. /. Hysterical palpitations require, accord- ing to the degree of plethora, or of inanition, nearly similar means to those already men- tioned, and attention to the uterine functions. The bowels should be kept open by cooling aperients ; and, if there be much debility, ton- ic infusions, with the hydrochlorate of am- monia, or nitrate of potash, or carbonate of so- da ; the infusion of valerian, with the foetid spir- it of ammonia, &c., and other remedies enumer- ated in the article Hysteria, may be directed, according to the pathological peculiarities of the case. The existence of pain or tenderness in any part of the spinal column should also be ascertained in this form of the affection ; and, if either be present, the means calculated to remove it ought to be resorted to.—g. When palpitation depends upon chlorosis or anaemia, a combination of the sulphate of iron with aloes and an aromatic powder, in the form of pills, is generally of service. I have seen great bene- fit derived from one or two grains of the sul- phate of iron, with three of the aloes and myrrh pill, and an equal quantity of the ex- tract of conium, given twice or thrice daily. The formulae, also, in the Appendix (F. 519- 525) will prove equally serviceable.—h. In the palpitation connected with chronic bronchitis, or with asthma, an infusion or decoction of senega, with aromatics and anodynes; cam- phor, asafeetida, and other remedies advised in these articles, are indicated.—i. When this af- fection is caused by intestinal worms, or by enlargement of any of the abdominal or pelvic viscera, or by ascites, or by effusion into the pleural cavities, the treatment should be chiefly directed to the removal of these maladies. Bibliog. and Refer.—Aetius, Tetrab. ii., serm. iv., c 58.— Avicenna, Canon,, ]. iii., fen. ii., tract. 2, c. 1.—Lan- gius, Opera, Epist., I. i., 22; 1. iii., 2.—Calani, Comment, in Galcnum de Cord. Tremore. Lugd. Bat., 1538.—B. Pa- tini, Consilium pro Maximiliano Csesare de Cord. Palp., 8vo. Brix., 1575.—A Camutius, Excussio brevis puecipue Morbi, nempe Cordis Palp., &c., 8vo. Flor., 1578.—A. Victori, De Palp. Cordis, 4to. Romas, 1613.—S. Pissinius, De Cor- dis Palpitatione cognosc. et curanda, Libri duo, 12mo. Franc., 1609.—Crocius, Qusest. Med de Palp. Cordis Natu- ra et Curatione. Marb., 1622.—Hollerius, De Morbis In ternis, 1. i., c. 29.—Horstius, Opera, vol. ii., p. 137, 139.— Schcnch, 1. ii., obs. 211.—Tulpius, 1. i., c. 15.— Zacutus Lu- sitanus, Prax. Hist., 1. ii., c. 8; 1. v., c. 2; 1. viii., c. 30 (Directs issues).—Ten Rhyne, Febr. Cardiaca et Palpitatio Cordis ex Flatibus, in Holler’s Biblioth. Med. Pract., vol 111., p. 256.—Riverius, Observ. Med., cent, iv., n. 21, &e.— Lentin, BeytrSge, b. iv., p. 415.— Tralles, De Usu Opi' sect, iii., p. 165.—F. Hoffmann, Opera, vol. iii., p. 90.—Lan- cisi, De Subitaneis Mortibus, p. 60.—Senac, Traitd du Cceur, 1. vi., c. 9.—Reil, Memorab. Clin., vol. i., fasc. ii., p. 5.— Baldinger, N. Magazin, b. v., p. 485 (Palp, caused by worms). —Odier, in Journ. de Mddecine, t. lxviii., p. 49 (The nitrate of bismuth advised for palp.).—Lettsom, Mem. of Med. Soc. of London, vol. i.—Marcard, Beschreibung von Pyrmont, b. 11., p. 205 — J. A. Albers, Ueber Pulsat. im Unterleibe, 8vo. Bremen, 1803. — J. P. Frank, Acta Institut. Clin. Viln,, ann. i., p. 125.—Lentin, in Hufeland’s Journ. der Pract. Ileilk., b. xiii., st. iv., p. 7.— Conradi, in Ibid., b. vi.. p. 501.—Michaelis, in Ibid., b. xviii., st. iii., p. 62 (Draughts (f cold water for palp).—Brugnatelli, Giornale, Ann. viii., l. i., n. 8 (Nitre with, tonics).—Laennec, Auscult. Mediate, t. ii., p. 227. Paris, 1829.—A. Portal, Mtim. sur la Nature < t Traitementde plusieurs Maladies, t. iv., p. 173. Paris, 1819.—Merat, in Diet, des Sciences MOdicales, t. xxxix., p. 134.—J. Johnson’s Med.-Chirurg. Rev , vol. iv., p. 370 ; iol. v., p. 277.—Andral, Diet, de Medecine, t. xvi., 8vo. l aris, 1826.—J. Frank. Praxeos Medic* Universal Prseoepta, ' ol. ii., pars ii., sect, ii., p. 370.—J. Hope, Cyclop, of Pract. Med., vol. iv., p. 232.—J. Bouillaud, Traild Clinique sur les Mai. du Occur, t. ii., p. 486. iii. Painful or Neuralgic Affections of the * In the summer of 1820,1 was requested by a practition- er to see the daughter of a clergyman residing in West- minster, labouring under most violent nervous palpitations, which had resisted the means advised by several physicians who had been consulted. She was in bed; and the im- pulse of the heart moved the bed-clothes, so that the pulse could be counted by the eye at the farthest part of the room ; and the knock of the heart against the ribs could be heard at the distance of some feet. She was thin, delicate, and highly nervous. Finding that the usual remedies for nervous palpitation had been prescribed without any relief, I suggested that a strong infusion of green tea should be given three or four times a day, and continued for a few days. Relief immediately followed, and perfect recovery in two or three days. HEART—Neuralgic Affections of—Diagnosis—Treatment. 207 Heart.—Classif. II. Class, I. Order (Ait- thor). 53. Charact.—Stidden attacks of anguishing vain in the cardiac region, returning at intervals ; the actions and sounds of the heart and respira- tion being but little affected. 54. In the same category with the disorders just considered may be arranged those painful affections which have been considered as neu- ralgia of the heart. They might be viewed as modifications of Angina Pectoris, and arran- ged with it, if there were sufficient evidence to prove that they are actually seated in the nerves of this organ. But, as Bouillaud ob- serves, although the functions of the heart may be disordered in connexion with them, the nerves of the adjoining viscera and structures are probably as much affected as those of the heart. A case of this complaint has been de- scribed by Dr. Elliotson, and is altogether similar 4o some that have occurred in my prac- tice. Indeed, neuralgia of the cardiac and com- municating nerves, or affections intermediate between it and angina pectoris, are by no means rare. A case of this affection came under my care in 1821 ; and since then I have treated six similar cases : two in females between the ages of twenty-five and thirty, three in gen- tlemen somewhat upward of fifty, and a sixth in a physician of about thirty-five years of age. 55. A. Diagnosis.—According to the phenom- ena observed in these cases, this complaint is characterized as follows : A most acute, ancinating, and anguishing pain is felt to the left of the sternum, darting through the region of the heart, often from under the left nipple backward to the spine or left shoulder-blade. Sometimes it is confined to this organ; and occasionally it extends to the left brachial plex- us, and up the left side of the neck, or left arm, or to other parts in the vicinity of the heart. This complaint is generally intermittent, or re- mittent, or even periodic in its character ; the paroxysms are sudden or almost instantaneous in their accession, and their duration is very variable. They leave the patient intervals of comparative ease, when the pain is dull or aching, and confined to the region of the heart. They return at various intervals, sometimes once or twice in the day, and occasionally not for several days. They are attended by the utmost agony and distress. The actions of the heart are somewhat accelerated during the fit, and sometimes more or less irregular or tur- bulent ; but they are also in other instances nearly natural. There is no morbid sound, be- yond a slight bellows sound in a few cases, heard on auscultation, and the breathing is tranquil. The paroxysm may take place at any period, and when the patient is perfectly quiet, mentally and physically, and without the occurrence of any cause sufficient to account for the seizure. This affection does not ap- pear to be aggravated, or its attack to be fa- voured, by exercise, or by motion or position ; but, on the contrary, it seems to be benefited by gentle exercise in the open air. Debility and loss of flesh generally are induced by the excessive suffering ; but the appetite is not materially impaired. The powers of digestion are, however, weakened, and the bowels are more or less sluggish. This complaint is gen- erally of long duration. The shortest period in my cases was six or seven months ; and in one, where the intervals between the attacks were very considerable, it was as many years. 56. B. Causes.—Of the six cases above re- ferred to, two were females. They were both unmarried; but the catamenia were perfectly regular; and neither of them had ever com- plained of any hysterical symptom, or had ex- perienced pain in the spine. Of the four males, the two most advanced in life had formerly had gout; and in one of them, who was under the care of Dr. Roots and myself, the cardiac neuralgia was induced by grief. The other two were medical practitioners: one of them had been engaged in a laborious practice in the country ; the other had experienced family contrarieties and disappointments, and was endowed with the utmost susceptibility and ir- ritability. The recurrence of the attack seems to be favoured by cold, especially by cold east winds; and there is reason to believe that malaria is concerned in causing it. In a vio- lent case, recorded by M. Andral, no trace of organic lesion was observed on dissection. 57. C. Treatment. — The means of cure in this affection are not materially different from those advised for Angina Pectoris, to which it is an intimately allied affectjpn. As in that complaint, so in this, and in Palpitations (6 50), the indications are, 1st. To shorten the attack; 2d. To prevent the recurrence of it.— a. The remedies I have found most efficacious in fulfilling the first intention are, camphor in large doses with opium, or acetate of morphia ; the hydrocyanic acid, with camphor, or ammo- nia, or other stimulating antispasmodics, or warm carminatives and tonics; a full dose of calomel, with camphor, capsicum, and opium, or the hydrochlorate of morphia ; the prepara- tions of colchicum conjoined with ammonia, camphor, the carbonate of soda, &c.; a mus- tard poultice applied as hot as it can be endured over the epigastric region ; and a plaster, con- sisting chiefly of extract of belladonna and cam- phor, placed over the prsecordia. I have tried various narcotics besides these just named ; but less certain advantage has been derived from them than from those. The extract or tincture of aconitum, or of stramonium; or the powdered root or leaves, or the extract of bel- ladonna are, however, often of service, espe- cially when the medicines just mentioned have failed. 58. b The second intention has been best answeri d by purgatives, by mild and chiefly farinaceous food, by abstinence from stimula- ting liqi ors, by tonics conjoined with absorbents and stimulants, and by external drains or deriv- atives long persisted in. The sesqui-oxyde of iron, in large doses, the bowels being kept freely open, has been sometimes of service. Dr. Elliotson found benefit from it in one in- stance : but it has failed in other cases; and equal a dvantage has been derived from a com- bination of sulphate of quinine, camphor, and as much purified extract of aloes as acted freely on the bowels. In one of the female cases al- luded to, the nitrate of silver, given with a nar- cotic extract, was extremely serviceable. In the other, pills, containing as much croton oil as procured at least three or four stools daily, were regularly continued for a considerable f me, and a large issue was kept long dis- 208 HEART AND FERICARDiUM—Inflammations of. charging. Complete recovery took place in both instances. In one case, change of air, travelling, attention to diet, and issues in the side effected a cure, the patient being a physi- cian of great learning and extensive medical knowledge. In another case, the symptoms were aggravated by depressants and abstinence; and recovery took place during a recourse to tonics conjoined with anodynes; to a generous and light diet, the patient being allowed from four to six glasses of old wine, or even more, daily; and to change of air, and the amuse- ments and distractions of watering-places. In one instance, great benefit appeared to follow the persevering use of croton oil as an external derivative ; and eruption over the epigastrium having been kept long out by its means. In the case of a medical practitioner from Devon- shire, who very recently consulted me, all these, as well as other means, altogether fail- ed. At last, an ointment containing aconitine was directed to be rubbed over the sternum; but of the effect of this I am yet ignorant. In another instance, no benefit followed the appli- cation of an ointment containing veratria. 59. Besides the substances already mention- ed, I have tried many others. Digitalis has been of no service. Some benefit, however, has followed the internal use of turpentine giv- en in drachm doses until it affected the urinary organs; and from the iodide of potassium, or iodide of iron, conjoined with narcotics : I tried creasote in one case without any advantage. I think that the disease may wear itself out, in some instances, without being much relieved by medicine, if attention be paid to diet' and regimen, and to the state of the stomach and bowels, and if the energies of life be supported or promoted by suitable means. At present, I am attending a gentleman who has been for many years afflicted with this complaint, the paroxysms of which, however, come on after considerable intervals. He was formerly sub- ject to gout, which I have attempted to excite in the lower extremities without avail. He has consulted many physicians in London and on the Continent, and has even given homoe- opathy a lengthened trial. On no occasion had he experienced any material relief. I was re- quested to see him six or seven years ago, and have since continued to prescribe for him oc- casionally, excepting while he had recourse to means prescribed by Dr. Turnbull, from which he derived no benefit. The attacks are short- ened and relieved by the medicines mentioned above (§ 57); but they still recur, although not so frequently as before ; attention to diet, an open state of the bowels, and gentle exercise in the open air, being found most efficacious in deferring their visitations. [Cardialgia will often be promptly relieved by the administration of a gentle emetic, con- sisting of a few grains of the sulphate of zinc and ipecacuanha, given in a single dose. We have known a patient labouring under this af- fection, with most distressing palpitations, ef- fectually relieved by this combination, even be- fore vomiting took place. Immersing the feet and hands in hot water, containing salt or mus- tard, will frequently tend to abate the pain, and cut short the paroxysm. Mental tranquillity is of the first importance in warding off attacks of this disease. Pure air, a regulated diet, and gentle exercise, are also essential to recov- ery.] Bibliog. and Refer.—J. Brown, Med. Essays on Fever, Inflam. Rheumatism, Dis. of the Heart, &c., 8vo. Lond., 1828, p. 221.— T. P. Teale, Treatise on Neuralgic Diseases, 115. The third variety, or yellowish softening of Laennec and Bouillaud, often is manifestly connected with chronic true carditis, although 221 ened and infiltrated with a similar substance. 2. In a very instructive case recorded by M. Raikem (Bullet, de la Fac- ulty, l’an. 1809), violent pain and anxiety in the cardiac re- gion, palpitations, dyspnoea, and leipothymia, consequent upon rheumatism and rigours, were complained of. To these were added a bloated and anxious countenance, distention of the jugular veins, small and frequent respiration, irregu- lar and excited action of the heart, pain at the epigastrium, and vomitings, followed by delirium, and by death about the fourteenth day. The heart was found large and flabby. Signs of inflammatory action were observed in its left valves and orifices. Its substance was of a reddish brown hue, in- jected, and contained three or four small collections of an opaque sanious pus. 3. M. Simonet has recorded a case in which the disease was connected with rheumatism. When the patient was brought to the hospital, the action of the heart was tumultuous and extensive, the pulse con- tracted and irregular, the respiration difficult, and the ex- tremities cold. Blood-letting was practised ; but he died a few hours afterward in a fit of syncope. Purulent collec- tions were found in the substance of the heart, especially in the interventricular partition. The internal surface of the cavities was red in several places ; the muscular struc- ture being of a yellowish gray hue, softened, and torn with the least effort. (Bouillaud, Op. cit., p. 266.) 4. Dr. Graves was consulted by a gentleman, fifty-five years of age, who had complained for many months of palpitations and dyspncea, and more recently of anasarca. Severe pain and anxiety were felt at the region of the heart, the former darting over the chest. Dr. Graves detected hypertrophy and dilatation of the ventricles, with a loud bellows sound, the purring tremour, and a very irregular pulse ; and in- ferred the presence of disease of the valves. The patient died suddenly a few weeks afterward. There were found considerable effusions of serum in both pleural cavities, en- largement of the heart, and adhesion of it to the pericar- dium by bands of coagulable lymph, which were strong at the apex. At this situation was discovered a cavity in the muscular structure, with a regularly defined wall, which contained about two ounces of pus. The parietes of both ventricles were greatly thickened. All the valves were more or less affected. The valves of the aorta were nearly altogether ossified. (Land. Med. and Surg. Journ., vol. vii., p. 803.) 5. In a case detailed by M. C. Broussais (Annul, de la Med. Physiol., t. xxi., 1832), the abscess in the sub- stance of the heart was encysted. A soldier, nineteen years of age, was attacked with smallpox, in the course of which abscesses, enormous infiltration of the left arm, probably caused by a consecutive phlebitis, &c., supervened. A con- stant fever, with anxiety, marasmus, &c., ultimately be- came the principal symptoms. He died on the fifty-fifth day from the attack. An abscess, of the size of a filbert, was found in the muscular substance of the left ventricle, near its base. The matter was well-digested pus, which was contained in a consistent cyst. 6. M. Laennec found a similar abscess in the substance of the left ventricle of a child who died of pericarditis. A case resembling the fore- going is also recorded by Henning (IIufeland’s Journ. der Pract. Arzneyk., b. vii., st. iv., p. 144). Two cases are recorded by M. Marechal, in which purulent collections were formed in the cavities of the heart, connected with their internal surface, and surrounded by a thin, friable membrane. The patients had experienced symptoms refer- rible to the heart during the latter days of existence. (Journ. Hebdom. de Med., t. ii., p. 494.) 222 HEART—Inflammation of its Structure. by no means generally. It differs from the former (§ 114) only in its yellow colour: and is most frequently greatest in the interventric- ular septum, and the centre of the muscular structure of the ventricles ; the parts nearest the internal and external surfaces of the organ being less evidently changed, or presenting red- dened points of the healthy consistence. The second of these forms of softening was observ- ed by me in a patient who died of the conse- quences of inflammation of the membranes of the spinal chord, many months after having experienced an attack of acute carditis, con- nected with articular rheumatism (see Lond. Med. Repos., \ol. xv., p. 26); and, judging from the appearances in that instance, this softening seemed to result from a change in the nutrition of the organ, consequent upon the antecedent inflammation of it. Bouillaud considers that its frequent coincidence with purulent effusion into the pericardium shows that it depends upon this latter circumstance. The juster in- ference would be to impute both the change in the substance of the organ and the morbid se- cretion from the pericardiac surface to per- verted vascular action, conjoined with impair- ed organic nervous power. That these are the true pathological conditions, is shown by the circumstances in which this as well as the yellowish variety of softening is found. I have observed them both—this latter variety espe- cially—where there had been no evidence of cardiac disease, either at any previous period or in a chronic form ; and particularly in cases of general cachexia, and of constitutional dis- ease, attended by discoloration of the surface of the body, by a bloodless, yellowish, or tallowy or waxy appearance of the integuments, and by other signs of a poor and deficient state of the blood, consequent upon impaired organic nervous energy and assimilation, as generally seen in the advanced stages of local malignant or contaminating maladies. 116. e. Ulceration of the heart may arise from an abscess, encysted or non-encysted, having opened either into one of the cavities, or into the pericardium. In the former case, the pu- rulent collection, and the subsequent secretion from the diseased part, mix with the blood ; in the latter, they accumulate in the pericardiac cavity, and increase a pre-existent pericarditis. M. Bouillaud supposes that they may open both ways, and occasion perforation of one of the compartments of the organ. It is more probable that, after opening in one direction, the tissue surrounding the abscess gives way, owing to the loss of substance, and to the softening consequent upon this lesion. That many of the cases of rupture of the heart arise from this circumstance will appear in the se- quel. Ulcerations are generally observed in the internal surface, most commonly in that of the left ventricle. Inflammation having commen- ced in, or extended to the connecting cellular tissue, and having given rise at one or more points to an effusion of a serous or puriform fluid sufficient to detach the internal membrane from its vascular connexions, this membrane necessarily loses its vitality at these points, and yields before the matter underneath it. Ero- sion of the endocardium, followed by ulceration, and limited softening, &c., of the substance of the organ, is thus produced ; the number, ex- tent. an'd depth of the ulcers being various. 117. Ulceration, in its course through the substance of the heart, gives rise to changes analogous to those observed after ulceration of arteries. The thinned and softened portion of the parietes yields before the pressure made upon it by the column of blood, and a saccula- ted aneurism, or tumour, varying from the size of a filbert to that of a large orange, is form- ed ; its cavity, as in the case of other aneu- rismsfbeing often, in a great measure, filled with lamellated coagula. The aneurismal tumours consequent upon ulceration generally form ad- hesions between the opposed surfaces of the pericardium stretched over them, their rupture being thereby prevented. They have been found only in the left ventricle ; and, according to M. Breschet, the summit of the ventricle is their sole seat; but M. Reynaud has shown, by the analysis of thirteen cases, that seven are exceptions to this rule. 118. /. Perforation of the parietes of one of the compartments of the heart may occur in either of the ways above described ; from ulceration consequent upon abscess ; from simple ulcer- ation following inflammatory action; or from ulceration attended by an aneurismal tumour. It seldom, or never, perhaps, proceeds from the last of these, for the reason just assigned ; and whenever it does take place in either of the former cases, rupture or laceration of the re- maining inflamed and softened tissues in the seat of ulceration usually takes place. When the perforation is made into the pericardium, death occurs suddenly; but when it is seated in the interventricular septum, then an admix- ture of arterial with venous blood results, and life may be prolonged for some time. Instan- ces of perforation from ulceration have been re- corded by Rulliek, Andral, and others. M. Maruejouls met with this lesion in the left au- ricle. 119. g. Induration and cartilaginous and osse- ous transformations of the substance of the heart are doubtless among the more remote or chron- ic lesions consequent upon carditis. Simple induration varies in degree and situation, and is generally limited to, or is most remarkable in a single compartment. It may be seated in the parietes of a ventricle, or in those of an auri- cle, or in the septa, or in the fleshy columns. Corvisart, Laennec, and Broussais have ob- served it to equal that of the shell of a nut. It is, however, most frequently characterized by a transformation into a cartilaginous, or an osse- ous, or osseo-calcareous substance, and limited to a portion only of a compartment. The connect- ing cellular tissue, especially that beneath ei- ther of the membranes, seems to be the origi- nal seat of this change, the muscular fibres be- ing atrophied from the pressure of the indura- ted, hypertrophied, or transformed cellular tis- sue connecting them. The cartilaginous and osseous degenerations of a portion of the sub- stance of the heart have been observed by Morgagni, Haller, Senac, Corvisart, Bail- lie, Filling, Renauldin, Bichat, Bertin, and many others. They are, however, much more frequently met with in the pericardium. The most remarkable instance of ossification of the muscular structure of the heart is recorded by A. Burns. In general, when ossific deposites are found in this latter situation, they seem to have only extended to it from either of the sur- HEART—Inflammation of its Structure—Symptoms. faces, especially the pericardiac, or, rather, from the cellular tissue subjacent to these surfaces, to that connecting the muscular fasciculi, which become atrophied as the osseous or cartilagin- ous change proceeds. This seems well illus- trated by an interesting case recorded by Mr. Smith (Dublin Journ. of Med. Science, vol. ix., p. 419). 120. That the change of a portion of the sub- stance of the organ into the cartilaginous or osseous states is actually the result of a form of chronic inflammatory action, seems to be pro- ved by what is observed in connexion with these lesions in other situations, and by the circum- stances of their association with increasad vas- cularity and swelling in hypertrophy of the parts in which they are seated, and of their occur- rence after undoubted evidences of inflamma- tion had been manifested. That the state of the circulating fluids may, however, be indirect- ly concerned in the production of these changes, as consequences of chronic inflammatory ac- tion, in preference to any other, is not improb- able ; the superabundance in the blood, owing to impaired eliminating function of those sub- stances or ultimate products of assimilation, which contribute to the formation of the mor- bid depositions in question, possibly favouring their supervention. 121. B. The Symptoms and Diagnosis of true Carditis are so little different from those of in- ternal and external carditis, that nothing pre- cise can be advanced under this head. The circumstance of inflammation of the substance of the heart occurring chiefly as a consequence, or as a complication of inflammation of either or of both the surfaces, nearly precludes the possibility of distinguishing between it and them, or of ascertaining its existence when thus associated, more especially when the dis- ease exists in a sub-acute or chronic form. This difficulty has been acknowledged by Corvisart, Laennec, and Bouillaud. M. Laennec very justly remarks that there is not on record a single case of carditis the symptoms and course of which have been accurately observed. M. Bouillaud states that he has never met with a case of carditis uncomplicated with pericar- ditis or endocarditis. It has been supposed that the dark softening of the structure of the heart, so very frequently observed after death from adynamic or putro-adynamic fevers, has been owing to the complication or superven- tion of inflammation of this organ. The un- common frequency of the pulse in many of these cases has been considered as evidence of this ; yet the slighter forms of simple endocar- ditis would give rise to the same symptoms, and these, very probably, not infrequently oc- cur in the course of those fevers, modified, how- ever, by the constitutional malady, although in general the heart’s substance undergoes no far- ther change from them than other organs. In the advanced stages, or near the termination of these diseases, the heart participates in the alterations which take place in muscular parts generally, and becomes more or less softened and discoloured. This change, however, is in- dependent of inflammation, and is the conse- quence of extremely depressed vital power, and impaired cohesion of the soft solids (see Fever, t) 18, 102), in connexion with deterioration of the circulating fluids. This change of the sub- stance of the heart is also not infrequent in ca- ses where the blood has been altered by the ab- sorption of morbid matters, or by the infectious operation of putrid and contaminating fluids and miasms. I have remarked it in the putro-ady- namic, or liquescent form of remittent fever endemic in low, marshy districts within the tropics, and in the more malignant states of puerperal fevers, especially those met with in crowded or ill-ventilated lying-in hospitals (see Puerperal Diseases). Several writers on the plague state that they have observed it in fatal cases of that pestilence. I also have found it after death from pestilential yellow fever, and in a slighter degree from pestilential cholera. (See art. Pestilences.) 122. a. Notwithstanding the difficulty of de- termining the existence of carditis during the life of the patient, Drs. Heim and Krause be- lieve that a diagnosis may be made in some in- stances ; and, judging from two cases in which I was consulted, and in which the opinion as to its nature was confirmed by the appearances observed after death, I nearly concur with them, especially if the disease exist in a very acute and fully developed form. In this case the pa- tient experiences a violent pain in the region of the heart, with anxiety, preceded or attended by rigours, chills, or tremblings of the whole frame. To these succeed increased heat about the prse- cordia, or in the trunk, while the extremities and face are cold, and the whole surface is cov- ered by perspiration, which is cold on the ex- tremities.* The pain is concentrated in the sit- uation of the heart, is lacerating or rending, accompanied by the utmost agitation and ex- pression of anxiety and distress, sometimes by screams, and occasionally by general convul- sions and swoonings. The patient feels every pulsation of the heart, rolls about to obtain ease, and presses his hand forcibly against the prse- cordia. The chest is elevated, the head thrown back, and the face and hands covered with cold sweats. There is great thirst, but drink is re- fused on its reaching the lips ; and there is oft- en loquacity, passing into delirium as the dis- ease advances. If no vascular depletion has been practised, the pulsations are indistinct, or fluttering, or tumultuous. After blood-letting, the action of the heart becomes more devel- oped ; palpitations, attended by intense suffer- ing, occasionally take place, and at other times syncope supervenes, or they both alternate. Immediately upon opening a vein, syncope or convulsions are apt to occur; but, upon pla cing the finger on the orifice till the patient re- covers, the depletion can be carried to a great amount, with relief to all the symptoms. The pulse varies remarkably, but is generally un- equal or irregular, and remarkably small and weak, or indistinct. There is neither cough nor expectoration, nor vomiting, but a frequent expression of pain and distress. The pain is increased by each contraction of the heart, so as to cause the patient to complain of palpita- tions, even when the impulse is not sensibly increased. If the disease is not soon arrested, constant jactitation or tremour, recurring fits of syncope, delirium, and death take place ; or, in consequence of the association with it of inflammation of the internal or external mem- branes, and of the effusion of lymph, the phe- nomena, local and general, observed in the ad- 223 224 HEART AND PERICARDIUM—Inflammations of—Causes, etc. vanced stages of internal and external carditis, supervene and constitute the chief character- istics of the malady. When acute carditis is associated with either of the other varieties, or passes into them, then the local and physical signs proper to each will be detected, accord- :ngly, on percussion and auscultation. 123. These are the most constant phenome- na of acute carditis, according to the descrip- tion of Dr. Heim, and the history of two cases which fell under my observation. The seizure is generally sudden, and the disease reaches its acme about the third day. In one of my cases, death took place on the fourth day. The patient (who was attended also by Dr. Walsh- man and another practitioner) was about fifty years of age, and of a full habit of body. In the spring of 1821, while labouring under an attack of rheumatism, he was recommended by some person to take a strong dose of croton oil. He took three drops, which produced vio- lent purging and vomiting. The rheumatism suddenly ceased, and was speedily followed by the most distressing pain and anxiety in the region of the heart, and entirely confined to it. There was no morbid sound on auscultation, although nearly all the symptoms enumerated above were present. The patient was repeat- edly bled, but extreme restlessness and jacti- tation appeared, and death by syncope soon afterward took place. On dissection, the peri- cardium presented hardly any signs of inflam- mation, but the substance of the heart was in- flamed, and portions of the internad surface more slightly. The alterations, however, were not so extensive as was anticipated, probably owing to the activity of the treatment, as med- ical aid was promptly procured, and the disease at once recognised, and to the rapidity of the fatal termination. In the other case, which occurred more recently, and which was of longer duration, dark softening, as described above, was very remarkable, with the usual products of inflammation on both the internal and external membranes, particularly the latter. 124. b. The consecutive alterations on true carditis are even more occult than the acute stage of the disease itself. Indeed, as these alterations most frequently proceed from a sub- acute or chronic state of carditis, or from in- flammation limited to one or two compartments of the organ, their greater obscurity is to be anticipated. When abscess or ulceration is fol- lowed by perforation or rupture, then sudden death takes place, unless the alteration occurs in the interventricular septum. But the symp- toms attending these lesions previously to their reaching a fatal extent have not been ascer- tained, and it is doubtful whether or not they admit of being distinguished. It is necessary to this end, that cases of this kind should be carefully observed and accurately described; but there is none on record possessed of either of these qualities. The same observations ap- ply to the sacculated dilatation or aneurism of the heart (<) 117), consequent upon ulceration or abscess. In none of the cases of it which have been published was this lesion either discov- ered or suspected during life. M. Breschet mentions only the signs that may be expected to occur, not those which have been actually observed; and IVi. Bouillaud advances no far- ther. In the case detailed by M. Reynaud, an affection of the heart was never indicated, the patient having died of a severe nervous dis- ease, caused by the oxyde of lead, in a manu- factory where he wrought; and the cases ad- duced by the authors referred to hereafter fur- nish quite as little information. 125. c. Softening of the heart, consequent upon various grades of inflammatory action, is indicated by a few symptoms, which, when duly weighed in connexion with the previous history of the case, may lead the acute physi- cian to presume its existence with some truth. These symptoms, however, taken by them- selves, often attend other diseases character- ized by extreme asthenia, and even the asthenic functional disorders of this organ (<) 39). But when, after more or less acute or sub-acute symptoms referrible to the praecordia, especial- ly if attended by any of the morbid sounds, or other physical signs observed in external or internal carditis, or after dyspnoea, &c., the impulse of the heart at the praecordia, and the pulse at the wrist, become obscure, weak, and irregular, the latter being small or indistinct, the face livid or tumid, and the extremities cedematous, the dyspnoea increased or more constant, and when fainting or syncope occur frequently, or from very slight causes, then softening of the muscular structure of the heart may be presumed. Still, all these symptoms may depend upon effusion into the pericardium, which, however, is often associated with soft- ening of the organ. But a careful examination of the chest by percussion and auscultation, and the diagnostic symptoms adduced in the article on Dropsy of the Pericardium (<) 151), will often lead to a just conclusion. The soft- ening of the heart, which, in a slighter degree, may be presumed to exist during convalescence from low or malignant fevers, is generally at- tended by a small and quick pulse, by a very weak and limited impulse, and by frequent re- turns of faintness or syncope. In the soften- ing observed in very old people, the pulse is often slow, feeble, indistinct, or intermittent, or irregular; and dyspnoea, with many of the symptoms just mentioned, is generally present. 126. iv. Of the Causes and Development of Inflammations of the Heart and Pericardium.— Inflammations of the surfaces and substance of the heart arise from the same predisposing and exciting causes. When either of these forms of carditis proceeds directly from these causes, or independently of a pre-existing malady, it has been denominated primary or idiopathic; but when it has followed another disease, and when a connexion can be traced between both, it has been called consecutive or symptomatic. The causes already adduced under the heads of pre- disposing (§ 18) and exciting (<) 19) are princi- pally concerned in the production of the pri- mary states of these inflammations. Some of those which have been termed pathological (<) 20) chiefly occasion the consecutive forms of carditis. 127. A. Of the predisposing causes (!) 18) al- ready stated, plethora, the rheumatic and ar- thritic diathesis, the irritable and sanguineous temperaments, hereditary constitution, mental emotions, and early age, seem to be most con- cerned in producing inflammations of the heart and pericardium. Although these diseases may occur at any age, yet they are most frequently HEART AND PERICARDIUM--!.ski.,ammations of—Causes, etc. 225 met with between the ages of six and thirty- , five. M. Bouillaud assigns the period between ! ten and thirty as that of their most common occurrence. I have, however, observed a large proportion of cases between five and ten years of age, and after thirty. I agree with him in considering them most frequent at those sea- sons when the vicissitudes of temperature and season are the greatest, and, I may add, du- ring spring, when northeast winds are most prevalent. 128. B. The exciting causes ($ 19) comprise nearly all those just referred to, especially the mechanical, the traumatic, the physical, and tije moral exciting causes. Of the physical causes, the most common are, exposure to cold when the body is perspiring, or after it has been much overheated or excited, and wearing damp clothes, or sleeping in damp sheets or beds. The impression of cold after the copious transpiration and exhaustion caused by bodily or mental exertion, or by both conjoined, is very apt not only to produce inflammation of either of the surfaces of the heart, but also to occasion pneumonia or pleuritis to be associa- j ted with it. A young man of talent, after ad- j dressing a meeting under great mental excite- i ment for upward of an hour, exposed himself i immediately to a cold easterly wind in the month of March, and was soon afterward ■seized with pericarditis, complicated with pleu- ritis of the left side. A middle-aged man, after great muscular exertion and fatigue, allowed aimself to be suddenly chilled: he was after- ward attacked by internal carditis, which soon became associated with pericarditis. The dan- gerous and often fatal consequences of violent <>r prolonged exertions in working the pumps of leaky or sinking vessels are generally ow- ing to the production of this malady in its most acute form. Of the truth of this, the author had, many years ago, a painful opportunity of assuring himself. The moral causes enumera- ted above 19 (c)), and in the article Disease 53), sometimes either induce, or concur with other causes in occasioning one or other of the forms of carditis. 129. C. The pathological states which have t>een adduced (<) 20) are by much the most common causes of inflammation of the internal and external surfaces of the heart; and of these the most frequently observed is rheumatism, particularly the acute articular form of that dis- ease. Internal or external carditis may be connected with rheumatism in three modes : 1st. The cardiac inflammation may follow the j disappearance or suppression of the rheumatic j affection, and may thus appear as a metastasis, \ nr translation of this affection; 2d. It may take place before the rheumatic disorder has ceased in an extremity or external part of the body ; and co-exist with this disorder in one or more joints, or in these situations, the external affection being, however, much less severe after the development of the cardiac malady ; 3d. Rheumatism may extend itself to the heart or pericardium without abatement in its exter- nal seat, or may affect, almost simultaneously, one or more joints, and the heart; or a very acute arthritic rheumatism may mask a sub- acute internal or external carditis. Of these three modes of connexion, the first and second are the most frequent; but the third is by no means rare. I believe that the more acute the rheumatic complaint, and the more it affects the joints, the greater is the risk of its occa- sioning- carditis or pericarditis ; the risk being also greater, the younger the patient: and I am moreover of opinion that this connexion between inflammations of the heart and rheu matism is much more frequent at the present day than twenty years ago.* Twenty-five years since, when I published a dissertation on rheu matism, and had my attention as alive to this circumstance as now, and with equal opportu- nities of meeting with it in public institutions, it was much less frequently observed. The modes of ascertaining it have certainly been improved since then ; but nearly as much now is often lost by inattention to the physiological or rational symptoms as is gained by ascer- taining the physical signs. Besides, as I have always resorted to auscultation and percussion since 1819, when I frequently accompanied Laennec in his rounds, the disease was almost as likely to have been detected by me then as now. [Dr. Latham states (“ Lectures on Subjects connected with Clinical Medicine, comprising Dis- eases of the Heart,” 2 vols., Lond., 1845) that between the years 1836 and 1840, there oc- curred under his care, at St. Bartholomew’s Hospital, 136 cases of acute rheumatism ; of which 75 were males and 61 females: and of the 75 males, the heart was affected in 47, and unaffected in 28. Of the 47, the seat of the disease was the endocardium alone in 30, the pericardium alone in 3, and both the endocar- dium and pericardium in 7 ; and while the heart was undoubtedly affected in 7 others, the exact seat of the disease was uncertain. Of the whole number of males in whom the heart was thus variously affected, 3 died; and in these 3 the pericardium and the endocardium were both inflamed. Of the 61 females, the heart, was affected in 43, and unaffected in 18. Of the 43, the seat of disease was the endo- cardium alone in 33, the pericardium alone in 4, and both the endocardium and pericardium in 4 ; and the exact seat of the cardiac disease doubtful in 2. Of the whole number of females in whom the heart was thus variously affect- ed, none died. The account of males and fe- males taken together will stand thus : Cases of acute rheumatism . . . .136 Heart exempt in 46 Heart affected in 90 Seat of disease in the heart: Endocardium alone in 63 Pericardium alone in ..... . 7 Endocardium and pericardium in . 11 Doubtful in 9 Deaths 3 ; in all of whom both endocardium, and pericardium were affected. Of the 63 pa- * [“ One law respecting the connexion between the car* diac and the arthritic symptoms,” says Dr. Watson, “ may- be stated with confidence ; namely, that the younger the. patient is who suffers acute rheumatism (and I have seen it so early as the third or fourth year), the more likely will1 he be to have rheumatic carditis. The chance of the com- bination appears to diminish after puberty, as life advances. I have known only two persons pass through acute rheuma- tism with an untouched heart prior to the age of puberty ; and in those two, I am by no means certain that the articu- lar disease was genuine rheumatism. In each of them the large joints became painful, and swelled, for a day or two only, towards the close of scarlet fever—a circumstance not, I believe, unusual. I was dreadfully apprehensive of cnr~ ditis, but it did not occur.”— (Loc. cit.)] 226 HEART AND PERICARDIUM—-Inflammations ok—-Causes, etc. tients who suffered simple endocarditis in the course of acute rheumatism, 30 were males and 33 females, of whom none died ; but aus- cultation showed that of these the membrane recovered its complete integrity of structure only in 17, and that it remained permanently injured in 46. Of the 30 males, the subjects of rheumatic endocarditis, the endocardial mur- mur ceased entirely in only 8 ; while it re- mained after they were convalescent, and as long as they continued under observation, in 22. And of the 33 females, the endocardial murmur ceased entirely only in 9, while it re- mained in 24. This denotes a most fearful disease in regard to its distant results, showing that the probability is as great as 4 to 1, that inflammation befalling the endocardium will become the rudiment of disorganization to the entire heart. The results of simple rheumatic pericarditis were that, of the 7 who suffered simple pericarditis in acute rheumatism, 3 were males and 4 females, of whom none died, and no exocardial murmur remained after conva- lescence, to denote a change of structure in the pericardium, although adhesion might exist and escape this as well as all other known methods of diagnosis. Of the 11 in whom endocarditis and pericar- ditis were combined, 7 were males and 4 fe- males ; out of these, inflammation was arrest- ed and life saved in 8 ; and 3 died. Of the 8, who were convalescent from this double dis- ease, the endocardium underwent perfect rep- aration in 2, for the endocardial murmur en- tirely ceased; and imperfect reparation in 6, for the endocardial murmur continued. As to the pericardium, although the exocardial mur- mur ceased in all, Dr. L. thinks it doubtful whether its reparation was perfect in any, there probably remaining a greater or less ex- tent of permanent adhesion. Thus, of these 8 cases involving both the investing and lining membranes of the heart, it is not certain, or perhaps probable, that the organ recovered a perfectly healthy condition in a single instance. The appearances on dissection in the fatal ca- ses corresponded with those given by Mr. Cop- land. Of 136 cases of acute rheumatism, Mr. L. also found that while the heart was inflamed in 90, or in two thirds of the whole, the lungs were inflamed only in 24, or one in 5£. These 24 cases w’ere made of 4 of bronchitis, 18 of pneumonia, and 2 of pleurisy. Of the 46 cases of acute rheumatism in which the heart was unaffected, the lungs were inflamed in 5, a ra- tio of 1 t.o 9 ; and of the 90 cases in which the heart was inflamed, the lungs were also in- flamed in 19, a ratio of more than 1 in 5. Of the 63 cases of endocarditis, the lungs were inflamdd in .7, a ratio of 1 to 9. Of the 7 cases of pericarditis, the lungs were inflamed in 4, a proportion of more than one half. Of the 11 cases of endocarditis and pericarditis simulta- neously, the lungs wrere inflamed in 8, a ratio of two thirds. Thus showing that, while in aeute rheumatism inflammation of the lungs does not occur more frequently when the en- docardium is inflamed than when the heart is entirely exempt from disease, yet that when this membrane and the pericardium are both involved, inflammation of the lungs is a fre- quent complication. The pulmonary affection consisted either in the existence of single or double pneumonia, single or double pleurisy, or bronchitis of one or both lungs. Dr. Charles Hooker states (Bost. Med and Surg. Journ., vol. ii., p. 336) that a remarkable change of diathesis was observed in the city of New-Haven and vicinity in the year 1830-1; and that rheumatism, complicated with pericar- ditis, pleuritis, &c., became very prevalent. For this, he says, the Actea raccmosa proved a most prompt and efficacious remedy. “ In the commencement of a severe case,” he re- marks, “ a full dose of calomel was commonly administered, and this was followed by a mix- ture of Tinct. Actcece, jvj., and Tinct. Opii, jij., in doses of forty or sixty drops every two or four hours. Scarcely any other medication was required, whether a case w'as pneumonitis, pleu- ritis, pericarditis, or phrenitis, all of which were of a rheumatic character; and with this plan the severest cases were almost sure to come to a favourable resolution within four or six days.” During the following year, the disease was also very rife, but wanting the usual acute symptoms of the affection. There was a strong predisposition to serous effusion into the peri- cardial sac ; post-mortem examination revealed copious liquid effusion into the cavities of the pleura, of a straw colour, with an admixture of yellowish, albuminous flocculi. The lungs were largely infiltrated with pus and serum, with such a preponderance of the serum as to occa- sion an unusually pale appearance, and the de- gree of softening was such that the lungs could hardly be handled without breaking into a thin, pultaceous mass. The pericardium was dis- tended with a liquid similar to that within the pleura, and in most cases the inner membrane was coated, so as to have a pale, buttery appear- ance. The muscular substance of the heart was remarkably softened, and in most cases paler than natural. Dr. H. remarks that the prominent feature of the disease was a tenden- cy to a separation of the serum and fibrin, with effusion of serum ; and that the principal dan- ger to be apprehended was from serous effu- sion into the pericardium, the lungs, the brain, and the spinal canal. The remedies employed were, therefore, aimed to prevent effusion and promote absorption ; for which purpose, after a full dose of calomel, one of the following pills was given every one, two, or four hours, ac- cording to the circumstances of the case: ELatent, gr. j. ; Calomel, fry. xv.; Pub. Digitalis, 9j. ; Pub. Scillce, 9j. ; Pulv. Cantharid , gr. v. ; Muc. G. Arabic, q. s. Ft. pill, No. 40. These were continued until eight or ten copious liquid evacuations were produced, after which they were so given as to procure two or three evac- uations daily. This plan, with blisters to the praecordial region and sinapisms to the extrem- ities, was the only medication ordinarily requi- red. In 'many cases, conjoined with this treat- ment, a mixture of 01. Terebinth., with muci- lage of gum Arabic, was advantageously used ; as, also, were infusions of Senega, Asclepias Syriaca, and bac. Juniper. This treatment, how- ever, is not recommended as adequate to the cure of pericarditis and carditis, but was found successful under the circumstances indicated. 130. The next most frequent pathological conditions whence carditis, esj ecially external carditis, may proceed, are pUurisy and pleuro- HEART—Inflammations of—Diagnosis, etc. 227 pncumony. The former disease may occur in consequence of the extension of the latter, or they may both appear almost simultaneously. I have even seen pericarditis give rise to, or followed by pleuritis. Inflammations of the heart, thus associated, are most commonly caused by some one of the numerous modes in which cold is applied to the surface—or, rather, in which the animal caloric is carried off—when the body is perspiring, especially after exertion or fatigue, and in the rheumatic diathesis. Gout is also sometimes a cause of carditis, and, I think, of the internal form of the disease, in preference to pericarditis. Internal carditis occasionally appears at an advanced stage of, or during convalescence from either of the eruptive fevers. It, as well as other forms of the disease, may also follow' other fevers, and the complaints mentioned above (§ 20). 131. v. The Diagnosis of Inflammations of the Heart may be inferred from the description I have given of the symptoms attending each of the varieties; but as these varieties are often associated with each other, or in some measure pass into one another, as the inflammatory ac- tion predominates more or less in one of the constitfient tissues of the organ, so the symp- toms will vary in different cases, and even in different periods of the same case. Attention, however, to the following circumstances, and groups of morbid phenomena, will generally enable the practitioner to arrive at a tolerably just conclusion as to the nature of the disease: 1st. The situation of the pain, in the more acute cases, and the tenderness, soreness, or pain on pressure felt in the left and upper part of the epigastrium, and in the left anterior in- tercostal spaces ; 2d. The increase of pain on stretching upward or backward, and the inabil- ity to lie on the left side; 3d. The frequent extension of pain to the left axilla, shoulder, or arm, and the occasional numbness of the latter; 4th. The greatness of the anxiety in proportion to the cough ; the anxious, haggard, or peculiar expression of countenance ; and the bloated or livid appearance of the face at a more advanced stage ; 5th. The state of the pulse at the wrist examined in connexion with the actions and impulse of the heart; the great frequency and irregularity of the latter, and the smallness, weakness, &c., of the former; 6th. The palpitations and tendency to syncope, or the alternation of these symptoms, and their connexion with pain, anxiety, dyspnoea, rest- lessness, or jactitation ; 7th. The signs on percussion and auscultation, especially the single bellows or blowing sound, with all its mod- ifications ; and the double friction, rubbing and creaking sounds : the former having reference to changes within the heart, the latter to alter- ations within the pericardium. 132 vi. The Complications of Inflammations of the Heart have been already noticed in gen- eral terms (<) 32). Inflammation of the internal membrane, whether acute, sub-acute, or chronic, is often associated with, or gives rise to, peri- carditis, at an early period of its progress ; but this latter is much more frequently complicated with, or occasions the former. Signs of endo- carditis are more commonly and more early detected in the course of pericarditis, than those of pericarditis are in the course of endo- carditis ; and both may be farther associated with inflammation of the cellular tissue or substance of the heart, or true carditis, in vari- ous degrees, or to a greater or less extent, as respects the different compartments of the or- gan. A. Internal carditis is much more com- monly observed in a complicated than in a simple state, especially when it is at all ad- vanced. It presents itself in connexion with the following diseases, and probably in a ratio of frequency approaching the order in which I am about to enumerate them : 1st. With peri- carditis and articular rheumatism; 2d. With pericarditis only ; 3d. With rheumatism only ; 4th. With pneumonia, pertussis, and pleuritis; 5th. With inflammation of the blood-vessels, especially phlebitis ; 6th. With eruptive or adynamic fevers; 7th. With purulent collec- tions or caries in distant parts. Internal car- ditis, when associated with rheumatism or with pulmonary or pleuritic diseases, is generally also connected with pericarditis ; but when it supervenes in the course of phlebitis, or of fe- ver, or from some cause which contaminates the circulating fluids, then it is generally un- connected with pericarditis, although the sub- stance of the heart may be more or less impli- cated, of even softened. 133. B. Pericarditis is also much more fre- quently met, even in its early stages, in a com- plicated than in a simple form—generally in connexion, 1st. With internal carditis, either acute or chronic ; 2d. With articular rheuma- tism ; 3d. With both internal carditis and rheu- matism, this being oftenest observed; 4th. With pleuritis, either pulmonary, diaphragm- atic, or costal; 5th. With pleuro-pneumony; 6th. With inflammation of the diaphragm or mediastinum; 7th. With true carditis ; 8th. With peritonitis ; 9th. With inflammation of some one of the abdominal viscera ; and, 10th. With eruptive fevers. Two or more even of these complications may exist in the same case, especially internal and external carditis, pleuritis, and articular rheumatism ; pericardi- tis, diaphragmitis, and pneumonia, &c. A body was lately brought into the dissecting-room of the Middlesex Hospital medical school, in which the liver was found inflamed and en- larged. It had formed adhesions with the dia- phragm on one side, and with the adjoining viscera on the other. Between these viscera and the concave surface of the liver the adhe- sions formed a large sac containing a turbid serum. The pericardium and diaphragm were inflamed, as well as the pleura on both sides. The pericardium and pleural cavities contained much turbid, thick serum. When pericarditis is associated with peritonitis, or with inflam- mation of some of the abdominal viscera, the additional complication of pleuritis, especially diaphragmatic pleuritis of the same side, is not infrequent. Bouili.aud adduces an instance of splenitis, diaphragmatic pleuritis of the left side, and pericarditis in the same patient. The opinion of Corvisart, that acute pericar- ditis rarely or never exists without being coim plicated, in some period or other of its course, is very nearly if not altogether true.—C. Of the complication of true carditis little farther need be added. It can hardly exist without more or less inflammation of one or both surfaces of the heart; and in the few cases of it that have been observed, several were also eon 228 HEART—Inflammations of—Progress, etc.—Prognosis. nected with rheumatism, with pleuro-pneumo- ny, with eruptive and other fevers, with phle- bitis, and with purulent or sanious matters ab- sorbed into the circulation. 13d. vii. Of the Progress, Duration, and Ter- minations of Inflammations of the Heart.—A.— a. Internal carditis may be acute, sub-acute, or chronic, and all the intermediate degrees. The most acute form may. especially from the ef- fects of treatment, assume a mild and very chronic state ; and this latter state may acquire greater activity, and become much more severe or acute. This latter change is, however, less frequent than the former. Where an amelior- ation has taken place, a recurrence or exas- peration of the acute symptoms is very apt to occur. The most acute cases, M. Bouilraud observed, arose from sudden chills while the body was perspiring, chiefly in persons of the Iymphatico - sanguine temperament, and em- ployed in laborious occupations; hot stimula- ting liquors, taken with the view of recalling the perspiration to the surface, having assisted in developing the disease. When the less se- vere cases appear in connexion with rheuma- tism, as they often do, in one or other of the inodes above stated (§ 129), a stimulating treatment of the latter disease renders much more acute the cardiac affection. 135. b. The duration of endocarditis is most indefinite, and altogether dependant upon the severity of the disease, the habit of body, age, strength, and constitution of the patient, the nature of the complication, the mode of treat- ment, and the period of recourse to it. Acute endocarditis may terminate fatally in twTo or three days; and in this case death is caused chiefly by the formation of fibrinous concre- tions, or coagula, in the cavities of the heart. When complicated with pericarditis, or with pleuro-pneumony, its duration will generally accord with that observed in these diseases. The slighter or more chronic forms of internal carditis are of long duration, the more conceal- ed states being prolonged indefinitely, or even for years; and organic lesiohs, especially of the valves and orifices of the organ, are usually the result at more or less early periods of their course. The inflammatory action either sub- sides or entirely ceases, after having produced these lesions, or it still continues in an obscure form. In the former case, especially when the amelioration proceeds from judicious treatment and regimen, the disease may remain, even for years, either stationary or more or less miti- gated ; but, in the latter, it generally advances with varying degrees of rapidity, until the func- tions of the organ and of the adjoining viscera are more or less impeded, or altogether inter- rupted ; or until fatal congestions take place in vital parts, or dangerous effusions of blood or of serum supervene in important organs, or from mucous or serous surfaces. 136. B.—a. The progress and duration of per- icarditis also vary with the causes which occa- sion the attack, with the age, temperament, and habit of body of the patient, and with the morbid connexions and treatment of the dis- ease. The most acute form may terminate fa- tally with great rapidity. M. Andral records a case which was fatal in twenty-seven hours. The celebrated Mirabeau was carried off by it so ranidly as to lead to the suspicion of bis liav- ing been poisoned: he was only improperly treated, although in the usual manner at that time in France. Such violent cases are gener- ally complicated, either with internal carditis, or with pleuritis, diaphragmitis, &c.; or with two, or even more, of these inflammations (<$ 133). The more moderate or favourable cases, however, generally terminate about the seventh or ninth day, or between the seventh and four teenth. But there are exceptions to this. The slighter and more chronic grades of pericarditis may continue for some months ; and the conse- quences, particularly adhesions, connecting the pericardium, partially or generally, to the sur- face of the heart, may remain much longer, 01 for years ; and, in some cases, especially when these lesions are slight, without materially dis- turbing the health. These adhesions are fre- quently attended by increased redness of the membrane, and by a little turbid serum, unless when they have obliterated all remains of the cavity. Bertin, Elliotson, and Bouillaud be- lieve that they do not occasion, even when gen- eral, any inconvenience beyond what proceeds from other coexistent lesions. But this is too favourable a view. They assist in developing, if they be not already associated witii, still more serious alterations of the heart ; and these latter frequently occasion other changes, either in collatitious or remote organs, more especially serous or sanguineous effusions ; and thereby greatly abridge the period of existence. 137. viii. The Prognosis of Inflammation of the Heart ought to be given with caution, gen- erally with reservations, even when the most favourable circumstances are present.—A. In endocarditis in its most severe states there is always more or less danger ; and the danger becomes extreme when the anxiety is very great, when the pulse is very frequent and ir- regular, and when swoonings or cold perspira- tions supervene. The slighter or more chronic states of the disease might be amenable to treatment, if it were possible to ascertain their presence before they produce lesions which are but little under the control of medicine. But where these exist in a manifest degree, the prognosis becomes unfavourable in proportion as they oppose the circulation through the com- partments of the heart; death being the ulti- mate result, although it may be long deferred, and various intermediate changes may occur. 138. B. Pericarditis is always a dangerous malady ; yet a considerable proportion of the cases will recover if their nature be early rec- ognised, and if an appropriate treatment be prescribed. M. Louis considers that perfect or partial recovery—partial, inasmuch as or- ganic change of some kind remains, particularly adhesions of the pericardium to the heart— occurs in five cases out of six. If, however, the disease, whether acute, sub-acute, or chron- ic, has given rise to effusion, an unfavourable opinion ought to be entertained of it, and espe- cially if the patient be far advanced in life, or of a cachectic habit of body. Whether the effusion be puriform, or sero-sanguineous, or pseudo-membranous, or sero-albuminous, the question is chiefly as to the length of time that may elapse before a fatal issue takes place; much depending upon the symptoms and signs indicative of the amount of effusion, upon the states of the pulse and of the respiration, and HEART—Inflammations of—Treatment. 229 upon the age and vital energies of the patient. When the effusion follows rapidly upon an acute attack, especially if there has been great fre- quency of pulse, and depressed constitutional powers, the danger becomes much more im- pending than when effusion takes place more slowly and to a less amount. If pericarditis be associated with endocarditis, as indicated by the bellows sound, or by any of its modifica- tions, or with pleuritis, pleuro-pneumony, or diaphragmitis, the danger is thereby increased very greatly—and increased in proportion to the intensity or extent of these inflammations. When the sub-acute or chronic disease has given rise, at more advanced periods, to adhe- sions, or to false membranes (§ 107), the actions of the heart and diaphragm may be much dis- ordered, and the functions of respiration, and of circulation in related or remote parts, greatly disturbed; but these consequences are not al- ways observed. Patients have lived for years without much disorder being complained of; although more frequently these functions, par- ticularly the latter, are more or less deranged, impeded circulation, or effusion into some cavi- ty or organ, sooner or later taking place. 139. C. Of the prognosis of true carditis it is unnecessary to speak. If it be presumed to exist, the opinion of the result should be unfa- vourable, inasmuch as a degree of inflammation of the substance of the heart so intense as to be recognisable generally induces the most se- rious changes either on one of the surfaces, or in the structure of the organ. If the symptoms of softening of the heart (<) 125) be such as to admit of recognition, with any degree of confi- dence, the prognosis is extremely unfavoura- ble, unless this lesion have taken place in fever, when a more favourable opinion may be enter- tained ; recovery sometimes taking place during an energetic recourse to tonics, chalybeates, change of air, &c. The other consequences of carditis need not be noticed at this place, as they rarely admit of recognition during the life of the patient. 140. ix. Treatment of Inflammations of the Heart.—The different forms of carditis require very nearly the same means of cure, the chief modifications consisting in the extent to which vascular depletions should be carried in the various circumstances that usually present, themselves, and in the choice of additional agents for averting the more serious changes which are apt to take place.—A. Blood-letting is necessary in the three varieties of carditis, and especially when either of them is associ- ated with pleuritis, or pleuro-pneumony ; but the utmost discrimination should be exercised as to its amount and repetitions. In all cases, it should be employed early in the disease, and the quantity of blood taken away ought to be in due relation to the violence of the attack, to the age and constitution of the patient, and to the effects produced. In general, vascular de- pletion may be carried farther in pericarditis than in internal carditis, and in the complicated, than in the simple disease. The practitioner ought not to be deterred from bleeding by the weakness and smallness, or irregularity of the pulse, or by the faintness complained of; nor induced to carry it too far by the palpitations and inordinate impulse of the heart, and by the cupped and buffed state of the blood. If car- ditis be connected with rheumatism, this state of the coagulum will continue, although deple- tion be carried to inanition. I have seen it greatest in the blood last taken, where I was confident that the depletion had been carried to a very dangerous length. In these cases, the disease is partly in the blood itself; there is a redundancy of fibrin and albumen, and an in- creased disposition to their coagulation. 141. B. Internal carditis, unless when asso- ciated with pericarditis, is not so much bene- fited by very large blood-lettings as may be supposed, although decided depletion, especial- ly early in the disease, is required. M. Bouil- laud thinks that this treatment should be car- ried farther in endocarditis than in pericarditis : but I differ from him in this; for the danger which he endeavours to avert by repeated ven- esections—and by them chiefly, if not solely— may be more certainly and safely prevented by the means about to be noticed, when prescribed after more moderate or less frequent depletions than he recommends. Besides, internal car- ditis sometimes occurs in cases where blood- letting had been previously, and even copiously practised ; as well as in others where it must be very cautiously and moderately resorted to. In all the forms of carditis, and particularly in pericarditis, it is often necessary to repeat the venaesection oftener than once; but as often, after one moderate or copious venaesection, cupping will be the best mode of abstracting blood. Indeed, a sufficient quantity may be taken away by this mode from the first, if the operation be properly performed. When the symptoms are severe, and the disease fully de- veloped, the depletion should be prompt, copi- ous, and repeated, according to circumstances ; but care ought to be taken not to defer the rep- etition of it until the recurring inflammation proceeds far : the least indication of unsubdued action, or the earliest sign of a return of the disease, requires that this means should be again cautiously resorted to, aided, however, by the remedies about to be noticed. In the circumstances under consideration, nervous ex- citement, or irritation, may be mistaken for un- subdued inflammatory action. This may be- come a dangerous, if not a fatal error; and acute observation and enlightened experience can alone guard against it. 142. C. After blood-letting, the rapid induc- tion of the mercurial action is of the greatest importance. With this intention, calomel should be given, every four or six hours, with opium and small doses of the potassio-tartrate of anti- mony, or James’s powder, or with colchicum or digitalis. These medicines act beneficially, not only by abating the morbid action of the heart, but also by inducing more rapidly the specific effects of the mercury. In the rheumatic forms of carditis, colchicum is extremely useful. It may be prescribed either with calomel, or with saline medicines, especially the alkaline carbon- ates. I agree with Dr. Roots in his recom- mendation that patients should be kept long under the mercurial influence, and that a local depletion should be resorted to whenever the symptoms become aggravated. When palpita- tions or nervous symptoms follow depletions and the production of the mercurial action, cam- phor (F. 373, 375, 555), or asafcetida (F. 905), or the decoction of senega (F. 74), in moderate do- 230 HEART—Inflammations of—Treatment. ses, will be found extremely useful in reducing the irregularity and the frequency of the heart’s action. If the irritability of the heart still con- tinue, these medicines may be given with digi- talis (F. 574), or with hyoscyamus (F. 460), or with opium (F. 493), or with the hydrochlorate or acetate of morphia (F. 537), or with the hy- drocyanic acid. This last has been strongly recommended by Dr. Elliotson in such cases ; and I have found it extremely useful. The ex- tract or tincture of hop, either alone or conjoin- ed with camphor, or with asafeetida, or with the compound galbanum pill, will also be found of service. Where it is still necessary to keep up the mercurial influence, the blue pill may be added to either of these. Anodyne plasters (F. 108, 117) may also be applied over the ster- num ; those containing camphor and extract of belladonna (F. 112, 113) will be found most beneficial. Anodyne liniments (F. 297, 313) will likewise be useful, particularly when pain or irritability continues after the mercurial action is induced. 143. D. In the more chronic or sub-acute states of inflammation of either of the constituent tis- sues of the heart, the means already recom- mended should be prescribed according to the severity and peculiarities of the case. If effu- sion have taken place into the pericardium, or if excrescences or other alterations about the valves or orifices be presumed to exist, exter- nal derivatives, by blisters, repeated or kept open ; by moxas, setons, or issues; by the tar- tarized antimonial ointment, or by croton oil, may be tried. These derivatives are most service- able when directed to a part at a little distance from the region of the heart. The praecordia will thus remain free for the application of ei- ther of the plasters, or of the liniments recom- mended above (§ 142), or of mercurial ointment with camphor. When, in these states of car- ditis, the action of the heart becomes inordinate, M. Bouillaud and some French physicians ad- vise eight or ten grains of powdered digitalis to be sprinkled over the blistered surface. I have had no experience of this mode of em- ploying digitalis. When, in addition to the ir- regular and excited action, there is more or less pain—a perverted state of sensibility fol- lowing the morbid vascular action—ointments or embrocations containing the narcotic alka- loids, especially veratria, dclphincea, or aconitine, may be then tried, in the manner advised by Dr. Turnbull. I have prescribed the first of these substances in two or three cases of this kind ; but, although it was not devoid of a cer- tain degree of efficacy, it wras not so beneficial as was anticipated from the praises bestowed upon it. In neuralgic affection of the heart, and in angina pectoris, the external use of these substances is sometimes productive of relief.* 144. E. When the inflammatory affections of the heart are connected with arthritic or acute rheumatism.—in these especially, but also in oth- er cases of carditis—a superabundance of fibrin or of albumen in the blood should be expected, and the disposition to its coagulation on the in- flamed surface ought to be prevented as much as possible. The only means which I know capable of fulfilling this intention are, mercu- rials, combined as above advised, particularly with colchicum or antimony ; the spirits of tur- pentine, given in drachm doses three times a day, until the kidneys become affected ; the bi- borate or the carbonate of soda or of the other alkalies ; and the iodide of potassium. These, after vascular depletion has been employed suf- fieiently, will often be of service, especially if they be judiciously combined with sedatives or narcotics, and aided by external derivatives; substances of an acid nature being, at the same time, avoided. Blood-letting will rarely, of it- self, remove altogether this or any other form of carditis, or change the morbid state of the blood, unless it be assisted by other means, more especially by those already mentioned. 145. F. When either of the forms of carditis supervenes in the course of eruptive or continu- ed fevers, after having a cautious recourse to general or local depletion, the milder prepara- tions of mercury in frequent doses, until the mouth becomes affected, the alkaline carbo- nates, spirits of turpentine internally, or exter- nally in the form of stupe or embrocation, mer- curial liniments or ointments with camphor, &c., and external derivatives, are most to be depended upon. The action of the kidneys should also be promoted by conjoining these with anodynes, nitre, or the sweet spirits of nitre, digitalis, camphor, opium, &c., according to the peculiarities of the case ; or by assidu- ously rubbing a stimulating liniment (F. 297, 311) over the loins. If the inflammation affect chiefly the internal membranes of the heart in the course of exanthematous or low fevers, or if it seem to have been induced by morbid or irritating matters in the circulation, vascular depletions must be employed with caution ; in the latter of these circumstances they will oft- en be more injurious than beneficial. The oth- er means, however, just recommended, partic- ularly camphor, nitre, the alkaline carbonates, and opium, should not be neglected. 146. G. Relapses of carditis, especially of per- icarditis, are very common, particularly when the patient relinquishes medical and moral treatment before the morbid condition is en- tirely removed and the functions of the organ entirely restored, or when the inflammation has left more or less alteration of structure, or when the mercurial influence has been imper- fect, of too short duration, or suddenly termi- nated. This influence should therefore be ex- erted fully, continued for some time—not less than two or three weeks—and allowed gradu- ally to subside. In cases of relapse, the large depletions, often required in a first attack, are frequently hazardous. Local bleedings and a moderate use of mercury are generally suffi- cient. Relapses are usually of a sub-acute or chronic form, and are often merely exacerba- tions of unsubdued disorder, or inflammatory * Dr. Turnbull prescribes veratria and delphintra in similar formula; and in the same doses. He directs half a drachm of the alkaloid to be dissolved in a drachm of sweet oil, and made into an ointment with an ounce of prepared lard ; or a scruple of the alkaloid to be dissolved in two ounces of rectified spirit, for an embrocation; or one grain in twelve pills, with extract of hyoscyamus, met with in children, most frequently afte/ i smallpox, scarlatina, pneumonia, hooping l \ cough, and measles ; but it occasionally, also, 233 234 HEART—Bibliography and References. appears as a primary-affection. It is often con- nected with articular rheumatism, or compli- cated with pneumonia or pertussis. I have ob- served it to attend, in its more acute states, the secondary fever of smallpox, but it more commonly appears during convalescence from these eruptive diseases. It is generally insid- ious in its attack and early progress. The pulse becomes quick, irritable, small, and irreg- ular. Cough, without expectoration, or in- crease of pain, is sometimes present. The sounds of the heart are extended, and the pul- sations are indistinct or tumultuous, or run into one another. Breathing is short or hur- ried, especially on any exertion. A heavy pain or aching, or soreness is felt under the sternum, and to the left side. The jugular veins often pulsate; the face is hnxious ; the hands become hot in the evening, and the child cannot preserve the horizontal posture in bed. Still it walks about, appears only much out of health, is short-breathed, irritable, and very delicate. On auscultation, a blowing or bel- lows sound is generally heard more or less dis- tinctly. At last hypertrophy, with dilatation of the heart, becomes manifest, and all its con- sequences. 151. B. Pericarditis is a much more common disease in children than is generally supposed. I have met with it often, both in its simple and complicated forms, and at all the epochs of childhood, from three or four years and up- ward. It is frequently associated with endo- carditis and true carditis, and with pleuritis or pleuro-pneumony. In the latter complications it often proceeds to a fatal issue, without hav- ing been recognised during life, it having been masked with the pulmonary affection. Most commonly, however, it is connected with acute arthritic rheumatism; and in this case there may exist also internal carditis, and diaphrag- matic or pulmonary pleuritis. 152. C. The Causes of pericarditis in chil- dren are nearly the same as in adults. I have observed the disease chiefly in children who live in low cellars, and in ground floors, and are much exposed to cold and humidity, es- pecially if they be imperfectly clothed and ill- fed. It is from these causes principally that articular rheumatism, with which the different forms of carditis are generally associated in children, also arises. Pericarditis is often oc- casioned by exanthematous fevers, and by in- flammations of the lungs or pleura ; or it fol- lows these diseases, most probably, in conse- quence of exposure to cold, or to vicissitudes of temperature during convalescence from them. It is extremely rare to meet with articular rheumatism in persons under puberty, and es- pecially in children, unconnected with external or internal carditis, or even with both. The Symptoms of pericarditis in children, and the structural lesions produced by it, as well as those consequent upon endocarditis, differ in no respect from the history given of them in adults. 153. D. The Treatment of inflammation of the heart in children should be strictly and ac- tively antiphlogistic at an early stage. Deci- ded local depletions, the exhibition of calomel or other mercurials with colchicum, or antimo- nials, or other anodynes; mild purgatives, ex- ternal derivatives, perfect repose, and a bland, low diet, with the emollient and alkaline drinks already prescribed, are the chief means of cure.* Bibliog. and Refer.—i. Carditis. — Rondelet, Me- thod. Curand. Morb., cap. x., p. 135. Lugd. Bat., 1575.— N. Andry, Remarques sur la la Purgation, &c., 12mo. Paris, 1700.—A. Pasta, Epist. de Cordis Polypo in Dubium Revocato. Berg., 1739.—Gloger, De Iuflam. Cor- dis Vera., 8vo. Jen®, 1758.—J. Pasta, De Sang, et Sang. Coucretionibus per Anat. indagatis, &c. Berg., 1780.— Borsieri, Insl.it. Med. Praot., t. iv., 0 254-279.—F. L. Hang, Selecta Diarii, &c. Annis 1783, 1785, et 1780, passim.— A. Portal, Cours d’Anat. Med., t. iii., p. 79.—Marcus, Ent- wurf einer Speciellen Thdrapie, b. ii., p. 235,—Kriegel- stein, in Hufeland's Journ. der Pract. Heiik., b. xix., st. iv., p. 119.—Schenck, in Ibid., b. xxvii., st. i., p. 08.—Gartner, De Polypo Coidis in Specie Infant. Wiirsb., 1811.—Merat, Diet, des Sciences Med., t. iv., p. 74.-7. F. Davis, Inqui- ry into the Symptoms and Treatment of Carditis, &o.,8vo. Bath, 1808.—Huber, De Carditide qu® epidemice grassata est inter Milites. An. 1814, in Obsid. Cast. Delf/.yl. Gron., 1819 —E. Stanley, Trans, of Med. and Chirurg. Soc. of Lund., vol. vii., p. 319.—James, in Ibid., vol. viii., p. 434.— Folchi, Riflessioni sulla Diagnosi della Carditide a Periear- ditide, 8vo. Rom®, 1829.—F. L. Roux, De Carditide Ex- udations ; cum Tab., 4to. Leips , 1820.—Author, in Lond. Med. Repos., vol. xv., p. 25, 1821.—7. F. Meckel, Fab. Anat. Path. Fasc., i. Leips., 1817.— Laennec, De 1’Auscul- tat. Mediate, ou Traite du Diagnostic des Mai. des Pou- mons et du Cceur, t. ii. Paris, 1819, 2d ed., 1820.—Glas, Ueher Her7.beutz.iind., 8vo. Wiir/.b., 1820,— HUdenbrand, Institut. Med. Pract., vol. iii., t) 571.—Broussais, Etamen des Doctrines Medicales Gen. adopt., &c., 2J ed., t. iv., p. 303.-—T Puchelt, De Carditide Infantum, &e., 8vo. Leips., 1821.—Recamier, in Revue M dicale. t. iv., 1824, p. 336.— Heim, in Rust’s Magaz. f. d. Gesammte Heiik., b. vi., lift. 3. p. 343 ; et in Journ. des Prog, des Scien. Mbd., t. xv., p. 227.—A. H. Krause, De Carditide Idiopathica Acuta Berk, 1826; et in Ibid., t. xv., p. 229; et m Archives Gin. de Med., 2d ser., t. v., p. 459.-7 B G. Barbier, Precis de Nosologie et de Therapeutique, 8vo. Paris, 1828, t. ii., p. 553-594.—Gairdner, in Trans, of Med. and Chirurg. Soc. of Edin., vol. ii., p. 237.—P. M. Latham, Lond. Med. Gaz., vol. iii., p. 118.—M. E. A. Naumann, llaudh. d. Medicin. Klinik., b. ii., p. i04.— Watson, in Lond. Med. Gaz.ette, vol. xvi., p. 56, 01, 164, 1835.—B. V. Cazaneuve, M6in. sur l’Endocardite Aigue, in Gazette Med. de Paris, 25th June, 1836. (See, also, the Bibi.iog. and Refer, to the other chapters.) ii. Pericarditis.—Zacutus Lusitanus, Med. Pr. Hist., t. i., 1. iv.. n. 41 ; et Prax. Admir , 1. iiobs. 138.—Salius Diversus, De Affect. Particul., cap. vi.—Bond, Sepulchre- turn, 1. ii., s. xi.. obs. 16 ; s. x., obs. 10, 18.—Riolanus, En- chirid. Anat. Pathol., 1. iii.,c. 4.—Boerhaave, in Sammluug Auzerles. Abhandl. Prakt. Aerzte, b. ix., p. 495, et seq. — Morgagni, De Caus. et Sed. Morb., Ep xxii., 10; Ep xxx., 7 ; Ep. xxiv., 2, et passim.—Pohl, Prog, de Pericardio Cor- di adh®rente ejusque Motum turbante. Leips., 1775.—iVe- bel, De Pericardio cum Corde Concrete. Giess , 1778.— Haller, Element. Phys., vol. i ,p. 285, et Add. ad Elementa Physiol., p. 128. -I). Haen, Rat. Med., t. xiv., p. 30.—Van Dceveren, Spec. Observ. Acad., cap. i., p. 74.— Sandifort Op. cit., 1. i., cap. ii., p. 43.—A. Monro, Prescript, of the * On referring- to my note-book for cases of pericarditis in children, I find that, in those from five to seven years of age, the following was the treatment most cormnoniy pre- scribed. All these cases were connected with articular rheumatism. After cupping or applying leeches over the sternum, according to the age and strength of the child, a powder, consisting of three grains of calomel and one of James’s powder, was directed to be taken three times a day, and continued till the gums were affected. This mix- ture was also pescribed, and the effects of both carefully observed : No. 252. R Mist. Camphor* fiij. ; Liq. Ammon. Acet. f j. ; Vini Antimonii Potassio-Tart. 3ss. ; Tinct. Sem. Col- chici ttlxxv.-xxx. ; Sirupi Tolutani 3j. M. Fiat Mist., cujus capiat Ooch. ij. minima, tertia vel quaria qufiquehorfi. Blisters were generally directed to the right side of the chest, with the precautions above enforced ($ 147); and where there appeared a tendency to effusion into the peri- cardium, the following was sometimes directed : No. 253. R Mist. Camphor®, Aq. Fceniculi, 55 Jjss. ; Liq. Ammoni* Acetatis §j. ; Potass® Acetatis 3ijss. ; Spirit. -Aether. Nit. 3j.; Tinct. Digitalis lllxxv. ; Tinct. Scill® 3ss. M. Fiat Mist., cujus capiat Coch. i., medium, quartis horis. If the internal surface of the heart seemed to be inflamed, after the remedies already noticed, the following was often employed : No. 254. Mist. Camphor® fivss. ; Potass* Nitratis 3ij. ; Sod® carbon, jj. (vel Sod® bi-boratis 3ss.) : Spirit. iEtheris Nit. 3jss. ; Tinct. Digitalis lllxx.-xxx.; Sirup! Papaveris 3j M. Fiat Mist., cujus capiat Coch. ij., minima, vel. j medium quater in die. HEART—Hypertrophy of—Description. 235 Bursae Mucosae, &c., p. 41.—Senac, De Corde, 1. iv., c. 2.— Stoerck, Ann. Med., vol. ii.. p. 232, 264.—Stoll, Rat. Med., pars ii.,''p. 385.— Watson, Phil. Trans., 1777, at 31.—Lieu- taud, Hist. Anat. Med., 1. ii., obs. 672, el seq —J. G. Wal- ter, in Nouv. Mein, de l’Acad. des Sciences 5 Berlin, 1785, t. iv., p. 57 ; Observ Anat., p. 63 ; et Mus. Anat., vol. i., p. 148-297.—Caldani, Mem. di Fisica della Soc. ltal. a Mode- na, t. xii., p. 2.—J. P. Frank, l)e Cur Horn. Morb., 1. ii., p. 173 —Biermayer, Mus. Anat. Pathol., No. 434 —Portal, Mem. sur. Plusieurs Malad.. t iv., p. i.; et Cours d’Anat. Med., t. iii., p. 24.— Prost, M6d. eclairee par POuverture des Corps, vol. i., p. 140.—Andral, M6m. de la Soc. Med. d’Emulation, t. ix., p. 380 — Tacheron, Recherches Anat. Path., t. iii., p. 226. Paris, 1825.—J. Abercrombie, Trans, of Med. Chirurg. Soc. of Edin., vol. i.—J. Frank, Rat. In- stil. Clin. Ticin..cap. ix., et Prax. Med. Univers. Pnecepta, par. ii., vol. ii., sect, ii., p. 120, et seq.—Muller De Con- cret. Morb. Cordis cum Pericard. Casibns aliquot illustrata, 8vo. Bon., 1825.—Rayer, in Archiv. Gen6r. de M6d., t. i., p. 521. —Tnulmouche. m Ibid., t. xviii., p. 593.—Louis, in Revue Med., t. i., p. 30, 1826 ; et MOm. et Recherches sur 1’Anat. Path., 8vo. Paris, 1826, p. 253.-7. P. Latham, Loud. Med. Gaz., vol. iii., p. 209.—Adams. Dub. IIosp. Hep., vol. iv., art. 19.—Bleuland, leones Anat. Pathol., 4to. Tab., 1, 2. Traj. ad Rh., 1826.—Brissault. Essai sur la Pericav- dite, consid. dans son Etat Aigu et ('hr., 8vo Strasb., 1826.—Stiebel, Monog. Cardit. et Pericardit. Acutte. &c., 4to. Franc, ad Mien., 1828.— R. Mayne, in Dublin Journ. of Med. Science, vol. vii., p. 255.—Seidlitz, in Hecker's An- nalen., b. ii., Heft. 2. fieri., 1835. — Hughes, in Guy’s Hosp. Reports, No. 1, p. 175.— Stroud, in Johnsons Med. Chirurg. Rev., No. 46, p. 411.—J. Watson, Med. Gaz., July 30. 1836, p. 701.—Roots, St. Thomas's IIosp. Reports, No. 4, June, 1836 ; and Med. Gaz., Nov. 12, 1836, p. 222.— R. W. Smith, in Dublin Journ. of Med. Science, vol. ix., p. 418. (See, also, Bibliog. and Refer, to Diseases of the Heart generally.) iii. Ulceration, Suppuration, Softening, Partial Aneurism, and Gangrene of the Heart.—Benivenius, Observ., cap. 42.—Schenck, Observ., &c., 1. ii., obs. 202- 207.—Columbus, De Re Anat., 1. xv., p. 489.—Bonet, Se- pulchret., 1. iv., sect. i„ obs. 2 ; sect, x., obs. 1 — Morand, in M6m de l’Acad des Sc. de Paris, 1732, p. 594.— G. Ga- leati, De Bonon. Scien. et Art. Instituto atque Acad. Com- ment., t. iv., p. 26, 1757.—Morgagni, Epist. xxv., 17-25; Ep. xvii., 5, 8.— Stoerck, Ann. Med., vol. ii., p.262.—Lieu- taud. Op. cit., vol. ii., obs. 510-543.—M. Akenside, in Phil- os. Trans., vol. liii., p. 353.—Cruikshanks, The Anat. of the Absorb. Vessels, &c. Loud., 1786. — Sandifort, Observ. Anat. Path , 1. iv., sect, x., p. 109 —Penada, Saggi di Pa- dova, t. iii., par. ii., p. 59.— Walter, Nouv. M6m. de l’Acad. des Scien. h Berlin, 1785.— Vering, in Den Abhandl. der Josephsakad., vol. ii., p. 345.—lohnstone, Mem. of Med. Soc. of Bond., vol. i., and in Med. Essays. Evesham. 1795. —Desault, Cours de Clinique Externe, p. 117. Paris, 1804. —M. Baillie, Morbid Anat., &c., ed. 5th, p. 5.—Corvisart, Op. cit., obs. 42, et p. 253.—Biermayer, Mus. Anat. Path., No. 374.—Portal, Op. cit., t. iii., p. 79, et passim ; et Mem. sur Plusieurs Malad., t. iv., p. 17-62.—Testa, Op. cit., p. 233-245.—Gaulay, M6m. sur la Gangrene du Cceur, 8vo. Paris, 1807.—Bagata, in Brera's Giorn. di Med. Practica, t. iii.. par. ix.—G. Jager, in Harles’s Rhein. Jahrb., b. ii., p. 146.—Josephi, Neuen Archiv. fur Aerzte, b. iii., n. 4.— Fitzpatrick, in Bond. Med. Repos., vol. xvii., p. 295.—Au- thor, in Ibid., vol. xvii., p. 298.—Laennec, Op. cit., t. ii., p. 286, 305.—H. Cloquet, Bullet, de la Faculty de Med. de Paris, 1822, p. 219.—J. Kennedy, in Lond. Med. Repos., vol. xxi., p. 124.— Scoutetten, in Journ. Universelle des Scien. Med., t. xxiii., p. 236.—Myruejouls, Journ. du Pro- gres des Sc. Med., &c., t. xvii., p. 253.—Rullier et Andral, in Revue Medicale, t. ii., 1824, p. 306.—Kreysig, Op cit., b. iii., p. 165.—Neubert, in Hufeland's Journ., &c., Nov., 1823, p. 91.—Berard, Diss. sur quelques Points d'Anat. Path, et de Path. Paris, 1826; et Archives Gin. de M6d., t. x., p. 364.—Brett, in Ibid., t. xiii., p. 110; et Repert. Gin. d’Anat. et de Physiol., 1st Trim., 4to, 1827 ( 7'he case of Talma).—R. Adams, in Dublin Hospital Reports, vol. iv., p. 353.—Breschet, in Rip. Gin. d’Anat. et de Phys., citing the heart, and, at the same time, loading 238 HEART—Hypertrophy op—Complications, etc. it w:th a rich blood ; and the abuse of spirit- uous and intoxicating liquors, are often more or less directly concerned in the production of this lesion, although other causes frequently co-operate with them.—b. The causes which produce reaction by obstructing the circulation are chiefly mechanical, as the alterations in the orifices and valves already described (§ 66, 67); contractions, dilatations, and aneurisms at the commencement of the arterial trunks, espe- cially the aorta ; congestion of the lungs, or in- terrupted circulation through them, from dis- eases of their substance, or of the bronchial tubes, or of the pleura, or from emphysema, and from the accumulation of fluids in the pleu- ral cavities ; the frequent recurrence of spas- modic and convulsive affections, particularly asthma and hooping-cough, and whatever im- pedes the circulation in the aorta, vena cava, and principal vessels immediately connected with them, as wearing strait corsets, the gravid uterus, and large tumours. Under this head, also, may be mentioned insufficiency of auric- ulo-ventricular valves, either from atrophy or contraction of them, or from dilatation of the orifices. Contractions of these orifices, or ob- structions caused by adhesions of, or excres- cences upon the valves, will occasion hyper- trophy not only of the auricles, but also of the ventricles—of the auricles, from the obstruction at their outlets, and the consequent distention of their cavities ; of the ventricles, from the augmented force of dilatation required to fill them ; the concentric form of hypertrophy de- pending chiefly upon this latter cause. Of the other causes of hypertrophy it is unnecessary to make particular mention, as they are of less frequent occurrence, and do not differ materi- ally from those already noticed in connexion with excited action (<) 19,45) and inflammations (i) 126) of the heart. 166. It may be stated, in general terms, that the same causes and lesions of structure which occasion thickening of the parietes of a com- partment, or thickening with dilatation, will pro- duce in other persons simple dilatation, or dila- tation with attenuation of the panel es. The al- terations of the thickness of the walls, as well as of the capacities of the cavities, seem to de- pend very much upon the states of vital energy and resistance, and of nutrition. In young and robust persons thickening of the walls, with or without dilatation of the cavities, of one or more of the compartments, will most likely occur; whereas in the delicate, the lymphatic, or leu- cophlegmatic, in the ill-fed, and in those either advanced in life, or exhausted by previous dis- ease, dilatation, or dilatation with attenuation of the parietes, of one or more of the chambers, will most probably take place ; but much, also, will depend upon the nature of the obstruction or cause out of which the hypertrophy or dila- tation arises. Where the obstruction to be overcome is relatively greater than the power of the organ to overcome it, dilatation of the cavity more frequently takes place than thick- ening of the walls of that cavity; and where the obstruction is before the hypertrophied cav- ity, more or less dilatation is usually observed, the degree of thickening or of attenuation of the parietes depending upon the states of vital power and of nutrition, as just stated. Where, however, the obstruction is behind the hyper- trophied compartment, thickening of its walls, ! witli or without diminution of its cavity, is the common attendant. When the cause of hyper- trophy is regurgitation of blood into the cavity, owing to insufficiency of the valves at the out- let, there is generally more or less dilatation; but there may be either thickening or attenua- tion of the walls, according to the states of vi- tal energy and nutrition. Where there is actu- al thickening of the muscular substance, the coronary arteries are found proportionally en- larged, indicating a greater activity of the vital and nutritive actions of the organ. Dr. Hope considers that when hypertrophy is connected with an obstruction behind it, the alteration is owing to the retarded circulation in the veins, which is propagated through the capillaries to the arterial system, and ultimately to the heart. He thus explains the occurrence of hypertro- phy of the left ventricle when the mitral orifice is contracted. But the active efforts made to fill the ventricle seem to me to be the cause of this association of hypertrophy (§ 165), for it is often observed where the extreme venous con- gestions, to which Dr Hope’s mode of accent- ing for it would necessarily give rise, are n®t met with.* 167. C. The Complications of Hypertrophy of the Heart are principally those morbid condi- tions of which the enlargement is a frequent consequence, particularly those just mentioned (§ 165), and chronic inflammations of the inter- nal and external surfaces of the organ. These latter lesions, as well as disease of the orifices and valves, not only give rise to hypertrophy, but also often complicate it during its future course. When inflammatory irritation is in- duced in the internal membrane of the cavities, excited action of the muscular structure is the usual consequence ; and when this is long kept up, hypertrophy will follow to a greater or less extent. When pericarditis is followed by ad- hesions or by false membranes, thickening of the walls of the compartments will also some- times result ; the increased action required, in this encumbered state of the organ, in order to keep up the circulation, developing and aug- menting the muscular structure of one or more of the compartments. In these cases, addi- tional lesions are often observed, particularly of the valves and orifices ; and adhesions of the pericardium to the pleura, or other alterations of the collatitious viscera, frequently also exist. 168. Nothing is so common as to find one or more of the above changes of the internal and external surfaces of the heart complicated with hypertrophy. M. Bouillaud remarks that when inflammation of the external, and especially of the internal sero-fibrous tissue of the organ has become chronic, hypertrophy of the muscular structure is sure to follow. Of thirty-three cases which he records of pericarditis and en- docarditis. that terminated in thickening and * [We are not, as yet, prepared to admit, with Mr. Cop- land, the doctrine of active expansion of the ventricles, es- pecially as a cause of hypertrophy. It seems to us much more rational to attribute the enlargement to the excitement and increased action of the whole heart, caused by disten- tion of its other cavities, thus leading to increased growth of the ventricle also. It hardly seems possible that the same fibres which encircle both ventricles can be excited in one and not in the other; or that the left ventricle, which is naturally the strongest and most aot'w. should not be exci- ted by sympathy or continuity of irritation, and this leads to a diminution of its cavity by the thickening of its walls.] HEART—Hypertrophy of—its Influence. induration, there was not one in which there was not also hypertrophy. Indeed, this latter lesion may be» associated with any of the alter- ations to which the pericardium and heart are liable, or even with several of them; and it may be, moreover, complicated with various changes of the arterial system, especially car - tilaginous, osseous, and albuminous produc- tions (see arts. Apoplexy, <) 96, and Arteries, § 38, et seq.), aneurisms, &c.; or with conges- tions of related organs, particularly of the lungs, the brain, and the liver; or with effu- sion of serum into shut cavities, or into the cellular tissue ; or with haemorrhages from mu- cous surfaces, or into the substance of the lar- ger organs, as the brains, lungs, liver, &c. [The combinations of hypertrophy and dila- tation are of frequent occurrence in proportion as they are higher in the following scale : 1. Hypertrophy, with dilatation of the left ventricle, and a less degree of the same in the right. 2. Simple dilatation of both ventricles. 3. Simple hypertrophy of the left. 4. Dilatation, with alteration of the left. 5. Hypertrophy, with contraction of the left. 6. Hypertrophy, with contraction of the right. Of the Auricles. 1. Distention, particularly of the right, from congestion during the period of dissolution 2. Dilatation, with hypertrophy. 3. Simple hypertrophy. 4. Hypertrophy, with contraction, which is almost unknown.] 169. D. Of the Influence of Hypertrophy, fc., of the Heart upon Cerebral and Pulmonary Haem- orrhage.—It is unnecessary to add much to the remarks already offered on this subject in the articles Apoplexy (§ 96) and Haemorrhage (<) 30, 107, 115); but certain points connected with it require to be considered at this place.— a. Cerebral hcemorrhage is probably a more fre- quent consequence of cardiac disease than pul- monary haemorrhage, but facts are wanting to determine to what extent it is so. That it is more common is shown by Bertin and Bouil- laud ; and it may partly be accounted for by the fact of disease of the pulmonary arteries being much less common than alterations of the cerebral vessels. That an intimate con- nexion often exists between the occurrence of apoplexy and palsy, and antecedent disease of the heart, is now fully established, although doubts are still entertained by some as to the nature of the connexion. As long ago as 1822 and 1823,1 discussed this question {Lond. Med. Repos , vol. xviii., p. 149, and xix., p. 17), and in the article Apoplexy (published Sept., 1832) the results of my inquiries were again stated. The occasional dependance of cerebral haemor- rhage on disease of the heart was first remark- ed by Baglivi, who observed it in the case of Malpighi, who died apoplectic after palpita- tions caused by structural change of the heart. It was only incidentally mentioned by Mor- gagni and Lieutaud, and not insisted on in the relation of cause or effect until M. Richerand treated of it in his account of the case of Ca- banis, in whom this complication was found. Portal, Testa, and Sprengel soon afterward expressed the same opinions as Richerand ; and Rossi met with this association of disease in the case of the crown prince of Sweden. The frequent connexion between cerebral haem- orrhage and disease of the heart has been shown in this country by Hutchinson, Aber- crombie, Craigie, Johnson, Hope, Watson, and myself; and in France by Bricheteau, Lal- lemand, Bertin, Cruveilhier, Brouissais, An- dral, and Bouillaud ; and the effect upon the brain has been too exclusively limited to haem- orrhage, and too generally imputed to hyper- trophy of the left ventricle. There is, how- ever, every reason to believe that softening of the brain, congestions of the veins and sinu- ses, and serous effusions into the ventricles or between the membranes, occasionally, also, proceed from cardiac disease, especially when it causes obstructed circulation through the right side of the heart; and that cerebral haem- orrhage may sometimes depend upon the le- sions in this situation, as suggested in the articles referred to. 170. M. Bricheteau has very recently in- vestigated this subject at some length ; but he has insisted chiefly upon the influence of hyper- trophy of the left ventricle in the production of haemorrhage in the brain. He has, howev- er, remarked that other changes within the head besides this may result from this cause, especially determination of blood to the brain, mental disorder, serous effusion, brain fevers, &c. He observes that when hypertrophy is accompanied with other lesions of the heart, particularly with such as impede the free egress of the blood from the left ventricle, as disease of the aortic orifice, the symptoms of cerebral disorder are then much less conspicuous ; and that dyspnoea, tendency to syncope, and drop- sical effusions are more marked. M. Bouil- laud found, out of fifty-four cases of hypertro- phy, in some of which the right ventricle only was affected, and the left one not at all, or very little so, that there were eleven with cer- ebral disease, six with apoplexy, and five with softening of the brain. In five of these eleven the cerebral arteries were ossified or cretace- ous at one or more points. In six of these cases the hypertrophy of the left ventricle was eccentric, in three it was concentric, and in two simple. 171. Dr. Watson (Lond. Med. Gaz., April 6, 1835) has made some very judicious remarks upon this subject; but in all the material points, particularly in the explanation of the connexion between diseases of the heart and brain, he has been anticipated by the observations I have offered, both in the papers referred to above, and in the article Apoplexy (<) 96), where I have succinctly given the results of my own investigations. The views there entertained, as Dr. J. Johnson has done me the justice of stating {Med,. Chirurg. Review, April, 1836, p. 512), in an able inquiry into this subject, are fully confirmed by his own experience, and by the more recently published researches of MM. Bouillaud, Bricheteau, and others. As the paragraph referred to in the article Apoplexy has so fully and completely anticipated the re- sults at which subsequent writers on this sub- ject have arrived, I have only to request the reader to turn to it, especially as I have no- thing farther to add to it.* 239 * [Dr. Hope proves, from the statistics of St. Mary Le Bone Infirmary, that in fatal cases of apoplexy, hypertrophy of the left ventricle of the heart exists in more than three fourths of the cases.] 240 HEART—Hypertrophy of—Symptoms and Diagnosis. 172. h. The influence of cardiac disease on pul- monary hcemorrhage has also been adverted to in the article Hemorrhage (<) 30, 115). M. Bouillaud found this form of haemorrhage less frequently to arise from lesions of the heart than that just noticed. He has adduced only three instances in which it seemed to depend upon hypertrophy of the right ventricle. And M. Bertin, while he admits the occasional connexion between pulmonary apoplexy and hypertrophy in this situation, considers it not common. A more intimate and more frequent dependance of the former on the latter has re- cently been contended for by M. Bricheteau. A different view of the connexion between pul- monary haemorrhage and cardiac disease has been lately entertained by Dr. Wilson and Dr. Watson, particularly the latter. The depend- ance of dropsical effusions within the chest upon organic lesions in the left side of the heart has been long known ; but the connexion between haemorrhage from the respiratory sur- faces and these lesions had been entirely over- looked. Mr. A. Burns seems to have been the first who took a judicious view of the subject. He observes that the pulmonic vessels, by the congestion occasioned by cardiac disease, and the continued vis d ter go, are ruptured, the blood being forced into the air-cells, or into the cel- lular structure of the lungs, until this organ appears like liver, or sinks in water. Dr. Wat- son has very fully shown that the pulmonary haemorrhage rarely depends upon hypertrophy of the right ventricle, but chiefly upon narrow- ing of the left auriculo-ventricular orifice, or rigidity of the mitral valve. Indeed, hypertro- phy of the right ventricle seldom exists with- out disease at the origin of the pulmonary artery sufficient to counteract the increased action of the ventricle. It is, therefore, the obstructed return of blood from the lungs, ow- ing either to narrowing or to dilatation of the left auriculo-ventricular orifice, or to insuffi- ciency of the mitral valve, and but rarely the increased impetus occasioned by the hypertro- phied right ventricle, that causes any of the forms of pulmonary Hemorrhage (§ 107, 115). M. Bertin admits the influence of narrowing of the left auriculo-ventricular orifice in the production of haemorrhage into the lungs, and considers the haemorrhage thus caused to be of a more gradual and passive kind than that produced by hypertrophy of the right ventricle. Dr. Townsend (Cyclop. of Tract. Med., vol. i., p. 138) states that, of twenty-two cases of pul- monary apoplexy examined by him, more than two thirds occurred in persons whose hearts were diseased, and in two only of these was the harmorrhage connected with tubercles; but he has neglected to assign the particular lesions of the heart observed in these cases. The very frequent dependance of pulmonary apo- plexy on cardiac disease has been insisted upon, also, by Chomel, Andral, Cruveilhier, Bouil- latjd, Hope, and others, but with a great want of precision as respects the seat and nature of the primary malady. That cases sometimes occur in which hypertrophy of the right ven- tricle is associated with narrowing of the left auriculo-ventricular orifice in tire production of pulmonary haemorrhage is shown by an inter- esting case recorded by Dr. Law (Cyclop. of Tract. Med., vol. ii., p. 403). A young lady had repeated haemoptysis, with palpitations, which were more frequent and profuse until death. Both lungs were found engorged with blood, &c. The right ventricle was hypertrophied and dilated ; the left auricle dilated and thick- ened ; the left auriculo-ventricular orifice con- tracted so as hardly to admit a quill; and the left ventricle contracted. The pulmonary ar- tery was dilated and thickened ; the aorta was smaller than natural. In this case, the con- gestion of the lungs, consequent upon obstruct- ed circulation through the left side of the heart, had not only caused haemorrhage, but also hy- pertrophy of the right ventricle. 173. It is, moreover, very probable, as I have stated in the article Hemorrhage (<) 115), that when the more powerful moral emotions are productive of haemoptysis, this effect is owing as often to their impeding the circulation through the left side of the heart as to their exciting the action of the right ventricle ; and that, when the same emotions occasion apo- plexy, palsy, or any other cerebral disease, they act as frequently by interrupting the cur- rent through the right side, as by inducing in- ordinate action, or hypertrophy, of the left ven- tricle. It is, however, to be presumed that the opposite passions produce opposite effects upon the heart, and that, while terror, fear, grief, anxiety, and other depressing passions impede the circulation through this organ, and cause congestion of its cavities, thereby favouring the occurrence of haemorrhagic or serous effu- sions either in the head or in the chest, the exciting passions, as anger, desire, revenge, &c., accelerate and increase the force of the circulation, by exciting the actions of the ven- tricles. From this it will appear that the same class of emotions may induce effusion into either the brain or lungs, according to the pre- disposition or previous state, functional or structural, of these organs, and to the side of the heart chiefly affected by them; and that, while the depressing passions act by interrupt- ing the circulation through the heart, and, con- sequently, by impeding the return of blood from these parts, the exciting emotions operate by increasing the frequency and power of the ven- tricular contractions, and by propelling the blood with greater force into these organs. 174. E. Symptoms ami Diagnosis of Hypertro- phy of the Heart. — a. The local signs consist chiefly of a permanent increase of the force of the heart’s contractions, of the sphere within which they are perceived, and of the double sounds attending them. These signs—the per- manently increased force, extent, and sounds of the heart’s actions—are always present; but they vary considerably, and are attended by other phenomena—commonly by an increased extent of dulness on percussion in the cardiac region, and often by some degree of prominence of this part, particularly in young persons. Where hypertrophy is considerable, the move- ments of the heart are visible in a large extent of the left side of the chest and towards the pit of the stomach, and often through the clothes. The apex of the heart is felt more to the left, and generally at the sixth, seventh, or eighth intercostal space, while the base corresponds with the third, or even the second intercostal space. On applying the hand upon the cardiac region, a stronger, a more extensive, and long- HEART—Hypertrophy of—Symptoms and Diagnosis. 241 er enduring impulse or shock is felt, consisting not only in the striking of the apex, but also in the pushing of the ventricle against the ribs, as the latter swells in each contraction. In these cases, the head, or stethoscope, on auscultation, is raised by the force of the impulse. The first sound is generally prolonged and duller than nat- ural, and the more so the greater the hypertro- phy or thickening of the ventricle. But when the thickening is moderate, and the cavity is somewhat dilated, the sounds are stronger and clearer than natural, and heard over a more extended sphere. When the thickening is very great, and the cavity diminished, the sounds become nearly or altogether imperceptible. In simple hypertrophy, the sounds are not usually otherwise morbid ; but when there is disease of the valves, then the sounds characteristic of this disease are heard. 175. In proportion as dilatation is great, the impulse is slighter, brisker, and lower than nat- ural ; and the first sound is louder, clearer, and of shorter duration. The greater the thicken- ing of the walls, the duller are the sounds, com- pared with the force of the shock or impulse ; and the greater the dilatation of the ventricular cavities and attenuation of their parietes, the clearer, louder, and shorter are the sounds, in relation to the force of the impulse ; which, in cases of great dilatation, is much less than nat- ural. Where the enlargement consists chiefly of dilatation, as well as where thickening pre- dominates, the sounds will be otherwise alter- ed, according to associated disease of the valves or orifices of the organ. In hypertrophy with slight dilatation, as Dr. Williams remarks, there is a strong heaving impulse, with an ab- rupt collapse or back stroke, and a prolonged, diffused, but not clear sound. In dilatation with slight hypertrophy, the sound is loud, commen- cing abruptly, and heard over a large space; while the impulse is unnaturally great only when the heart is excited, as in palpitation, when it produces hard, abrupt, and circumscri- bed blows, without heaving. The palpitations attending hypertrophy will be violent and heav- ing when the thickening predominates; but noi- sy, fluttering, and accompanied with a feeling of faintness when dilatation is the chief lesion. 176. Cardiac hypertrophy is seldom accom- panied with pain; but when it is considerable, or very great, a sensation of uneasiness, of weight, or of anxiety is often felt in the prae- cordia or at the epigastrium. Dulness on per- cussion is in relation to the extent of hypertro- phy and dilatation, and is observed to extend downward and towards the left side, owing to the explanations given above (<$ 160), unless when the heart is confined by adhesions. Prom- inence of the cardiac region is not uncommon when the hypertrophy is great. Bouillaud has directed particular attention to this sign ; 'but it has been incidentally noticed by others. 177. b. The general or rational symptoms vary much with the form of hypertrophy, and with the other lesions of the heart with which this is associated. The pulse, in simple and eccen- tric hypertrophy, is generally strong, large, full, vibrating, and free; but it is small or oppressed in the concentric variety. When there is also disease of the left orifices and valves, the pulse is weak, small, or otherwise affected. Where the hypertrophy is simple, the face and general surface are animated, the animal heat is devel- oped, and a tendency to active haemorrhage sometimes observed. The venous circulation is also unimpeded, and neither sanguineous nor serous congestions or effusions take place. But when the hypertrophy is complicated with le- sions, interrupting the passage of the blood through the heart, the pulse is weak, small, and irregular; congestions or effusions of blood, and dropsical infiltrations and collections, being common results. Respiration is but little dis- turbed as long as the hypertrophy is moderate and simple. But when it is excessive, it then encroaches on the lungs, and causes dyspnoea ; and, as this state is usually a consequence of impeded passage of blood in the heart, causing congestion of the lungs or serous infiltration of their substance, the dyspnoea is principally owing to these circumstances. Indeed, the majority of sympathetic phenomena observed in connexion with hypertrophy are no farther dependant upon this lesion than that they re- sult from the same alterations as it. Cough is seldom present in the early stages, especially when the hypertrophy is confined to the left ventricle ; but when sanguineous or serous congestion supervenes in the lungs, this symp- tom is commonly observed. (Edema occurs when the hypertrophy is very considerable, and is attended by dilatation. It often appears first in the eyelids and face ; and, as the obstruc- tion to the circulation through the heart increas- es, the serous infiltration augments, and be- comes more general. In simple hypertrophy, the countenance retains its complexion, or is more than usually florid ; but when there is dil- atation, and in proportion as the enlargement is complicated with obstructed circulation, and as the obstruction extends to the lungs, the lips, cheeks, and even the nose present more and more of a purplish tint, and the general surface assumes a sallow and cachectic hue. Apoplec- tic, paralytic, or convulsive attacks, and pulmona- ry hcemorrhage, have been already noticed as consequences of hypertrophy, particularly of its more complicated states. Epistaxis some- times occurs, and prevents or defers the occur- rence of either of these, or of some other se- rious symptomatic malady. 178. c. The signs and symptoms of Hypertro- phy of the individual compartments require some notice, those just mentioned having reference to this change of the ventricles generally. The physical signs of hypertrophy of the auricles cannot be stated with any precision in our pres- ent knowledge ; but, as this change is usually associated with hypertrophy of the ventricles, the distinction between them is not material. Hypertrophy of the left ventricle may be recog- nised by the following signs : The impulse of the heart is greatest under the cartilages of the fifth, sixth, seventh, and eighth left ribs ; and in this situation there is the most dulness on percussion, and prominence of the thorax. The pulse, if there is no obstruction at the aortic or- ifice, is strong, tense, full, vibrating, or hard ; the face is flushed, and the patient experiences throbbing headaches, giddiness, and sometimes even epistaxis. Hypertrophy of the right ventri- cle is attended by a palpitation, or an impulse, which is strongest under the lower part of the sternum, where, also, is the greatest dulness on percussion, especially if this lesion be not 242 HEART—Hypertrophy of—Terminations—Prognosis—Treatment. associated with hypertrophy of the left ventri- cle ; and the pulse possesses neither the force nor tension observed in this latter alteration. There are commonly more or less dyspnoea, short breathing, cough, and, subsequently, ex- pectoration and lividity of the face; but, as I have shown above (§ 172), these symptoms are still greater, and more frequently attended by haemoptysis when the lungs are congested in consequence of interrupted circulation through the left side of the heart, with which, however, this form of hypertrophy is occasionally associ- ated. Turgescence, pulsation, or undulation of the jugular veins, was noticed as a symptom of this alteration by Lancisi ; was rejected by Corvisart ; but admitted by Laenngc and Hope. Bertin and Bouilgaud consider that it is present chiefly in hypertrophy with dilata- tion, extending to the auricle, and when the right auriculo-ventricular orifice is imperfectly shut during the systole. 179. F. Terminations and Prognosis.—a. As long as hypertrophy continues simple and mod- erate in degree, the patient may experience but little inconvenience from it beyond slight dysp- noea and palpitations, particularly on exertion. But if intemperate living be indulged in, or great corporeal exertion be resorted to, the disease wTill increase rapidly, and will lead to farther change either of the heart or of the more im- mediately related organs, especially of the brain and lungs. The progress of the malady will consequently vary with the peculiarities and complications of the case, and with the habits, occupations, and treatment of the patient. The terminations of hypertrophy depend, also, very much upon the same circumstances. In its simple states, apoplexy and active haemorrha- ges are its occasional consequences (<) 169); but, if these result not from it, the patient may live many years. When hypertrophy is attend- ed by much dilatation, the symptoms are more severe, and its course more rapid. It does not so frequently cause apoplexy as the foregoing state, but it is generally accompanied with greater disorder of the respiratory functions. I)r. Hope remarks that, when this form of the disease demands, owing to the palpitations and dyspnoea, periodical bleedings at short intervals, it hurries, with an uninterrupted course, to its fatal termination. In the majority of such ca- ses, however, bleedings are not the appropriate means of alleviation. 180. Both the progress and termination of the malady, and consequently the prognosis, more especially depend upon the pathological causes and complications of it. When these consist of diseased valves or contracted orifi- ces, the hypertrophy and dilatation usually pro- ceed to a greater extent, and the balance of the circulation is more disturbed than in the simple form of the complaint. In such cases, congestions, and even effusions of blood, or of serum, generally supervene, either in the sub- stance of important viscera, or on venous or serous surfaces, and occasion various consec- utive maladies, according to the particular le- sion of the heart, and to the consequent seat of congestion, effusion, or infiltration of paren- chymatous structures. Hence result pulmona- ry haemorrhage, &c., oedema, or effusion into the bronchi, or into the pleural cavities, &c., followed by asphyxy. Abolition of the func- tions of the lungs causes stupor, or acceler- ates the alterations which often take place in the brain, especially congestion and sanguine- ous or serous effusions ; 'or these latter are the first to occur, especially when the primary lesion is in the right side of the heart (<) 169). 181. b. The prognosis, it is evident from the foregoing, is generally unfavourable, especially in the more complicated cases, in proportion to the extent of lesion of the orifices and valves, and where hypertrophy is accompanied with adhesion of the pericardium. Debility, age, a cachectic habit of body, and disease of the lungs also increase the danger, or, rather, ren- der it more imminent. In the simple states and early stages of the malady, when the con- stitution is not impaired, and when the patient can be subjected to appropriate treatment, and is so circumstanced as to pursue it, the prog- nosis is much more favourable; and, although the alteration already existing may not be di- minished, its progress may be arrested. 182. G. Treatment.—The circumstances which influence the terminations of hypertrophy and the prognosis of it should also control the treatment. The simple form of the malady, particularly in young and otherwise sound per- sons, requires very different means from the complicated, especially when occurring in bro- ken-down constitutions : in the former, vascu- lar depletions may be employed, and repeated from time to time; in the latter, they require great caution and discrimination, or they may be injurious. Laennec and Bouillaud advise blood-letting and other reducing and tranquilli- zing means, in the manner recommended by Albertini and Valsalva, and to a decided ex- tent. But I agree with Dr. Hope in consider- ing these measures hazardous, and often inju- rious, when pushed as far as these writers di- rect. M. Laennec, especially, insists upon co- pious depletion at the commencement of the complaint—upon a repetition of it every two, four, or eight days, until the palpitations cease, and the heart gives only a moderate impulse— upon spare diet, with very little or no animal food—and upon physical and mental repose. If the treatment is not commenced until hyper- trophy has occasioned dyspnoea, dropsical effu- sions, oedema of the lungs, &c., he still advises bleeding and abstinence ; and, in all cases, a perseverance in this plan, especially in absti- nence, for many months ; and he has no confi- dence in a cure until the expiration of a year (if the patient live as long) of complete absence of all the symptoms and physical signs of hy- pertrophy. As to blood-letting, the opinion of M. Bouillaud is not materially different from that of Laennec. He prescribes, for an adult of medium strength, and for a medium degree of the complaint, three or four bleedings at the arm, each consisting of twelve or sixteen oun- ces, followed by one or two cuppings on the praicordia of eight or twelve ounces each, in the course of the treatment. He considers di- gitalis as the next most important remedy—as the true opiate of the heart; and employs it both internally and endermically. He applies a blister on the praicordia ; and he sprinkles the blistered surface with from six to fifteen grains of powdered digitalis, directing, at the same time, and long afterward, mental and bodily repose, and a very restricted diet. 183. a. Respecting blood-letting in this mala- dy, my experience and opinions are in accord- ance with those of Dr. Hope ; and I consider, with him, sparing abstractions of blood, at in- tervals of two or three weeks or more, to be the most beneficial. More copious depletions have given temporary relief, but the symptoms have soon returned with increased violence and carried off the patient, especially in cases where there were also dilatation and lesions of the valves or orifices of the heart. As I have shown in the article Blood (<) 58), large deple- tions increase the frequency of the heart’s ac- tion ; and this effect is more readily produced by them when this organ is in a state of en- largement. I perfectly agree with the above writer in considering that the indications of treatment should be to diminish the quantity, without deteriorating the quality of the blood, and without producing reaction, or permanent- ly enfeebling the action of the heart and the energies of the constitution ; that from four to eight ounces of blood, taken every two, three, four, or six weeks, according to the circum- stances of the case, will be sufficient to fulfil this indication, to keep down inordinate ac- tion, and to relieve the dyspnoea; that the diet should be spare, and consist of white ani- mal food, and liquids in small quantity, and that everything heating or stimulating, or cal- culated to accelerate the circulation, ought to be avoided. [In the treatment of this affection, our first aim should be to remove any exciting cause of the malady, as violent exercise, intemperance in food or drinks, mental excitement, &c. ; and as it consists in an increased power and action of the heart, a reducing and tranquil- lizing treatment will be appropriate. The plan, however, of rapid depletion by general blood- letting, so strongly urged by Valsalva and Al- bertini, and more lately by Laennec, has at present but few followers among judicious practitioners. We formerly tried the plan rec- ommended by Laennec in several instances, abstracting blood as copiously as the patient could bear without falling into a state of sink- ing, repeating the operation every few days until the palpitation ceased, and the heart gave but a moderate impulse under the stethoscope, at the same time diminishing, by one half, the quantity of aliment which the patient usually took. In the early stages of hypertrophy, spa- ring abstractions of blood at intervals of two or three weeks or more, we have found very useful; but, in the latter periods of the disease, bleeding has generally exasperated all the symptoms, especially the dropsy, and parox- ysms of dyspnoea. Repeated blood-letting inevitably brings on a state of anaemia, characterized by a diminished proportion of fibrin and red globules, and al- ways attended with a quick, jerking beat of the heart and arteries, palpitation and breath- lessness on exertion or excitement, and that disposition to serous infiltration usually called dropsy from debility.] 184. b. Much benefit will result from a judi- cious selection of internal medicines. Of these, digitalis, colchicum, the sub-borate of soda, mer- curial alteratives, hydriodate of potass, refrige- rants, and diuretics are most deserving of notice. The secretions and excretions should be freely HEART—Hypertrophy of—Treatment. promoted by a mercurial alterative taken at bedtime, and a mild purgative in the morning. Equal parts of infusion of digitalis and cam- phor mixture may be also given twice or thrice a day with five or six grains of the sub-borate of soda ; or small doses of colchicum, with an alkaline subcarbonate, may be prescribed in an infusion of tilea Europea, or decoction of marsh-mallows. Diuretics are also of service, especially the super-tartrate of potash with the sub-borate of soda, in the compound decoction of broom-tops, or in a weak infusion of senega, or in camphor julap, or in the decoction of ta- raxacum—the nitrate of potash or soda, with spirits of nitric aether—and the acetate of pot- ash, with small doses of squill, or the infusion or spirit of juniper. When dropsical effusions take place, these, varied according to the peculiari- ties of the case, and aided by hydrogogue pur- gatives, are required ; and one or other of the liniments prescribed in the Appendix (F. 297, 311), with the addition of a little of the hydrio- date of potash, may be rubbed or applied over the thorax daily. When the breathing be- comes much affected, camphor, with small do- ses of ipecacuanha, and with hyoscyamus or belladonna, &c., may be tried; and when de-. bility or irritability is urgent, camphor, con- joined with hydrocyanic acid, or with digitalis and the extract of hop, or with gentle tonics and other narcotics, as the acetate of mor- phia, will be very serviceable. Digitalis was much praised by Feeriar in palpitations from organic lesions ; and, when hypertrophy is at- tended with excessive action and distressing irritability, the following will be found use- ful: No. 256. K Infus. Digitalis 5v>jss- i Potass* Nitratis jij.; Acidi Ilydrocyanici Tllxiv. ; Sirup. Aurantii 31'j. ; Misce. Capiat aeger Coch. i., amplum secundH quaque hora. 185. c. When diseases of the valves and orifices of the heart have been concerned in the pro- duction of hypertrophy, the treatment is not ma- terially, if indeed at all different from what is here advised. The fixed alkalies, especially the liquor potassae, may be given in suitable combinations, as with digitalis, camphor, and various diuretics. The internal exhibition of the hydriodate of potash has been tried by me. in several cases, but the results have not al- ways led me to persist in the use of it in car- diac hypertrophy from this cause. It may, how- ever, be given in small doses with liquor po- tassse ; it will then not be injurious. 186. d. External derivatives, especially setons or issues, inserted near the margins of the false ribs, or below them, have been prescribed by me in several cases, and in some with marked advantage. In every instance the treat- ment should be assiduously persisted in, and a most abstemious diet and regimen rigidly ob- served. Repose of mind and body, and resi- dence in a dry and pure air, are also most ben- eficial. As the features of the disease vary, so should the treatment be modified, care being taken not to reduce the vital energies too low. As soon as exhaustion appears, it ought to be met by restorative means. Where a free dis- charge is procured by setons or issues—which are especially indicated when the hypertrophy has been consecutive of rheumatic disease of the heart—a gently tonic treatment will be often requisite ; and if any preparation of col- 243 244 HEART—Dilatation of its Chambers and Orifices. chicum be exhibited, it should be given with camphor or ammonia, or even with stomachic or gentle tonics. ii. Op Dilatation of the Chambers and Ori- fices of the Heart. — Syn. Cordis Aneu- nsma, Ballonius, Baglivi; Passive Aneurism of the Heart, Corvisart; Cardieurysma, Car- diectasis, Auct. ; Expansion of the Heart's Cavities. 187. Charact.—Slight palpitations, with dysp- noea and cough; the impulse of the heart being weak and diffused ; the sounds being louder, clear- er, shorter, and heard over a larger extent of the chest than natural; and the pulse being weak, small, or irregular. 188. A. Description.—Dilatation (a) may af- fect equally the whole parietes of one or more of the cavities ; or (b) it may be so confined to a portion of the parietes of a chamber as to form an aneurismal pouch.—a. The first of these va- rieties usually presents itself in three forms: 1st. With thickening of the walls of the com- partments. 2d. With a natural state of the walls ; and, 3d. With attenuation of the walls. The first of these has been considered in connexion with hypertrophy, and most of the remarks made with respect to it also apply to the sec- ond of these forms. It is chiefly, therefore, to the third, or to dilatation with attenuation of the parietes of the chambers, that attention is now directed. The muscular substance of the heart is often healthy, although dilated ; but it more frequently is soft, flaccid, or even re- markably softened, especially when the atten- uation, as well as dilatation, is great. Some- times its structure is readily broken down by the pressure of the finger, and is of a deeper or darker red, or of a paler or more fawn-col- our than natural. The more remarkable states of softening observed in connexion with dila- tation have been consecutive of inflammation of one or other of the surfaces, probably ex- tending, in some degree, to the substance of the heart, and occurring in debilitated, pre- viously diseased, or cachectic constitutions. 189. This lesion of the heart is much rarer than dilatation with thickening, or with a nat- ural state of the parietes of the cavities ; and the instances recorded of it are not numerous. Lancisi, Morgagni, Corvisart, Bertin, Krey- sig, J. Frank, Laennec, Louis, and Hope have described but few cases of it. Burns and Laennec believed that rupture might proceed from dilatation; and Dr. Hope and Dr. Will- iams have met with this occurrence, which is most likely to take place in aged persons. Dil- atation with attenuation seldom affects one ventricle without the other; but it is more common, or greater in the right than in the left ventricle. It more rarely is seated in all the chambers of the organ. The attenuation exists in various degrees. It may be so ex- treme that the walls of the ventricles hardly are equal to two lines at the thickest parts (Hope and Chomel). The fleshy columns are usually stretched and spread out. The inter- ventricular septum is proportionately les.s at- tenuated than the other parts. The dilatation is more in the tranverse than in the longitudi- nal direction of the ventricles, the heart there- by assuming a spherical form, and the apex being nearly effaced. When both the ventri- cle and auricle of the same side are much di- lated, the intermediate orifice is generally also widened, and the valve insufficient to close it. As in cases of hypertrophy, the position of the organ is somewhat altered when the dilatation is great, it being more or less transverse, and towards the left. A very slight attention is sufficient to distinguish the distention that takes place during the last moments of life from morbid dilatation. The former is slight, presents the appearance of tension, and the muscular substance is healthy, the organ often resuming its natural size when emptied. The latter consists not only of distention, but also of flaccidity, thinning, and softening of the parietes. 190. b. Partial dilatation of one of the heart's cavities is but rarely met with. M. Bertin states that he has seen one portion of a cavity dilated, and another in its natural state, or even thickened, especially in the right ventricle, near the pulmonary artery. This is evidently a slighter grade of that lesion which has at- tracted, more recently, considerable attention under the appellation of11 false consecutive aneu- rism" (Breschet), “ sacculated aneurism," and “ true aneurism of the heart" (Ollivier). This alteration has been observed by Galeati, Butt- NF.R, CORVISART, BaILLIE, ZaNNINI, BeRARD, Rostan, Cruveilhier, Breschet, J. Johnson, Elliotson, Adams, Dance, Reynaud, &c. It was found in the heart of Talma, the celebra- ted French tragedian. It is exactly similar to the aneurism of large arteries, and has been met with only in the arterial side of the heart; and, excepting in a single case recorded by Dr. Elliotson, where it existed in the left auricle, always in the left ventricle. In many of the cases it was found at the apex ; in some at the base, or at the middle of the ventricle ; and in others at the front or side. In this last situa- tion it was detected in Talma. In the instan- ces which occurred to Reynaud and Elliot- son two aneurisms wTere found in the same ventricle. This form of aneurismal tumour varies in size from that of a filbert to that of the heart itself. The larger tumours usually contain layers of dense coagula, similar to those which fill the cavities of arterial aneu- risms. They communicate with the ventricle by a more or less narrow opening, which, with the whole of their interior surfaces, is gener- ally lined with a membrane continuous with that of the ventricles. Like other aneurisms, they are most common in adult males. 191. c. Dilatation of the orifices of the heart is not less frequent than expansion of the cavi- ties, and often coexists with it. The orifices may be dilated in various degrees, as already shown ($ 189); but generally, when the change is very considerable, the valves become in sufficient for their purposes, and the expan- sion, owing to the regurgitation into the auri cles, extends to them. The auriculo-ventrie- ular orifices are most frequently dilated, but in very lare instances the arterial orifices have experienced this alteration in a slight degree. 192. B. Causes.—a. Most of the causes, re- mote and immediate, of hypertrophy are also those of dilatation of the chambers and orifices of the heart. As Dr. Hope observes, dilatation is merely a mechanical effect of over-disten- 1 tion. Blood accumulated within the cavities, owing to an interruption to its exit from them. HEART—Dilatation of its Chambers and Orifices. 245 will dilate and attenuate their parietes, in pro- portion to the resistance opposed, and to the force exerted by the muscular structure, in or- der to overcome it. When that force is weak, or insufficient to overcome the resistance, the parietes yield, and the cavities undergo dilata- tion with a rapidity depending upon the weak- ness of the walls and the extent of interrup- tion. It necessarily follows that the cavity immediately behind the seat of obstruction will be the first to undergo dilatation, and will experience it to the greatest extent. The compartment, also, having the weakest pari- etes, is, cceteris paribus, the most frequently di- lated. Permanent dilatation is the result of prolonged or repeated causes, as contractions of an orifice, disease of the valves, and fre- quent returns of nervous palpitations. The depressing passions and emotions, as anxiety, fear, &c. (§ 19), and whatever tends to weak- en the power of the heart, may occasion this alteration. The walls of the cavities may also be unusually weak or thin, congenitally and hereditarily. Lancisi observed this lesion in four successive generations ; and Albertini saw a female die of dilatation, five of her broth- ers having been cut off by the same malady. It is most common in persons of a tall, thin, delicate, feeble, and nervous or lymphatic con- formation and lax fibres. Age has also great influence on its production. It is not uncom- mon in young children, but it is most frequent in the aged. It rarely occurs in young adults, unless it has been induced by masturbation, or by fevers and diseases of the respiratory or- gans. In general, all obstructions to the cir- culation, whether situated in the orifices of the heart, or in the aortic or pulmonary sys- tem, will produce it as well as hypertrophy, the supervention of the former being the result chiefly of debility of the organic nerves sup- plying the organ, and of impaired tone or defi- cient nutrition of the muscular structure ; of antecedent disease, characterized by debility or cachexia, or by both. 193. b. When the auricles are protected by a natural state of their valves, and of the auric- ulo-ventricular orifices, the ventricles may be dilated without the former being materially af- fected ; but when the auricular valves are dis- eased, so as to occasion interruption to the pas- sage of the blood from the auricles, or when the auriculo-ventricular openings are dilated, so as to permit regurgitation from the ventricles, then the auricles become dilated, although rare- ly without some increase in the thickness of their parietes. 194. c. The diseases of which dilatation is most frequently consecutive are, inflammations of the heart, and the lesions of the valves and orifices caused by them ; rheumatism extending or translated to this organ ; tubercular consump- tion ; asthma and emphysema of the lungs ; sec- ondary syphilis, especially when treated by ex- cessive quantities of mercury (Albertini) ; adynamic, typhoid, and exanthematous fevers ; scurvy, and carcinomatous and haemato-en- cephaloid maladies. M. Bertin contends that dilatation is generally consequent upon some ob- stacle to the course of the blood ; and that the obstacle, at the same time that it gives rise to this lesion of the heart, produces other phenom- ena, as engorgement of the vessels, serous ef- fusions, passive haemorrhages ; these phenom- ena, as well as the dilatation, being the result of the same proximate cause. Dr. Hope justly observes that the change in the capacity of the cavities may result not only from obstacles to the circulation, but also from debility. There can be no doubt of deficient tone of the muscu- lar parietes, and of the softening and asthenia of the organ, shown to follow adynamic fevers, and of protracted nervous palpitations, particu- larly when connected with chlorosis, anaemia, &c., being sufficient to cause dilatation of one or more of the chambers of the heart, inde- pendently of any appreciable obstacle to the cir- culation. Curvatures of the spine, and what- ever diminishes the cavity of the chest, or presses inordinately upon the large vessels, may also occasion this alteration. 195. d. The same causes and pathological con- ditions which occasion the expansion of a whole compartment or of an orifice may give rise to the dilatation of a portion of it only in the form of an aneurismal cavity, especially whatever opposes the transmission of blood from the heart, as laborious occupations, the more vio- lent mental motions, as hatred, revenge, jeal- ousy, anger, &c. This—the only lesion of the heart which ought to be called aneurismal— may be produced independently of inflammato- ry action, owing to great muscular efforts, or obstacles to the circulation. Where the inter- nal membrane is not destroyed nor thickened, and where the muscular fibres are stretched, separated, or ruptured, antecedent inflamma- tion may not have existed ; but where there is thickening of the internal membrane, or ulcera- tion, or adhesion of the external surface of the dilated part to the pericardium, this lesion may be considered to be a more or less remote con- sequence of chronic inflammation, affecting a portion of the parietes of the ventricle, the di- lated part having lost its elasticity and contrac- tile power. In connexion with this, some ob- stacle to the circulation, or to the passage of blood from the left ventricle, has frequently also been present; the increased lateral pres- sure arising from impeded circulation dilating or extruding the most softened, weakened, or yielding portion of the ventricle. In the unique case of aneurism of the left auricle recorded by Dr. Elliotson, there were extreme cohesion and ossification of the mitral valve, and con- sequent reduction of the auriculo-ventricular opening, changes always consequent upon in- flammatory action, as above insisted upon ($ 68). The sinus of the auricle formed a large aneurism, containing dense and thick layers of fibrin; the interior of the tumour being lined with the smooth membrane of the cavities, as in aneurism of the ventricle. 196. C. The Signs and Symptomatic Effects of Dilatation have been partly noticed under the head of hypertrophy with dilatation (8.—Schenck, Obs., 1. ii., No. 203. —Bartholin, cent, ii., Hist. 32.— F. Von Hilden, Obs. Chirurg., cent, i., ob. 51.—Gantius in Boneti, Sepulchretum Anat., 1. ii., sect. 1., Addit. Obs. ii. — VP. Rutty, Philosoph. Trans., 1728, p. 562. — Lancisi, de Mort. subitan, ob. iv., p. 161. Bonet, 1. 11., sect, vii., obs. 56, 132, addit. obs. 9, sect, viii., ob. 34 ; 1. 111., sect, xxi., add. ob. 60; et sect, xxxvii., ob. 4; 1 iv., sect, i., ob. 15.—Pyl, Aufsatze und Beobachtungen, vol. vi., p. 78. — Lieutaud, vol. ii., obs. 544-553. — Penada, Saggio secondo d’Osservazioni e Memorie Medico-Anatomiche, 4to. Padua, 1800.—Forlani, Obs. Rarior. Med. Pract.,dec. i.,p. 70 ; dec. ii., p. 1U.—J. F. Meckel, Tab. Anat. Pathol., Fasc. 1., vol. i., tab. 8. — Walter, in Mem. de l’Acad. de Berlin, 1785, p. 65, tab. 4, tig. 2.—Trotter, in Med. and Chym. Es- L says. Lond., 1796—Eph. Nat. Cur., dec. i.,ann. ii., 1761, obs. 5, p. 6.—Ludersen, De Hydatidibus, Gott, 1808, p. 11. t —Fleisch, in d. Allg. Annalen, 1811, Jul.,p. 6M>.—Morgag- ; ni, Ep. xxi., 4 ; ep. xxv., 15 ; ep. xi., 11.—Spangenberg, in Horn’s Archiv., 1811, July, p. i.—Heuermann, Physiologie, ’ v0], j j p. 202.—Salzmann, in Haller’s Disputat., vol. iv., p. [ 248.— Clossius, in Baldinger’s Magazin., vol. x., p. 543.— - Portal, Cours d’Anat. Medic., vol. iii., p. 29, Ii—Testa, p. - 64, 67,277, 278.—Dupuytren, in Corvisart's Journ. de Med. j vol. v., p. 139. — Soemmering, Addit. to Baillie, p. 21. D . Price, in Lond. Med. Chir. Transact., vol. xi., p. ii., 1821 264 BIBLIOGRAPHY AND REFERENCES. —Arndt, de Tumoribus Cord tunicatis, 4to. Ber. 1817. Pclletan, Memoires et Obs., iii , n. 3. — Beauchamp,\n Re- cueil Periodique de la Socidte de Med., n. xxym.- Cruveil- Mer vol i., p. 301.— Andral and Bayle, m Revue Medicale franc et dtrangcre. F6vrier, 1821— Macmichael, m Lond. Medeand Physf Journ., August, p. 239 1826.-Wedemeyer, in Rust’s Magazin, b. xix. P. n., p. 239. — Autenreith, m Tubinger Blatter, vol. i., P. ii., p. lJl. —Otto, Selt. Beo- bach., part i., p. 98; part ii , p. 58 ; and Path. Anat, p. 288 — Spens, in Edinb. Med. and Surg. Journ, 1816, vol. xii „ ]9p —Lawrence, in Med. Chir. Transact, vol. m, a 78 — Laennec, vol. ii.. p. 325 and 334. —Sandifort, Obs. Anat. Path.. 1. i, c. i, p. 31 ; 1. iii, c. i, p. 41 .-Costallat, in Journ. Hebdom, vol. iii, p. m. - Corvisart, p. 223.- Bertin in Bulletin de la Facultd de Mduec., 1812, p. 68. Elliotson. Op. cil, p. 32.—Bertin, Trait6 des Maladies du Cceur, n. 232—Tesla, p. 314—Desruelles, in Revue Medic. Histor. et Philos, vol. iv, p. 305. Paris, 1821. — Cruveil- hier, Anat. Path, 1. xix, p. i, pi. 4. viii. Medullary Funous and Carcinoma of the Heart.—Carcassone, in Hist, et Mein. de la Soc. Roy. de M6dic, 1777 and 1778; Hist, p. 252, ann. 1786; Hist, p. 320 —Bartzku, Obs. singularis Fungi medullaris in Corde ; pr®f. Dzondi, 8vo. Hal®, 1821. - Hodgson, jp Savenko, Tentamen Anat. Pathol, de Melanosi,4to. Petropoh, 1825. Segalas d'Etchepare, in Revue Medic, 1825, vol. iv, p. 24/. —Ibid., in Nouv. Bullet, des Sc. par la Soc. Philom, May, 1825 —Gerson und Julius, Magazin d. Ausl. Litter, d. ges, Heilk, p. 199, Sep. and Oct, 1823. — Staupa, Anweisung zur Gerichtlichen u. Path. Untersuchung Men. Leichname, p. 164, 8vo. Wien, 1827.—Duchateau, in Jour, de Medec, p* 243,’ Oct, 1810.— Rullier, in Bulletin de la Fac. et de la Soc. de Mddec. de Paris, No. 5, p. 367, 1813 ; and in Journ. de Mddec. Chir. et Pharm, vol. xxvii, 1813. —■ Dupuytren, in Cruveilhier, vol. ii, p. 87.—Andral and Bayle, in Revue Mdd, Feb, 1824. — Recamier, in Ibid, Nov, 1825. Ulli- vier, De la Moelle Epinidre et de ses Malad, p. 262, 8vo. Paris, 1824—Velpeau, Exposition d’un cas remarquable de Malad. Concere, &c, 8vo. Paris, Churchill, in Lond. Med. and Phys. Journ, March, 182/. ix. Organic Lesions of the Pericardium.— cher et Schmiedel, De Exulceratione Pericardii et Cor. Ex- emplo illus. Jen®, 1742—Lieutaud, Hist. Anat. Med, 4to, p. 210. — Meckel, M6m de Berlin, 1756, vol. xii, p. 31.— Boerhaave, vol. ix, p. 498.— Haller, Add. ad Elem. Phys, p. 128.—Saviard, in Journ. des Savans, 1691 ; Obs. Chir, i iv p. 25. — Aurivillius, in Nov. Act. Upsal, vol.i, |>. 1Q1, — Morgagni, De Sed. et Caus. Morb or., ep. xviii., p. 34 ; xx, 20, 35; xxii, 10 ; xliij, 17 ; xlv, 16 ; liii, 29.— Stoll, Rat. Mod, vii, p. 172— Van Doeveren, Specim. Obs. Acad, c ai>. v.—Senac, De Corde, 1. vi, cap. ii. Stoerck, Anr.tis Medicus, ii, p. 92.—Chambon de Montaux, Markw. Kraukengeschichten und Leiehenberichte. Leipz, 1/91. — Uicrmayer, Mus. Anat. Pathol, No. 434—Portal, Cours d Anat. M6d, iii, p. 24 —Riolanus, Anthropographia,1. m, p. 12.—Hautesierk, Recueil d’Obs, vol. ii, p. 583.—-Testa, Peterb. Vermischte Abhandl. a. d. Gebiete der Heilk, 1 ste. Samml, p. 232. 1821 — Walter, Obs. Anat, p. 63, and Anat. Mus, vol. i, p. 148, 149, Wl.-Pasta, Ep. de Cordis Polypo, p. 75.—Prost, Mddecine eclairde par l’Ouverture des Corps, i, p. 140.—Abercrombie, in Trans, of Med. Chi- rurg. Soc. of Edinb, vol. i. — Rust's Magazin, f. d. ges Heilk, vol. xvi, P. i, p. 185. — Rayer, in Archiv. Gener. de M6d, March and April, 1823.—Rochoux, in Journ. Gen. de Mdd. et Chir, vol. xxix, Feb, 1814. Bulletin, p.^33. — Bidois, fils, in Archiv. Gdner. de Medec, Dec, 1823. (See, also, Bibliog. and Refer, to Pericarditis.) x. Adventitious Productions in the Pericardi- um.—Musgrave, in Philos. Trans, 1685, p. 860.—Lancisi, De Aneurism, 1. i, 5.—Haller, Op. Minora, vol. iii, p- 365. —Meckel, Mdm. de 1’Acad. de Berlin, 1756, p. 79. Godart, in Journ. de Medec, 1761, May, vol. xiv, p. 401. Boneti, Sepulchret. Anat, lib. ii, sect. 2, obs. 16 ; sect. 8, obs. 6 ; lib. iii, sect. 21, obs. 21 ; and sect. 37, obs. 3.—Morgagni, Epist. xix, 7.—Bourru, in Hist, de l’Acad. de Paris, 1763, p. 35—Voigtel, Path. Anat, lib. ii, p. 220. — Heuermann, Physiologic, vol. i, p. 202.—Lieutaud, Hist. Anat. Med, vol. ii, p. 271.—C Bell, System of Dissection, ings. It appears on the neck, cheeks, fore- head, arms, shoulders, and other places, in red, oval, or circular spots, of half an inch to two inches in diameter, and is attended by itchiness and smarting. The redness is much less in the centre than towards the circumference of the smaller spots, and is entirely wanting in the areas of the larger patches. Small vesi- cles, whose bases are slightly inflamed, con- taining a transparent fluid, rapidly appear m the circumference of the patches, the areas be- coming temporarily of a slight red colour. From the fourth to the sixth day of the eruption the redness declines, the vesicles become turbid, and either burst or are covered with thin, brownish incrustations, which are detached between the tenth and fifteenth day, a slight desquamation at the same time taking place from the centres of the patches, when the red- ness had extended to them. Patches of small size often have the fluid in their vesicles ab- sorbed, the cuticle exfoliating. The duration of this eruption does not extend above the time just specified, but it may be protracted very much longer when the eruption of the vesicu- lar rings is successive. In some instances the areas of the patches are covered with minute vesicles, and when this is the case, the patches spread, and extend over a considerable space. M. Rayer and Dr. A. T. Thomson state that this eruption is seldom accompanied by any constitutional disturbance. This, however, does not agree with my experience. The gen- eral disorder is certainly very slight, and thus escapes detection; but in most cases the di- gestive canal is more or less deranged, and the evacuations morbid. 10. C. Herpes Labialis—herpes of the lips—is similar to the varieties already described, as respects the characters and progress of the vesicles, the only differences resulting from situation. It may be seated either in the low- er or in the upper lip, or it may extend around the mouth. It is sometimes confined to the angles. It usually appears outside of the true lips, extending to the line of union between these and the skin. Sometimes patches of the eruption also appear on the cheeks and alee of the nose. In three or four days the vesicles contain a yellowish, purulent fluid. The lips swell, and, as the disease proceeds, become hard, sore, stiff, hot, and smarting. After the vesicles break, and crusts form, and especially if the latter are prematurely removed, the red- ness increases, the surface becoming harsh or cracking, and the disease is often protracted. When it is consequent on disorder of the di- gestive organs it often assumes a chronic form. This variety is generally consequent upon a febrile state of the system and disorder of the prima via. The patient complains of headache, chills, pains in the limbs, lassitude, and want of appetite for some time before the eruption appears. The alvine evacuations are usually morbid, and the abdomen often tumid or tender. Sometimes this variety is critical of catarrhal complaints, of agues, and of sev- eral acute diseases attended with pyrexia. It is occasionally preceded or accompanied by vesicles or aphthae in the mouth. [This variety is often produced directly by the application of any irritating cause ; we have often seen it result from the application of a strong solution of nitrate of silver to the throat and fauces. It is frequently met with in those who use distilled liquors, and some- times cannot be traced to any appreciable cause. ] 11. D. Herpes Prceputialis (Aphtha prceputii vel vulvce—Ulcuscula prceputii) is characterized by one or more groups of small, round vesi- cles on the outer or inner surface of the prae- puce, or on both, that usually disappear in about HERPETIC ERUPTIONS—Causes—Diagnosis. 269 a fortnight. It begins in one or several patch- r es of from four to eight lines in diameter, c which are circumscribed, and of a vivid red, t and rarely appears on the glans penis. The t eruption of vesicles is preceded by itching and < tingling of the part, which is slightly inflamed i and tumid. Small vesicles arise between the < second and fourth day, containing a transpa- ( rent serum, which about the fourth day be- 1 comes turbid, and afterward puriform. On the i exterior they dry and form scabs, from the fifth | to the seventh day, of a lamellar or conoid form ; ' and if the part be not exposed to irritation or ] friction, the healing process proceeds under- 1 neath the scabs, which are thrown off from the \ seventh to the tenth day. When the eruption 1 occurs on the inner surface of the prepuce, the vesicles generally break as early as the fourth day, and the inflamed rete becomes exposed, forming a superficial sore, which has been mis- taken for chancre. 12. This variety of herpes not infrequently occurs on the labia vulva, of women affected with leucorrhcea, or during pregnancy and af- ter delivery; and the eruption may be either internal, or within the labia. In these cases, the characters and progress of the vesicles, and of the consecutive sores, are the same as al- ready described. 13. ii. Herpes Iris.—Charact. Small groups of vesicles surrounded by four concentric erythema- tous rings of different hues. 14. This species was first arranged under herpes by Dr. Willan. It was accurately de- scribed by Dr. Bateman. It occurs most fre- quently on the back of the hands, olecranon, knees, ankles, instep, and similar parts. It commences in small, red spots, consisting of concentric rings of varying shades. These spots enlarge from two to about eight lines in diameter, and in their centres a yellowish- white, flattened vesicle appears from the sec- ond to the third day, surrounded by several others of a smaller size, arranged in a ring. This central vesicle is surrounded by a circle of a dull brown colour, this by a second nearly of the colour of the vesicle; this second by a third circle of a deeper red ; and the third, by a fourth, formed on the seventh, eighth, or ninth day. This, the most external ring, is of a rosy tint, which passes insensibly into the colour of the healthy skin. The third is the narrowest of these rings ; and they may all be- come covered with vesicles, but the first is most frequently so covered. From the tenth to the twelfth day the fluid of the vesicles is absorbed, or it escapes and dries into scabs, which are detached two or three days after- ward. 15. II. Causes.—The causes of the varieties of herpes are often very obscure, and consist rather of some anterior disorder of the consti- tution, characterized by deranged digestion and excretion, and by vascular irritation, than of direct agents. The truth is, that they are altogether symptoms of pre-existing disorder of the system, implicating especially the digest- ive, the biliary, and excreting functions. They do not depend upon contagion, and they may occur several times in the same person. They are often an advanced symptom, which frequent- ly proves critical, of catarrhal, febrile, or in- flammatory affections. — a. Herpes Zoster is most commonly observed in persons having delicate and irritable skins, between twelve and thirty years of age; but it is also met with in the aged. It is most prevalent in summer and autumn, and is generally dependant upon de- rangement of the biliary organs and digestive canal.—b. Herpes Circinnatus is common in chil- dren, especially in girls of a delicate frame, with thin, irritable skins, and often depends upon the same internal disorder as the fore- going.—c. Herpes Labialis is often consequent upon catarrhs produced by vicissitudes of tem- perature ; but in its more chronic states it is usually connected with derangement of the or- gans of digestion.—d. Herpes Prceputialis is fre- quent in middle-aged men, or in those advan- ced in life. It sometimes accompanies stric- ture, or an irritable state of the urethra, or dis- order about the neck of the bladder. More frequently it depends upon acrid secretions from the root of the glands. It is independent of the use of mercury, as it is also of affections of the urethra, although often connected with these af- fections. It is frequently symptomatic of chronic derangement of the liver and digestive tube. It is non-cotagious.—c. Herpes Iris is most com- mon in children and fair, delicate females. It may also be considered as dependant upon inter- nal disorder.—All the varieties of herpes occa- sionally appear after unwholesome articles of food, and other errors of diet; and after pertur- bations of the mind, especially when disorder of the digestive functions had previously existed. [The Rhus radicans (poison vine) and the Rhus toxicodendron (poison oak) produce a vesicular eruption which can scarcely be distinguished from herpes ; so close, indeed, is the resem- blance, that herpes is often attributed to poison- ing from these plants. Prof. Dunglison has described two cases {Am. Med. Intelligencer, Oct. 1, 1838) in which a vesicular eruption was produced by the leaves of the Pastinaca saliva, or common garden parsnip, on the extremities of individuals who worked in a garden where the vegetable was cultivated.] 16. III. Diagnosis.—Herpes was often con- founded, by writers previous to Willan, with erysipelas, impetigo, and eczema.—a. It is to be distinguished from Erysipelas by the numerous, small, clustering vesicles; by the healthy sur- face between the clusters, and by the absence of redness and tumefaction before the vesicles appear; and from Pompholyx by the vesicles arising in groups or patches on an inflamed base. —b. Neither Eczema nor Impetigo assumes the purely vesicular form, nor runs the same course within a limited time, nor forms the dry, harsh scab which characterizes herpes. — c. Herpes Circinnatus, when appearing on the forehead i and at the roots of the hair, may be mistaken ; for Porrigo scutulata, but the vesicular form of ■ eruption, the regular course it pursues, and the i persistence of the hair, distinguish it from this i affection.—d. Herpes Prceputialis may be con- j founded with syphilitic pustules or ulcers. The r common chancre commences by a single pus- - tule, whereas the herpetic affection consists of r a cluster of vesicles, the thick scabs of the for- t mer differing from the thin incrustations of the r latter. When herpes is seated on the inner - surface of the prepuce, and has passed into the - | state of excoriation, the diagnosis is more dif- s ficult. But the superficial clustering character 270 HERPETIC ERUPTIONS—Treatment. of the sore is different from the deep ulcer of syphilis, with its hard, elevated edges, and the small, gray-coloured false membrane covering its bottom. [Herpes is also sometimes confounded with pemphigus, but the bullae in this affection are rapidly developed, sometimes in twenty-four hours ; they frequently acquire a very large di- mension, and are commonly isolated and scat- tered bn various parts of the body ; sometimes they fade and dry up in two or three days with- out forming any notable crusts. It is also some- times mistaken for scabies, or itch, especially when its vesicles are accompanied by slight in- flammation, the colour of the skin but little al- tered, and the seat of the eruption only on the hands and forearm. But in herpes it is the dor- sal portion of the hands which is commonly at- tacked, and not the interdigital spaces, the wrist, and the folds of the elbow-joint. Instead of the small, few, and isolated vesicles of the itch, there are a number of closely approximated ones, which almost acquire the size of a large pin’s head, or even a larger size ; besides, the eruption has a regular march, and terminates spontaneously by desquamation at the end of one, two, or three weeks.] 17. IV. Treatment.—A. This is nearly the same in all the varieties, and should be based upon the pathological dependanceof the disease insisted upon above (§ 15). Keeping the con- nexion of the eruption with disorder of the di- gestive organs closely in view, a mild ipecacu- anha emetic should be exhibited, and subse- quently any gentle purgative, with magnesia or an alkaline carbonate. Afterward a free use of diluents and abstinence are all that will be required in most cases. In the more severe attacks, especially of herpes zoster, additional means will often be called for. Where there is much antecedent or attendant fever, M. Ray- er advises a moderate bleeding, or the applica- tion of a number of leeches to the anus, or around the seat of eruption. Neither of these is often necessary. When the evacuations are morbid, and the biliary functions impaired, a dose of blue pill, or of calomel, at bedtime, and a mild purgative, containing an antacid, the fol- lowing morning, will generally be of service. It may be even requisite to repeat these, and afterward, particularly when the urinary and fecal excretions are disordered, to promote the actions of the liver and kidneys by small do- ses of colchicum, with magnesia or an alkaline subcarbonate. In the more painful cases of zona, these means will be found most benefi- cial. During the course of the complaint, the diet should be mild, chiefly farinaceous, and in small quantity. The beverages should be de- mulcent and cooling. 18. B. When herpes assumes a chronic char- acter, owing to the successive eruption of clus- ters of vesicles, or to the excoriation of the in- flamed skin, small doses of blue pill, or of the hydrargyrum cum creta, and mild stomachic aperients, are the most appropriate means. In addition to these, the decoction of sarsa, or of the elm-bark, with liquor potassae, are often very serviceable. In herpes labialis and herpes pree- putialis these remedies are especially required. In more obstinate cases, particularly when the excretions continue disordered, mild stomachic purgatives and alteratives should be persisted in, and warm or tepid bathing, or even vapour baths, occasionally employed. In herpes iris, the warm bath and minute doses of the arsen- ical solution, with the liquor potassaj, are gen- erally of service. Dr. A. T. Thomson recom- mends for this species the decoction of the Rumex obtusifolius with these alteratives. 19. C. When herpes occurs in cachectic or aged persons, not only should great attention be paid to the state of the excretions, all faecal and morbid accumulations being duly evacua- ted, but the digestive and assimilating func- tions ought to be promoted, by exhibiting gen- tle tonics with the alkaline carbonates. If the eruption ulcerate, the application of nitrate of silver in substance, or in a strong solution, will promote cicatrisation. If there appear a dis- position to slough, the preparations of bark, &c., will be required. When violent sub-cutaneous pains accompany zona, hyoscyamus or other narcotics may be given with the medicines al- ready recommended ; but the warm or vapour bath and colchicum, as above prescribed (§ 17), will be found the most successful. In herpes praputialis and herpes vulva the early applica- tion of nitrate of silver will often shorten the duration of the eruption. Where there are much heat and stinging of the parts, a wash containing; the sub-borate of soda, or the sul- phate of zinc, or of alumina, will often be use- ful. These may also be prescribed in herpes circinnatus ; but in all cases the chief attention must be directed to the removal of disorder in the digestive and biliary organs, and to the regi- men of the patient. [When herpes circinnatus passes into the chronic state, sulphur baths will be found very useful, and the following ointment will often suffice to disperse the small furfuraceous rings which remain on the surface of the skin. R Lard jj.; Sulphuret of Lime, 3j. ; Camphor, gr. xv. M. The use of the natural sulphur waters, as at Avon and Sharon Springs, will also be found efficacious in the removal of the different forms of this complaint. Sulphur baths are generally prepared in the French hospitals by adding four ounces of the solid sulphur et of pot- ash, or eight ounces of the liquid, tn the bath ; but we may substitute, as equally efficacious, and far more economical, the sulphuret of lime, and, by adding a small quantity (5ij.) of muri- atic acid to the water, we increase the precipi- tation of sulphur and the disengagement of sul- phuretted hydrogen. There is reason, howev- er, to believe that the crystallized hydro-sulphate of soda will prove still better adapted to this purpose, being less odoriferous, and furnish- ing a water more nearly approaching those of nature. In chronic, herpetic, and other cutane- ous eruptions, the use of a preparation called Fdtz's Mixture will often succeed after other remedies have failed. R Sulphuret of Antimo- ny, ; place in a linen bag, and boil in water for one hour ; then remove it, and place it in a vessel with Sarsaparilla in pieces, ;iij. ; Isin- glass, 3xiv.; Water, 0. vj. ; boil down to one half, and strain. Dose, three glasses a day be- fore eating. The treatment of these affections is now so well understood as to render any far- ther remarks upon the subject unnecessary. A great variety of local treatment has been recommended for the cure of herpes, as chlo- rinated lime, chlorine, hydrocyanic acid, crea- eote, soot, cyanuret of mercury, iodide of mer- cury, tincture of iodine, iodide of potassium, acetate of lead, cod liver oil, impure oxyde of zinc, &c. Where the vesicles are large, some advise to open them and apply an emollient cat- aplasm, and where there is much inflamma- tion, a few leeches have been found useful; blisters have succeeded in checking their ex- tension, and in severe cases may be resorted to with benefit. We have been accustomed to rely chiefly on general remedies in treating the various forms of herpes, and if these are prop- erly adapted to the circumstances of the case, local applications will rarely be found necessa- ry-] Bibliog. and Refer. — Celsus, De Re Med., 1. v., c. 28, t) 4.— Scribonius Largus, De Com. Med., c. 99, 100. — Plinius, Hist. Nat., 1. xxvi., c. 11. — Oribasius, Synopsis, 1. vii., c. 33, 49.—AStius, Tetrab, serm. ii., cap. 40, p. 73. —Avicenna, Canon, 1. iv., fen. iii., tr. i., c. 6.—Schenck, Obs. Med., 1. v., p. 639.—Tulpius, Obs. Med., 1. iii., c. 44. — Zacutus Lusitanus, Med. Pr. Hist., 1. iii., n. 15. — Ru- land, Cur. Emp. cent., cap. 39 (Balsamum Sulphuris).— Turner, Diseases of the Skin, ch. v., p. 80.—Hoffmann, in Bergii Institut. Med., t. ii., p. 34.—Bergius, in Eph. Nat. Cur., dec. ii., an. 3, obs. 171.—Russell, De Herpetibus, 8vo, p. 29. — Lorry, De Morb. Cut., vol. i., p. 182. — Haller, in Nova Comment. Goet., vol. viii., art. 4.—Gillibert, Adver- saria Practica, p. 28. T. T. Klein, Tentamen Herpetolo- giae, 4to. Leid., 1755.—Aaskow, in Acta. Reg. Soc. Med. Haun., vol. i. (On the impropriety of repelling herpes, and the internal disorders resulting therefrom). — Lettsom, in Memoirs of Medical Society of London, vol. iii., art. 16.— Adair, in Edin. Med. Comment., vol. ix., p. 35 (The arseni- cal solution recommended).—Halle, in Mem. de la Soc. Roy. de M6d., t. vii. (Purgatives and warm bathing). — Home, Clinical Experiments, passim (Sarsaparilla—the elm bark). —Rahn, Med. Briefw., b. i., p. 399 (Decoctum dulcamara:). Akerman, in Baldinger N. Magazin, b. vii’i., p. 161 (Elm bark recommended).—D. Lysons, Farther Obs. on Calomel, 45), the remedies mentioned in the articles Cachexy, Chlorosis, Cancer, Fungoid Disease, &c., may be resorted to, when these or any other malignant malady resembles jaundice, owing to contamination of the circulating fluids, or is associated with it. In such cases of contami- nation, as well as in the very acute and febrile form of jaundice, denominated malignant or per- nicious (§ 58), the alkaline carbonates with cam- phor, solutions of the chlorate of potash, or of chlorinated soda, and the other means advised for the hepatic complications of Typhoid and Putro-adynamic Fevers (<) 49), will be most ap- propriate. 75. c. Traumatic jaundice (§ 52) must be treat- ed according to the symptoms evincing the ex- istence of any of the pathological states and alterations above referred to (<) 26), and con- formably with the principles already stated. 76. d. Infantile jaundice (po6ioia, Anaphrodisia (from a, neg., and utppodtota, and that from ’AOpoihrrj, Venus), Auct. var. Im- puissance, Fr. Unvermogen zum Beyschlaf, Ohnmachtigheit, Germ. Impotenza, Ital. Classif.—4. Class, 1. Order {Cullen). 5. Class, 2. Order {Good). I. Class, II. Order {Author). 1. Defin. — Incapacity of sexual intercourse, and inability of procreation. 2. Impotence and Sterility are so intimately related that they must necessarily be consid- ered under one head, although disjoined by Good and some other nosologists. They are subjects of much greater practical importance than has been conceived by many, and often involve the happiness and perpetuation of fam- ilies. Yet have they, by a sort of professional prudery, been either entirely overlooked by medical writers, or very imperfectly discussed, and thereby relinquished to the irregular prac- titioner, or to the entirely unqualified empiric. In the present era of high refinement and of luxurious if not vicious enjoyments, and un- der the influence of noxious plans and systems of education, instances are very numerous for which medical advice is required for the re- moval of the morbidly disqualifying conditions about to be considered, but is not resorted to so frequently as it ought to be. Since advice is thus often necessary, the ability of those from whom the community have a right to ex- pect it of the most judicious kind, should be equally great in providing it. There is every reason, also, to believe that it would be often- er sought after if the subject were known to be more fully entertained by the duly qualified members of the profession. The practical con- sideration only of these morbid conditions falls within my plan : their legal relations are very ably discussed in the classical works of Paris, Beck, and Smith, [as well as those of Guy and Tailor]. 3. Impotence may exist in either sex, but most commonly in the male, owing to the sexual conformation. Sterility most frequently de- pends upon the female, although it sometimes is owing to the male ; and, in a practical point of view, if not in a medico-legal one, it is more frequently thus owing than is stated in books. 4. Impotence and Sterility, in respect of both sexes, have been differently arranged by wri- ters—into absolute and relative ; constitutional and local; direct and indirect; permanent and temporary; and, by Dr. Beck, into absolute, cu- rable, and accidental. These distinctions are all of importance in the consideration of the sub- ject ; but the divisions founded on the nature of the causes are more useful. M. Raige De- lorme has arranged impotence into, 1, that de- pending upon lesions of the sexual organs ; 2, that proceeding from disorder or interruption of seminal emission ; and 3, that caused by de- 370 IMPOTENCE AND STERILITY—In the Male. feet of the faculty of erection. The division adopted by Dr. Beatty into, 1. Organic; 2. Functional; and, 3. Mural; although not mate- rially different from the foregoing, is preferable to it. I shall consider the subject with refer- ence, first, to the male, and, secondly, to the female ; and view in succession the mental, the functional, and the organic states, from which impotence and sterility most frequently pro- ceed. 5. I. Impotence in the Male—Agonia, Age- nesia, Impotentia Generandi Masculina, Sterilitas Palerna, Dyspermatismus, Dyspcrmasia, Auct. var.—Male Sterility—may depend upon, 1. Men- tal influences or causes; 2. Functional disor- der ; and, 3. Organic lesions of the sexual or- gans. 1st. Mental influences or causes may oc- casion temporary, or more or less prolonged im- potence, even in persons of a sound constitution in every respect. In them the removal of the cause leaves the generative organs in a condi- tion capable of performing their functions. The moral or mental influences which most fre- quently occasion impotence are, chiefly, too eager, too violent, or over-excited desire, affec- tions of the imagination, and the depressing passions. Fear of incapacity, or of not being loved, timidity, shame, disgust, hatred, jeal- ousy, surprise, terror, or any of the more vio- lent mental emotions, most commonly have this effect. The first of these causes is, how- ever, the most frequent; and the second—the influence of the imagination—the most power- ful and permanent. In former times, when su- perstition, and a belief in the power of magi- cians, of incantations, of sorcery and witch- craft, prevailed, the state of the imagination was often not only the cause, but also the cure of this affection ; and, while incantations and other modes of impressing the mind were re- sorted to for the purpose of destroying sexual power, amulets and charms were worn, not only for the purpose of guarding against their effects, but also for the restoration of this pow- er when lost or impaired. In the East and in Egypt, in Greece and in Rome, in uncivilized countries and in the seats of civilization, until a belief in witchcraft ceased, these means were daily resorted to, as well as others, which could operate only through the medium of the ima- gination. The bane and antidote were both confided in, however obscure, or impenetrable, or even absurd either of them might have been. Montaigne was the first to penetrate and to expose the mystery of their operation. The twentieth chapter of the first book of his Es- says will be read both with interest and instruc- tion ; and the thirty-seventh chapter of the sec- ond book will be found not less profitable to the practitioner of the present day. [See Guy’s “ Forensic Medicine,” Am. Ed., p. 60.] 6. 2d. The generative function may he variously impaired, and by diversified causes.—M. Virey remarks, with his accustomed desire of effect rather than of accuracy, that “ the genital or- gans offer two states during life in the young and old, which are the frozen zones of exist- ence, the intermediate period being the torrid zone of life. The child has nothing to give, the old has lost all.” Instances, however, oc- casionally occur of genital precocity; and those in which the function continues till a late pe- riod of life are by no means infrequent. The generative function appears with puberty, and continues until the sixty-fifth year, or even much later, unless impaired by excesses, or by local or constitutional disease. During, how- ever, this long period, numerous circumstances tend to weaken or permanently to destroy it. The constitution and energy of the parents are sometimes the cause of the imbecility of the offspring. Children from premature connexion, or of exhausted, aged, or worn-out persons, oft- en inherit the incapacity of their parents, in re- spect both of the function in question and of the system generally. Those who are thus heredita- rily or constitutionally impotent are of a leuco- phiegmatic or lymphatic temperament ; their soft solids, especially the fibrous and muscular structures, are soft, lax, and weak ; their forms are rounded, from the superabundance of cellu- lar and adipose substance ; their hair is soft and fine, and deficient on the face and pubes ; their frames are delicate and feminine ; their voices are shrill, clear, sharp, or weak ; and their testes are small and soft, the cords and scro- tum being soft, lax, and pendulous. 7. Functional impotence is most commonly caused by premature or excessive venereal in- dulgences, and especially by the pernicious crime of manustrupatio. By these most inju- rious habits the organs are excited to action before they are fully developed, and the semi- nal fluid excreted before it is duly elaborated. The muscles concerned in the generative func- tion, and those, also, of the lower extremities, are either imperfectly formed, or have their en- ergy remarkably impaired, so that they become susceptible, vacillating, and ultimately nearly paralyzed. The imagination is morbidly acute or excitable, and erection imperfect, or frequent and momentary. The seminal and prostatic secretions are consequently weak, thin, clear, scanty, and serous ; the whole frame, and par- ticularly the nervous system, languish, and be- come enfeebled by the too frequent discharge of a fluid essentially vital, partly recrementi- tious, and necessary to their support; and ul- timately the testes emaciate, or become soft. The variety of impotence noticed by Dr. Paris depending upon a want of consent between the male organs of generation, or that in which erection takes place without discharge, or in which the latter takes place too quickly, and •after imperfect erection, is most commonly the consequence of the causes just mentioned. But in such the evacuation consists chiefly of the prostatic fluid. General debility, from im- perfect or unwholesome nourishment, may weaken the procreative energy, or render the desire less frequent, but it rarely destroys it altogether, or even for a time. Severe dis- eases, intense application to study, or to ab- stract inquiries or pursuits, have a still more remarkable effect in impairing, or temporarily destroying, the generative functions. In some instances, prolonged disuse of this function is followed by the wasting of the testes, and, con- sequently, permanent impotence is the result. These organs, like others of the economy, are strengthened by moderate use, are weakened by abuse; their functions being often entirely lost by protracted disuse. 8. There are various other causes which may occasion functional impotence, particularly in certain constitutions ; as the use of narcotics, IMPOTENCE AND STERILITY—In the Male. 371 especially of tobacco, hyoscyamus (Marc), ci- cuta, and opium. The sedative gases (Fodere), particularly carbonic acid gas, may produce it. Various refrigerants have a similar influence, as nitre, thf carbonates of soda, camphor (Di- emerbroeck and Lossius), and some cooling diuretics. The smell of camphor has long been considered as anaphrodisiac ; and colchicum has certainly this effect, as noticed by Dr. Beat- ty. Soda water also exerts the same influ- ence. The effect of these, however, are only temporary or partial. Injuries of the spine or spinal cord, or of the head, particularly the oc- ciput (Marcellus Donatus, Fabricius Hilda- nus, Hennen) ; venajsection behind the ears (Hippocrates) ; arteriotomy, &c., have been considered causes of impotence. Of the influ- ence of the first of these there can be no doubt. The use of mercury has been assigned as a cause ; but it can hardly be viewed as such, unless carried to excess. 9. 3d. Organic lesions occasioning impotence are, (a) Diseases of the generative organs or of the adjoining parts; (b) Malformations of these organs ; and (c) Deficiency of one or more of them. Anaphrodisia from the first of these is often only temporary and relative ; but from the second and third it is generally absolute and permanent. A. The diseases which most fre- quently cause impotence are, first, those of the penis ; secondly, of the testes ; and, thirdly, of adjoining parts.—a. The penis may be so ex- cessively irritated as to occasion a temporary impotence by obstructing the opening of the seminal ducts and the urethra. Much more frequently, however, complete or partial paraly- sis, or deficient energy of the nerves, and, con- sequently, of the muscular and vascular action of the organ, occurs, constituting the anaphro- disia paralytica of authors. This latter state is merely an aggravated form of functional impo- tence, and most commonly produced as above stated. A singular instance, in which the cells of the corpora cavernosa were apparently dis- organized or altered by inflammation and sup- puration, so as to prevent the influx of blood, and consequent distention of the penis, and to occasion impotence, has been recorded by Mr. Callaway. A similar change to this may take place in one side of the organ, and have nearly the same effect upon its functions. 10. Various obstructions to the seminal dis- charge occasion temporary or permanent impo- tence. The chief of these are strictures of the urethra and disease of the seminal ducts. Fo- dere (Med. Leg., lib. i., p. 382) adduces two ca- ses in which the powers of copulation existed, but without the seminal discharge. In one the ducts were obstructed by hard concretions ; in the other they were constricted and callous. As stated by Dr. Beatty, the opening of the conjoined ducts of the vesicules seminales and vasa deferentia may be closed by scirrous en- largement of the neck of the bladder, by en- largement of the prostate gland, by scirrosity of the verumontanum, or by lesions of the duct itself. Strictures of the urethra can hardly be considered a cause of impotence, unless they are so extreme as not to permit the passage of a fine bougie. In the states of disease just mentioned, the inability of procreation arises from obstruction to the discharge of the semi- nal fluid, which is duly secreted ; and when the obstruction is seated iu the urethra, it may be removed by modern surgery. M. Fodere and Dr. Dunlop state that double scrotal hernia, by pressing upon the spermatic cords, sometimes causes as complete emasculation as if the tes- tes were entirely removed. 11. b. Impotence may also depend upon or- ganic lesions of the testes—upon scirrus, carci- noma, fungoid disease, or scrofula of these or- gans. But unless the whole structure of both organs be changed, the faculty of procreation may not be entirely or permanently lost. Un- common smallness of these organs may occa- sion only temporary impotence ; for this state may depend upon delayed evolution, or arise from the wasting consequent upon disuse. Mr. Wilson mentions the case of a person, twen- ty-six years of age, in whom the penis and tes- tes remained of the same size as in childhood. He married at this age, and at twenty-eight the organs had reached their natural size. When, with smallness, there are remarkable flaccidity and softness conjoined, impotence is much more complete and even permanent. In a case of this kind in a strong young man, some time under my care, no benefit resulted from treatment. Severe bruises of the testes may be followed by wasting or disorganization of them. Dr. J. G. Smith alludes to this mode of making eunuchs, and states that it some- times failed. I believe that most of the instan- ces in which impotence has been said to have been produced by riding have been owing to bruises or injury of these organs, or to the pressure to which they have often been sub- jected. Wasting of the testes may, however, arise without any very obvious cause. In the extreme case in which I was consulted, I was unable to ascertain its source. It occurred in a most robust and muscular young man, who would not admit that he had ev*er had recourse to excessive or vicious indulgence, or that he had been unusually continent, until his inclina- tion ceased with the decay of the organs. Fo- dere states that it was a common disease among the labourers in the canal at Arles ; and Larrey, that it was not uncommon among the French troops on their return from Egypt. It has sometimes occurred as a consequence of the metastasis of Cynanche parotidcea to the testes. Induration of these organs, independ- ently of scirrous disorganization, may be so great as to destroy their functions. According to M. Andral, the seminiferous tubes are en- tirely obliterated, and the structure of the or- gan is hard, homogeneous, and without trace of organization in cases of extreme induration. Impotence from inflammation of the testes is only temporary. [We have observed one instance where im- potence was caused by a bruise, which result- ed in the absorption of the testicles ; and one where the same consequence followed from the long-continued and excessive use of iodine. Chronic inflammation of the testicle from any cause may result in impotence, as from the pressure of a truss, hydrocele, metastic inflam- mation after mumps, a blow of any kind, &e. We sometimes meet with impotence from ar- rest of development of the testicle. In such cases, the individual presents the appearance of a person void of sexual characters. There are no beard or whiskers, and no hair on the 372 IMPOTENCE AND STERILITY—In the Male. pubes. Curling mentions cases where one testis, in an adult, weighed but two scruples and one grain, whereas the average weight of a fully developed testis is six drachms. In these cases, moreover, there are no spermato- zoa in the seminal fluid. Where a testis weighs less than three drachms, Mr. Curling thinks it must be regarded as in a state of atrophy. Where a testis is undergoing the process of wasting not arising from disease of the gland, it usually preserves its shape, but feels soft, having lost its elasticity and firmness. The epididymis does not usually waste so soon, nor in the same degree as the body of the testes.] 12. c. The lesions of adjoining parts occasion- ing impotence are, chiefly, uncommon obesity, very large scrotal hernia, and hydrocele. Nei- ther of them requires any mark. A varicose state of the spermatic veins may also have this effect, when it is very remarkable. But I am unacquainted with cases in which this cause has been assigned. 13. B. Malformations of the male genitals may occasion impotence. Great size of the penis is seldom, and smallness of the organ perhaps never a cause of it, if the functions of the tes- tes are duly performed. According to Zacchi- as, Fodere1, Beatty, and others, excessive size, particularly excess in length, may produce rel- ative or temporary impotence, by injuring the female organs. The chief malformations of the penis having this effect absolutely or per- manently are those in which the urethra ter- minates in the perineum; and even in these impregnation may be accomplished by art. John Hunter was consulted in a case of this description, and was induced, by the experi- ments of Spallanzani, to recommend the pa- tient to collect the seminal fluid emitted from the perineum during intercourse, and to inject it into the vagina. Impregnation took place, and a healthy child was born in nine months. 13. In cases where the urethra opens in a part of the penis admitting of being introduced within the vagina, impotence may exist, but it is only relative ; for procreation may be effect- ed when the opening is thus situated, whether it be on the dorsum (epispadias) or on the infe- rior surface (hypospadias), as more frequently observed. Numerous instances are recorded by Simeons, Belloc, Kopp, Blundell, and Fo- dere of impregnation by persons in whom these malformations existed. Mr. J. Hunter met with a case in which the epididymis termi- nated in a cul-de-sac instead of passing to a vas deferens. Dr. Beatty states that a simi- lar conformation sometimes exists in the vesic- uhe seminales, where, instead of entering the urethra, they terminate, after being joined by the vasa deferentia, in shut sacs. When these formations of the excretory ducts of the testes exist on both sides, absolute impotence neces- sarily results, but they are extremely rare. 14. C. Deficiency of one or more of the male or- gans occasions absolute or relative impotence. —a. Congenital deficiency of the penis is rarely observed, and complete deficiency still more rarely. M. Fodere mentions a case in which no vestige of the organ existed from birth. The testes were perfect, and sexual desire was not impaired. In most of the instances of con- genital partial deficiency or malformation of the penis recorded by authors, the urinary or- gans presented other malformations, particu- larly in respect of the urinary bladder and ure- ters. This is illustrated by several cases in Dr. Duncan’s Memoir on this subject. (Edin. Med. and Surg. Journ., vol. xxv., p, 31.) Acci- dental deficiency of the penis is sometimes met with. The organ may have been either ampu- tated or destroyed by disease. Some years ago a surgeon, a friend of the author, was sent for in great haste. He found a man in a state of syncope from haemorrhage proceeding from a very recent amputation of the penis close to the pubis. The strictest secrecy was preserv- ed as to the cause and mode of amputation, which had evidently been effected by a sharp instrument. 15. The glans penis, and, indeed, the great- er part of the organ, may be lost without caus- ing more than relative impotency ; and possi- bly, nearly all of it may be removed without producing an absolute loss of the procreative faculty, if the means resorted to by John Hun- ter ($ 12) be employed. Instances of extensive mutilation of this organ, without destroying this power, are referred to by Frank, Paris, Beatty, and others; and although there is ev- ery reason to conclude that a complete remo- val of the penis will generally occasion impo- tence, yet the proper function of this part be- ing to excite the female organs, and to convey the prolific fluid to the parts destined to receive it, if these purposes can be at all accomplished, impregnation may follow. 16. b. Congenital deficiency of the testes is rarely observed; and most of the cases in which these organs have been said to have been wanting are merely instances of their re- tention in the abdomen. When they are not found in the scrotum, their entire absence can be inferred only from the history of the case, and from the state and appearances of the pa- tient ; for when they are altogether wanting, the usual characters of the male are partially lost, and those of the female assumed. As de- lay in the descent of the testes may arise from some imperfection, or delay of development, as J. Hunter reasonably infers, certain of the female characters may be presented, and yet these organs may exist nevertheless. The question then is, whether or not the state ot development to which they may have attained is sufficient for procreation. M. Marc adduces the case of a person of a feminine appearance, who yet possessed the full procreative power. The external characters cannot, therefore, al- ways be confided in ; but when all the external appearances of virility are present, although the testes are not found in the scrotum, there is every reason to infer that impotence does not exist; for numerous instances are on rec- ord proving that the mere retention of these organs within the abdominal ring does not af feet the procreative power. 17. The congenital absence, destruction, or removal of one testis is not a cause of impo- tence. It may, however, be a cause of relative incompetency, and even of complete impotence, if the remaining one be soft, small, or withered. Castratioh, or the removal of both testes, is fol- lowed by complete and permanent impotence, if it have been performed before puberty. But, subsequently to this period, the power of pro- creation may exist for a very short time after IMPOTENCE AND STERILITY—In the Female. 373 its performance, owing to the seminal fluid col- | j lected in the vesiculse seminales previously to s the operation. M. Marc supposes that, the j ; time taken for the cure of the wound is suffi- j < cient for the absorption of this fluid into the j 1 circulation ; but the cases adduced by M. Boy- < er and Sir A. Cooper prove that a temporary ; power exists or is retained until the vesiculae 1 seminales are emptied. On this subject, the 1 works of Paris and Beck will be consulted with < advantage, for it hardly comes within the scope 1 of this work. 18. II. Impotence and Sterility in the Fe- male. A female may be impotent, but not ster- il, and she may be steril, but not impotent; for, as respects the former condition, a state of the sexual organs may exist sufficient to pre- vent intercourse, and yet upon its removal im- pregnation may take place ; and, as regards the latter condition, perfect competency to in- tercourse may exist, and yet conception may never occur. She may also be both impotent and steril, or, in other words, were the imped- iment to due intercourse entirely removed, im- pregnation might not be effected. Sterilite is very much more common than impotence in the female, and even than impotence in the male. 19. A. The causes of Impotence in the female are an impervious state of the vagina, absence of this canal, remarkable constrictions of it, the division of it by a septum running downward from a double uterus, adhesions of the sides of the vagina, or of the labia, and the termination of the passage abruptly in a cul-de-sac. An impervious vagina may arise from changes in the soft parts, consequent upon protracted in- flammation or irritation, the passage becoming first constricted or remarkably contracted, and. ultimately obliterated. In a case respecting which I was consulted, a recto-vaginal fistula, seated at the upper part of the vagina, had oc- casioned so remarkable a contraction of the vagina that its canal was almost obliterated, its parietes having become callous and indurated. A similar result may also follow a vesico-vagi- nal fistula. Fodere believes that malforma- tions of the bones of the pelvis may be so great as to prevent intercourse, but this can hardly be the case. Exostoses, however, on the inter- nal or inferior surface of the bones of the pubis may have this effect, but their occurrence in this situation, and to this extent, must be very rare. Congenital absence of the vagina has been met with by Villaume, Moulon, Syme, and Warren ; and absence of both vagina and uterus by Mott, Davis, Macfarlane, and oth- ers. In a case adduced by Fodere, the uterus and vagina were found, upon dissection, to constitute one solid mass, without any cavity in either. In a child, examined after death by Hufeland, no trace of genital organs, peculiar to either sex, was found, externally or inter- nally. Although such instances are rare, there is no doubt that one or more of the different parts forming the female organs may be want- j ing. Congenital narrowness of this passage | has been observed in a very few instances. In one or two of these, however, impregnation j occurred, and the passage became enlarged in the progress of gestation. Contraction of the j vagina was said to have existed in the celebra- j ied Joan of Arc. The division of the canal by i a septum has been met with in a very few ca- ses only. Firm adhesions of the labia pudendi are not unfrequent in children, in consequence of neglected excoriation or inflammation. I have seen several instances of these adhesions of various extent, duration, and firmness. They are more rare in females after the age of pm berty ; but they have been met with at this age by Benevoli, Merriman, Ryan, Tucker, and others, and in some cases they have been so complete as nearly to prevent micturition. In- flammation or injuries, by instruments or oth- erwise, during parturition, have been followed by adhesion of the sides of the vagina, and to- tal obliteration of the canal. Several of the in- stances of obstruction by a strong membrane placed at the commencement, or in some part of the passage, recorded by Fabricius Hilda- nus, Ruysch, Ambrose Pare, Benevoli, Fo- dere, Physick, and others, may be imputed to adhesions long previously formed, which have subsequently assumed an organized and mem- branous state, rather than to an inordinately firm and resistant hymen. The hymen may, however, be thickened and hypertrophied, and be a cause of impotence by preventing inter- course. Yet impregnation may be effected nevertheless, as proved by numerous cases. This state of the membrane is therefore not productive of absolute impotence, even should it be allowed to continue ; and it is not a per- mament cause, as it may always be removed by an operation. Complete prolapsus or proci- dentia of the uterus, retroversion of the uterus, prolapsus of the vagina, cancer of the vagina or uterus, and extreme brevity of the vagina, are generally productive of impotence, although impregnation has occurred in rare instances, notwithstanding these lesions. 20. B. Sterility, may proceed from absence of the uterus, or of the ovaria, or of both. When the uterus is wanting, the vagina is usu- ally short. It may also proceed from a scir- rous or indurated state of this organ, from tumours in its substance, from polypi in its cavity, or attached to its neck, from occlusion of the Fallopian tubes, or adhesions of their fimbriated extremities to adjoining parts, from narrowness or entire obstruction of the os ute- ri, and from disease of both ovaria. Several of these require farther remark. Extreme con- striction of the os uteri has been shown by Dr. Mackintosh to be productive of difficult, pain- ful, or obstructed menstruation, and it most probably is also one of the causes of sterility. The mouth of the uterus may be completely obstructed by agglutination of its sides, or by a false membrane stretched across it, either in- ternally or externally. The openings of the Fallopian tubes may be also closed by a mem- branous production, or by an albuminous exu- | dation from the internal surface of the uterus. The tubes may be either partially or altogether obliterated, in consequence of the extension of inflammatory action to them from the uterus i or adjoining parts. When these alterations 1 extend to both tubes, sterility must necessarily I result. Although tumours developed in the I body or neck of the uterus, and polypi attached | to its internal surface, generally prevent im- | pregnation, yet instances have occurred in which conception has nevertheless taken place, i These are, however, very rare, and abortion 374 IMPOTENCE AND STERILITY—Tkeatment. has always occurred during the early months. A tumour or polypus may be formed on the in- ternal surface of the uterus, and yet after its removal the patient may conceive and bear a child at the full time. • A case illustrative of this has been recorded by Dr. Beatty. 21. The above causes are mostly productive of absolute or permanent sterility; but there are others which are either relative, or admit of removal. These are, chiefly, too profuse, or too frequent, and difficult menstruation, constant or profuse leucorrhcea, inflammatory affections of the uterus or of its appendages, dislike, disgust, and indifference on the part of the female, &c. Profuse or frequent menstru- ation is a more common cause of sterility than is generally supposed ; this state, particularly when associated with irritation of, or increased vascular determination to the womb, prevent- ing the retention of the ovum until it has un- dergone the changes necessary to its attach- ment to the uterus. Leucorrhcea is a cause of sterility chiefly when it depends upon the in- flammatory irritation of the internal surface or neck of the uterus, or when the secretion pro- ceeds from relaxation of the vessels in this situation. When it is a consequence of inflam- matory action, sterility may continue after the discharge has ceased, owing to organic chan- ges in the surface of the uterus, or in the Fal- lopian tubes, especially the formation of a false membrane in the former, and the produc- tion of an albuminous exudation in the canals of the latter, or consequent obliteration of them. When barrenness depends upon leucor- rhcea proceeding from local relaxation or gen- eral debility, it may be removed upon the dis- appearance of its cause. Delayed, retained, obstructed, or suppressed menstruation fre- quently occasions sterility. Some females have, however, conceived who have never menstruated ; and the mere suppression or ob- struction of the catamenia may or may not prevent impregnation; various other contin- gent changes or concurring circumstances either favouring or preventing this result. Difficult menstruation is sometimes a cause of sterility, but its influence also will depend much upon other circumstances. That form, however, of dysmenorrhcea, described by Dr. Duncan and Dr. Dewees, which appears to de- pend upon the formation of a membranous sub- stance in the uterus, having a strong resem- blance to the decidua, is very generally pro- ductive of barrenness ; but this is only one of the several forms which sub-acute or chronic inflammation of the uterus assumes, either of which may occasion temporary or permanent sterility. 22. There are other causes of temporary or relative sterility. Among these, the most common are too frequent, yet inefficient sex- ual intercourse, too early marriages, general ill health, and debility or exhaustion of the fe- male organs, owing to premature or too fre- quent excitement. Various circumstances con- nected with sterility in prostitutes have, per- haps, thrown some light upon certain of the causes of this state ; and particularly the fact that many of this class have had children after marriage, or after relinquishing promiscuous intercourse. Numerous instances have occur- red of females who, having been obliged to marry contrary to their inclinations, have not conceived, and yet have had children from a second marriage. It is generally understood by females of all ranks in society that indiffer- ence during intercourse, or suppression of the orgasm, will prevent impregnation; and al- though they are sometimes deceived in this respect, yet their inference is correct in the majority. This is one of the principal causes of the sterility of prostitutes, other circumstan- ces, however, besides those just alluded to, combining with it to produce this effect in them. 23. III. Treatment. The treatment of im- potence and sterility depends entirely upon the causes of either the one or the other, as far as they can be known. Many of these causes maybe fully ascertained, and the consequences correctly anticipated ; but as to the existence of others, inferences only can he drawn from a number of circumstances, and these inferences cannot be always fully confided in. Most of the organic lesions and deficiencies enumerated above cannot he remedied, yet a few of them may be assisted by art, either temporarily or permanently. But many of the functional and moral causes, and their effects, may be entirely removed. Absence of an organ or part essen- tial to the function of generation in either sex is generally productive of impotence and ster- ility. Yet an imperfection only, and disease of one or more of these organs, occasioning either inability in the male or barrenness in the female, may be remedied. Adhesions of the prepuce to the glans penis, phymosis, strictures of the urethra, fistulous openings in the course of the urethra, some of the diseases of adjoin- ing parts that prevent intercourse, paralytic and debilitated states of the penis, and the slighter injuries of the testes, may be perma- nently removed, and their consequences disap- pear. Contractions of the vagina, and even constriction or narrowness of the os uteri, oc- clusion of the entrance of the vagina by adhe- sions of the labia, or by a morbidly dense hy- men, or by a false membrane, prolapsus or pro- cidentia of the uterus or vagina, uterine polypi, leucorrhcea, difficult or painful menstruation, and inflammatory states of the uterus may be severally remedied, and although sterility may not be always, it will be frequently also remo- ved. 24. Cases of impotence and sterility from moral and functional causes are the most com- mon ; and although they require the most sci- entific and judicious treatment, yet the mental as well as the physical imbecility that often characterizes them, brings them more frequent- ly in the hands of pretenders and empirics, than in those of the qualified practitioner. The cases which proceed from these causes may be arranged into, 1st. Those which de- pend upon exhaustion ; 2d. Those which pro- ceed from disuse, or from an imperfect exertion of the function; and, 3d. Those which arise from excessive mental and physical excitement, relatively to the susceptibility and sensibility of the nervous system.—a. When impotence and sterility proceed from exhaustion, or from a premature decay of the generative functions, owing to premature, unnatural, or excessive excitement, the treatment is nearly the same in both sexes, according as either may be chief ly or solely affected. In these cases the indi IMPOTENCE AND STERILITY—Treatment. 375 cations are, to restore, 1st. The energies of j the constitution ; and, 2d. The functions of the procreative organs. To attempt the second, without either previously or contemporaneous- ly fulfilling the first indication, will generally be futile, and often injurious. Persons wffio are thus exhausted sometimes perpetuate their infirmity by having recourse to noxious excitants, and to the means advised by em- pirics. The scientific practitioner will be guided in the selection of remedies by the causes, circumstances, and phenomena con- nected with the case ; and he will find it neces- sary to associate a moral or mental regimen with the physical means which may be required. When the affection depends upon an excited imagination, in connexion with a depraved habit, the former part of the treatment is the most necessary, but the most unpleasant for the physician to prescribe, and the most diffi- cult for the patient to adopt. In these cases the mental weakness has advanced pari passu with the constitutional and local infirmity, un- til the mind has become incapable of exerting its more reflecting and moral powers. It will, therefore, be often necessary to restore the en- ergy of the nervous system by suitable diet, appropriate medicines, regimen, occupation, and change of air, before the moral part of the treatment wall receive due attention from the patient. 25. In other and slighter cases, the debility is principally local, the general health, as well as the mental energies, remaining only partial- ly or but little impaired. In these the local, constitutional, and moral means of cure will frequently prove successful, especially in the male. In this sex, when the inability depends chiefly upon weakness of the sexual muscles, invigorating modes of treatment, general and local, usually remove it, if its causes be avoid- ed. In all these, attention to the digestive and secreting functions, vegetable and mineral tonics, especially the preparations of iron, and chalybeate mineral waters, the shower bath, or the cold salt-water bath, with regular exercise in the open air, mental occupation, and early hours, will generally be most beneficial. Where the patient is subject to discharges from the urethra upon passing a stool, or on the excite- ment of sexual desire, a turgid and irritable state of the prostate gland may be inferred. WThen he is liable to frequent emissions during sleep, an irritable condition of the testes, and of the vesiculce seminales, obviously exists. In these, the more cooling tonics and the more astringent chalybeates may be employed, par- ticularly the mineral acids, alone or with bitter infusions, and the tincture of the muriate of iron, aided by the regimen already stated. When the general and local asthenias are great, a moderate use of wine, of warm spices and aromatics, with as full and nutritious diet as the digestive organs can dispose of, will also be requisite. But the mental and local causes of sexual excitement should be avoided, so that the function should not be exerted beyond what may be necessary to restore and to for- tify it. 26. When impotence in the male depends upon a too frequent exertion of the sexual function, the means of cure are sufficiently ob- vious. Yet the patient may be unable, from mental or nervous weakness, to exert the con- trol necessary for its cure. In such a case the usual restorative remedies should be prescribed, especially chalybeates and cold sea-water ba- thing. In most of these, the male organs are so irritable, that their functions are performed too rapidly and imperfectly, or before the or- gans, more or less necessary to procreation, can be excited in the female. At the same time, the male secretions are inadequate, par- ticularly in respect of elaboration and retention in the vesiculce seminales, for the accomplish- ment of the purpose for which they are intend- ed. This form of male impotence and sterility is commonly produced by masturbation, and is most benefited by whatever will improve the general health and restore the tone of the sex- ual organs. Attempts at intercourse in these cases should not be more frequent than may strengthen or promote the function, without exhausting or weakening it. 27. The other states (§ 7, 8) of functional im potence and sterility above alluded to hardly require a particular notice, as they are tempo- rary only, and soon disappear, as circumstances generally arise which soon remove their caus- es. It is, indeed, chiefly to the removal of the causes that the attention of the physician should be directed in the treatment of this com- plaint in both sexes. 28. In ancient times, and recently in some countries, both civilized and savage, the re- moval of impotence and sterility by the use of heating substances, supposed to possess aphro- disiac properties, was generally attempted. The prematurely aged, worn-out debauchees, and the community generally, in some parts, es- pecially in China, Japan, Africa, &c., often em- ploy substances which are reputed to possess these properties. But the effects they produce, when they produce any, are more commonly injurious than beneficial. Musk, ambergris, cantharides, phosphorus, opium, the hot spices, aromatics, coffee, vanilla, borax, genseng, cas- tor, saffron, &c., are supposed to possess aph- rodisiac virtues; and a diet consisting princi- pally of fish or shell-fish has a similar repute. Circumstances may arise in which it may be proper to prescribe certain of these as pos- sessing stimulating and restorative properties ; but others of them ought to be employed with extreme caution, particularly cantharides, phos- phorus, and borax. The nostrums said to pos- sess the virtues in question ought not to be re- sorted to. Certain articles of food, as pigeons, eggs, particularly raw or undressed eggs, ca- viare, herrings recently pickled, oysters, truf- fles, &c., may be employed, as being at least harmless ; but the less that heating medicines are prescribed the better, unless under certain circumstances which may occur to require them; as in cases where the sexual function has not been restored after exhausting and de- pressing diseases, or after prolonged exertion of the mind on abstract subjects. I was very recently consulted by a gentleman about forty, who had no return of the sexual function after a severe attack of influenza a twelvemonth be- fore. He had perfectly recovered from it in other respects for several months, and the re- maining imperfection was a source of distress to him. In a case of this kind, the physician should at least know the means most likely to 376 be of service, particularly as the inability may become a matter of family trouble, as well as of individual misery. Kjempfer states that a combination of musk, ambergris, opium, and aromatics, in the form of small pills, are much employed by the Chinese and Japanese as an aphrodisiac; and I believe that it is not with- out some degree of efficacy. But it is very obvious that the prolonged or too frequent re- course to these and similar substances is most injurious, both morally and physically. 29. The sterility of females must be treated with strict reference to the causes, as far as they may be ascertained or inferred. When it is chiefly functional, and induced by exhaustion, or by the noxious practices already alluded to, the means of cure are very nearly the same as have been here recommended, especially atten- tion to the digestive and uterine functions, the use of chalybeates, or of chalybeate or other tonic mineral springs, with air, exercise, and early hours. For them also, the cold salt-water bath, the show’er bath, or the salt-water douche on the loins, will also be of great service The importance of a due regulation of the mind, of healthy occupations, and of abstemiousness, should be duly estimated.* IMPOTENCE AND STERILITY.—Bibliography and References. Bibltog. and Refer.—ASlius, tetrab. iii., serm. in., c. 35; and tetrab. iv., serm- iv., c. 26. —Paulus JEginetus, L- 1., c. 36; 1. iii., c. 58. — Avicenna, Canon., 1. iii., fen. 20, tract i., cap. 15.—Augenius Horatius, t. ii., ep. 62.—Mon- taigne, Essays, &c., t. i., c. 20. —Trincavellius, Consil., 1- 111., n. 78. —Akakia, De Morb. Mul., 1. ii„ c. 16.—Mercuri. alis, Consil., t. i., n. 48 ; and t. iii., p. 3. —Mercatus, De Morb. Mul., 1. iii., c. 5. — Zacchias, Qmest. Med. Leg., 1. iii., tit. i., quest. i., seq. —Tagereau, Discours sur l’lmpu- issance de l’Homme et de la Femme, 8vo. Paris, 1611.—J. a Pratis, De Arcenda Sterilitat.e et Progignendis Liberis. Amstelod, 12mo, 1834.—liatlonius, Cons, ii., n. 26 ; iii., n 6, 20, 21, 28. — Arnatus Lusitanus, cent, ii., cur. 19; cent, vi., cur. 95.—Zacutus Lusitanus, Med. Pr. Hist., p. i., 1. iii., n. 18 ; et Prax. Admir., 1. ii., obs. 120, 123, 124. — Bonet, Sepulch., 1. iii., s. xxxiv., obs. 5. — Schurig, Gynsecologia, p. 223 ; et Spermatalogia, p. 506, seq.—Zwingcr, Theatrum VitiB Human®, p. 512.—Bartholinus, Epist. Med., cent, iii., op. 10.— Ettmuller, De Seminis Excretione et Retentione Lies;], opp. v., t. ii., p. i., p. 897.—De la Peyronie, in M6m. de l’Acad. de Chirurgie, t. i., p. 430.—Petit, in Ibid., t. i., p. 434.—Morgagni, De Sed. et Caus. Morb., ep. xlvi., art. 5, seq.; et Opusc. Miscellan, p. 34. — Kampfer, Amcenit. Exotic®, Fasc. i., p. 19 ; Fasc. iii., obs. 16, p. 654.—Hux- ham, in Philosoph. Transact., vol. xxxii., p. 408.—Taschen- buch, fur Freuude der Gesundheit, ad., 1785, p. 24.—Sau- vages, Nosolog. Metli., t. iii., p. ii. —T. Smith, Treatise on the Venereal Disease. Lend., 1788. — Herhcldt, in Arne- mann, Magnzin fUr die Wundarzneyk, b. ii., p. 112.—Fo- dere, vol. i., p. 361, &e.—Mahon, vol. i., p. 52, 54, 55, 57.— K. F. Burdach, Eugon Order iiber Impotenz und Schwaehe of the object most desirable, is also an admitted fact. The depressing influences of prevailing epidemics, as influenza, cholera, and the like, are known to have induced extreme indifference to sexual gratification, and lead to inability in the generative act for some time after their general preva- lence : this is well known as to the Asiatic, or malignant pes- tilential cholera. Rush inclines to rather an opposite opin- ion with regard to yellow fever ; but that disease, from its constitutional action, has, in many cases, manifested its noxious agency in torpifying the genitals for many months. I am aware of a formidable enlargement of the kidneys ex- tinguishing the venereal propensity; and three cases of diabetes mellitus, for which I prescribed, were accompanied by impotence. Neither cases of epispadia nor hypospadia are necessarily fatal to successful venereal intercourse. Belloc mentions a case where an individual affected with this last-named infirmity proved, nevertheless, the father of four children. I am apprized of a like case where the sufferer is the father of two children ; and Dr. Mott is aware of examples of a similar nature. The most frequent sources of barrenness or sterility in the female may be con- sidered as associated with the disordered condition of the monthly period, and of these the most common are amenor- rhosa, dysmenorrhoea, an immoderate flow of the menses, or their too frequent occurrence, leucorrhoea, and its divers causes, physometra, and disease of the os tincse. Dysmen- orrhea, accompanied with the formation of the deciduous membrane, almost invariably prevents conception. I have become acquainted with but five cases as exceptions. 1 have never known physometra allow of pregnancy until the original disorder was removed. A reference to tiie individ- ual causes of this defect in the female, as well as those oc- curring in the male, is indispensable to a successful treat- ment of these infirmities. The triumphant results of the administration of several forms of iodine gives cheering views of the issue of many of these sources of trouble in the tender sex, inasmuch as we find the constitutional in- fluence of the several preparations of iodine and the iodurets to be of saving efficacy in numerous uterine maladies. I have known three instances of extensive ovarian dropsy ex- isting, and pregnancy, nevertheless, to ensue : hydatids of the uterus have been removed, and pregnancy has followed venereal congress. In the case of a lady, aged thirty-three, the mother of three children, a tumour of the internal cav- ity of the womb, growing from the fundus, did not prevent conception. I delivered her of a well-formed living child at the usual termination of the period of gestation. The remedial powers of the tincture of cantharides I have tested with the happiest effects, more particularly in the male sub- ject, and none, I believe, will be reluctant to admit the vast importance of the practical precepts recently urged by Lal- lemand with regard to caustic applications. The armed bougie is sometimes indispensable to the male urethra, where the atony is not to be controlled by ordinary meas- ures. I am convinced that our apprehensions of the direful consequences of the lytta, when given internally, are more imaginative than real. I have used it with great freedom in a vast number of cases f*r long periods, with demon- strative evidence of its potency, and also of its harndess- ness. Blended with the terebinthinates, cold bathing, pleasurable exercises of the mind, and fortified at all times by such advice as removes despondency and invigorates hope, the victim of impotency is often released from the horrors of despair and restored to his virile functions.”] * [On the legal relations of impotence and sterility, and their bearing on questions of medical jurisprudence, the ed- itor would refer to his additions to Guy’s Forensic Medi- cine (N. York, 1845, p. 62). Some of the causes are there, also, more particularly detailed, and remarkable cases given. “ It is no easy matter to affirm,” says Dr. Francis, “ which of the two forms of disease, impotence or sterility, is most frequently to be met with by the general practitioner, the sources of these two affections are so numerous and so va- rious in both sexes. That masturbation in the male sex is productive of this infirmity in a greater number of cases than all the other causes generally assigned for its origin, is a conclusion which seems to be justified by clinical ex- perience ; while the numerous disturbances to which the sexual functions of the female are exposed, such as the va- rious modifications of the monthly lustrum, amenorrhcea, dysmenorrhcea, profiuvia mensium, irritability of the os uteri, leucorrhma, affections of the ovaria, and the like, may fairly be pronounced the most frequent source of sterility or barrenness in the softer sex. Nevertheless, the practi- tioner who should be indifferent in scrutinizing the entire catalogue of causes which science has unfolded as adequate to the origin of this deficiency of power in the procreative organs, when medical advice is solicited in cases of this annoying kind, would prove derelict in his duty, and justly be liable to the censure of neglect. A practice of upward of thirty years has brought within my observation a large number of instances of this infirmity, both in the male and in the female. The vicious practice of self-indulgence is to be recognised as the primary origin of disability in at least eight cases out of ten, when occurring in males : men- tal causes, or the depressing emotions of the mind, often the sequelae of onanism, have also a formidable agency in leading to a like result. I have known the excessive abuse of mercury to cause impotence ; and two instances of this infirmity came to my knowledge, arising from the metasta- sis of cynancha parotidea. While the canal policy of the State of New-York was carrying on, in 1816-18-19, several of the workmen became affected with a disorder not unlike the sivvens of Scotland, and several of these cases termina- ted in disability of the generative power. I have known constitutional disturbance, originating from the bad man- agement of syphilis, prevent conception, until the alterative action of mercury has restored the sufferer to his wonted health, and a natural secretion. The atony induced by the abuse of saccharum saturni has also led to inability to beget offspring. 1 am inclined to the theory sustained by numer-' ous physiologists, that there are occasional instances of in- congruity in the seminal flux with the peculiar ardour of the female ; and several cases in which the female, as well as the male, were in good health, though without children, have, by a second marriage on either part, proved prolific. Several cases are known in this city where the venereal congress has been followed by fecundation by individuals with only one testicle ; and in a remarkable example, where it was conceded by several competent judges that three tes- ticles existed, the generative act was not crowned with pregnancy. That excess in the venereal orgasm, even when properly and naturally performed, will sometimes fail INDIGESTION—Pathology 377 der Zeugungskraft, &c., 8vo. Leipzig-, 1804. — Hiilfsbuch, fiir Alle, die an Schw&che der Gesciilechtstheile leiden, 8vo. Hamburg, 1807.—Hufeland, Journal der Practischen Heil- kunde, b. ix., st. 3, p. 107. — J. P. Frank, De Cur. Horn. Morb., 1. v.,p. 45, et p.253.—Schneider, Journ. des Progr. des Sc. Med., t viii., p. 258 (erectio nulla, sed pollutiones noct.). — A. B. Granville, in Loud. Med. Repos., vol. viii., p. 347. —Callaway, in Ibid., vol. xxi., p. 286. —J. Copland, in Ibid., vol. xxv., p. 106.— Gunther, in Ibid., vol. xxv., p. 185.—Renauldin, in Ibid., vol. xxvi., p. 78.—Stein, Annals of Philosophy, vol. xvi., p. 114.—Coats, in Edin. Med. and Surg. Journ., vol. i., p. 39.—.4. Duncan, in Ibid., vol. i., p. 43 and 132.—A. Cooper, in Ibid., vol. i., p. 128.—Pears, in Ibid., vol. iii., p. 105.—Conquest, in Ibid., vol. vii., p. 23.— Maclure. in Ibid., vol. xxi., p. 315.—Maitland, in Ibid., vol. xxv., p. 31. —Vernon, in Ibid., vol. xxvii., p. 81. —Syme, in Ibid., vol. xxxii.,p. 246 ; vol. xxxiii., p. 243 ; et vol. xxxvii., p. 337.—Stedman, in Ibid., vol. xxxvii., p. 26.—Houston, in Ibid., vol. xxxviii., p. 266. — Turnbull, in Ibid., vol. xxxix., p. 128.—Edwards, in Ibid., vol. xli., p. 403.—Paris, Medi- cal Jurisprudence, vol. i., p. 205.—Duchachet and Drake, in New-York Med. and Phys. Journ., vol. v., p. 443.—Hosach, in Ibid., vol. ii., p. 12.—V\ Mott, in Ibid., vol. ii., p. 19.— M'Naughton, in Ibid., vol. vi., p. 252.—Moulon, in Amer. Journ. of Med. Science, vol. ii., p. 193.—Ashwell, in Ibid., vol. iv., p. 149.— Williams, in Ibid., vol. xi.,p. 408.—Hoille- min, in Ibid., vol. xv., p. 407.—Barret, in Drake's Western Med. and Phys. Journ., vol. iii., p. 206. — Dewees, On the Diseases of Females, p. 43 ; and in Coxe's Medical Museum, vol. i., p. 165. — Litters Monthly Journ. of Foreign Med., vol. i., p. 189.— Villaume, in Ibid., vol. i., p. 376. — Hay- ward, in Boston Med. Magaz., vol. i., p. 91 ; and in Amer. Journ. of Med. Science, vol. xiii., p. 79.—Hamilton, in Bost. Med. and Surg. Journ., vol. xi., p. 93. — Lasserre, in New- England Journ., vol. ix., p. 161.—Delpech, in Med. Chirurg. Rev., vol. xvii., p. 553.—A. Cooper, in Ibid., vol. xviii., p. 389.—Macfarlane, in Ibid., vol. xxii., p. 450.—R. Hamilton, in Transact, of the Royal Society of Edinburgh, vol. ii., art. 9.—Marc, in Diet, des Sciences Mhdicales, t. xxiv., p. 176. — Hennen, Military Surgery, 2d edit., p. 303. — Brewster, Edinburgh Encyclopedia, vol. i., p. 825.— Wilson, Lectures on the Urinary and Genital Organs, p. 408 and 424.—Chap- man's Journal, N. S., vol. iv., p. 34.—Baillie's Morbid Anat- omy, p. 371.—Eberle's Med. Review, vol. ii., p. 394.—Dor- sey’s Surgery, vol. ii., p. 368.—G. Lee, Ecclesiastical Re- ports, Appendix, vol. ii., p. 580. — Raige Delorme, Diet, de Medecine, t. xii.,p. 74.—Blundell, in Lancet, N. S.,vol. ii., p. 771. —Elliotson, in Ibid., vol. viii., p. 55.—Macfarlane, in Ibid., vol. x., p. 624. — Liston, in Lond. Med. Gaz., vol. vi., p. 252. — Earle, in Ibid., vol. x., p. 8. — Dupuytren, in Ibid., vol. xi., p. 128; et vol. xiii., p. 878.—Pereira, in Ibid., vol. xix., p. 447.—Hurd, in Lond. Med. and Surg. Journ., vol. iv., p. 323.—M. Ryan, in Ibid., No. 170, p. 422. — G. Langstaff, in Medico-Chirurg. Transact., vol. viii., p. 505. — W. Russell, in Ibid., vol. xi., p. 445.— Arnott, in Ibid., vol. xii. — T. E. Beatty, Cyclop, of Pract. Med., vol. ii., p. 594.—Andral's Pathol. Anat.,vol. ii., p. 414.—Gooch, On Midwifery, p. 8 and 45.—Good's Study of Medicine, vol. v., p. 7.—Burns, A Treatise on Midwifery, &c., chap, iv., note 47. — Denman, Midwifery, p. 148, 149. —D. D. Davis, Obstetric Medicine, vol. i., p. 513. [Am. Bibliog. and Refer.—George Bushe's Med. Chir. Bulletin, volii., p. 1.— Gross, in West. Journal Med. and Physical Sciences, vol. x., p. 46.—Fish, in Bost. Med. and Surg. Jour., vol. xv., p. 268. — White, in Baltimore Med. and Surg. Journal, vol. ii., p. 314.—Mussey, in Am. Jour. Med. Sciences.—Hopkins’s Chancery Reports, vol. i.,p. 557. —Revised Statutes of the State of New-York, vol. ii., p. 142, 143.— Paige’s Chancery Reports, p. 554.—Griffith’s Ryan, p. 111. — C. A. Lee, Am. Ed. of Guy’s Forensic Medicine, Art. Impotence.—Laws of New-Hampshire, 1830, p. 157.— Revised Laws of Illinois, 1833, p. 233.—Revised Laws of Indiana, 1831, p. 213.—Digest of Laws of Tennessee, 1831, p. 74.—Laws of Missouri, 1825, p. 329.—Wright’s Ohio Su- preme Court Reports, p. 518.—R. Dunglison, in Am. Med. Intelligencer, vol. i., p. 138.—Pancoast, in Ibid., p. 147.] INDIGESTION. — Syn. AvaiteijiLa (from 6vf, with difficulty, and rteitTu, I digest), fpadv- tteipta, attnpta, Gr. Concoctio tarda, Stomachi resolutio, Cruditas, Indigestio, Passio Stoma- chia, Auct. Lat. Apepsia, Vogel. Soda, Lin- naeus. Anorexia, Sagar. Bradypepsia, Sau- vages. Dyspepsia, Swediaur, Cullen, Parr. Dyspepsia Simplex, Young. Limosis Dyspep- sia, Good. Schwere Verdauung, TJebel Ver- dauung, Germ. Indigestion, Fr. Indiges- tione, Ital. Bad digestion, Sloiv digestion, fyc. Classif.—2. Class, Nervous Diseases ; 2. Order, Defect of Vital Energy (Cullen). 1. Class, Diseases of the Digestive Function ; 1. Order, Affecting the Ali- mentary Canal (Good). I. Class, I. Order (Author in Preface). 1. Defin.—Impaired or fastidious appetite; slow and difficult digestion ; sensations of discom- fort referrible to the stomach, and frequently cos- tiveness. 2. Dyspepsia or indigestion has been employ- ed as the generic designation of several disor- ders ranged under it as species by most mod- ern writers, and particularly by Sauvages and Cullen. Young and Good have limited the meaning of the term, by considering some of those disorders as altogether distinct from it. Dr. Todd, however, in an able and comprehen- sive article on the subject, has applied this term to all the functional disorders of the alimentary canal. Having discussed several of the affec- tions viewed by some writers as species of indigestion in separate articles, according to their natures and seats (see articles Ccecum, Colon, Costiveness, Duodenum, Flatulency, Pyrosis, Stomach, Painful affections and inflam- mation of), my observations, at this place, will necessarily be confined to the simpler forms of this disorder. 3. Indigestion is either primary or secondary, idiopathic or symptomatic, simple or complicated. When it is complicated, it may have been either the primary or the secondary affection. Dr. Todd distinguishes between symptomatic and sympathetic dyspepsia ; and remarks that “ a secondary dyspepsia maybe conveniently divided into symptomatic, forming only a part of a more general disease, and sympathetic, the conse- quence of consent with the disorder of some other organ.” The distinction is, in some re- spects, wanting in precision, but it maybe pre- served as being one usually recognised. 4. The varieties or forms of indigestion have been variously described, named, and arranged by the numerous recent writers on this disor- der ; and a most eager disposition has been evinced by all to assign new terms, and to de- vise distinct pathological states for each. In some instances, distinctions have been multi- plied to an extent bewildering the inexperi- enced, and beyond the actual morbid manifes- tations of the organs affected. It will be readily admitted that different forms of indigestion will depend upon different states of the stomach, and of its associated viscera; that, in one, the organic sensibility will be especially affected; in another, the secretions ; in a third, the mus- cular contractility ; in a fourth, the circulation ; in a fifth, two or all of these functions ; and that these particular affections will be variously associated with disorders of the liver, or of the pancreas, or of the duodenum, and not merely with these, but with others in remote organs. Yet these individual affections, even in their simpler or less complicated states, will seldom be manifested by symptoms enabling the most close observer to determine with precision which of them is the one actually present, either in a simple or predominant form, or the exact associations to which it. may have given rise. It will, therefore, be proper not to mul- tiply distinctions beyond those which will be found useful for practical purposes. The dis- order which proceeds from a simple diminution of the functions of the stomach, from impaired secretion, weakened organic contractility, and 378 INDIGESTION—Asthenic—Description. languid circulation, from asthenia of the organ, will, with propriety, form one variety of indi- gestion ; and that which depends upon a state of erethysm, or vascular irritation, approaching, but not amounting to inflammation of the villous surface, will constitute another. This latter, especially, will present certain modes, accord- ing as the sensibility, the villous membrane, or the follicular apparatus is prominently affected. Those states of disease which are generally consequent upon dyspepsia, although some- times appearing independently of it, and which have been classed by some writers as severer forms of this complaint, will be found under the heads referred to above. 5. I. Description. — i. Simple Asthenic Dvspepsia—Stomachi Resolutio, Celsus ; Fri- giditas Stomachi, Prosper Alpinus ; Dyspepsia Idiopathica, Cullen ; First Stage of Indigestion, W. Philip ; Atonic Gastric Dyspepsia, T. J. Todd ; Dyspepsia per Asthenic de VEslomac, An - dral ; Dyspepsia Apyretiquc Asthdnique, Brous- sais—is characterized chiefly by a sense of dis- tention of the stomach, by acrid or acid eructa- tions, and flatulence soon after a meal; by loss of appetite, or loathing of food, and occasion- ally by nausea. These symptoms, however, vary with the nature and quantity of the food. Heartburn, nidorous or putrescent eructations, and a feeling of weight or oppression at the epi- gastrium, are generally present after a very full meal, particularly of fat, oily, or rich meats. The tongue is pale, flabby, whitish, slimy or coated, and often indented by the teeth; the bowels are costive, sometimes irregular; the urihe is pale, copious, and occasionally deficient in urea, or contains albumen ; the pulse is soft- er, weaker, and often slower than natural; the temperature is diminished, or irregularly dis- tributed, the extremities being cold, and the surface pale or flaccid; the eyes are languid, and the physical and mental powers deficient in vivacity and energy. The symptoms, how- ever, vary much in grouping and intensity with the kind, quantity of the solid and fluid ingested, with the temperament and constitution, and with the manner in which associated viscera are sympathetically affected. In some cases, they are gradually and very slowly developed by the continued operation of the causes ; in others they are more rapidly or suddenly in- duced by errors in diet, or by other powerful circumstances. 6. A. The latter, or the more acute and sud- den attacks of indigestion, are generally conse- quent upon some manifest cause, particularly an overloaded state of the stomach, and is identical with the cruditas of the ancients and the emharras gastrique of the French. It may occur, however, from substances which disor- der the organic sensibility of the viscus, or from other causes. When it proceeds from this source, the symptoms soon follow a full meal, or appear in the morning. The patient experiences various uneasy or even painful sensations, with oppression or weight at the epigastrium, and heartburn. These often ex- tend to the pharynx. The tongue becomes dry, clammy, or loaded, and the taste is lost or per- verted. Rancid, oily, indigested, or acid sub- stances are eructated or brought off the stom- ach, without nausea or retching. There are generally headache and languor. If nausea and vomiting take place, the contents of the stomach are thrown up, either partially or alto gether undigested, with a ropy phlegm. Where vomiting does not occur, a sense of irritation or constriction of the fauces and pharynx, with a copious secretion of a watery fluid, and pains in the stomach, are often present. The appe- tite is abolished, or savoury articles of food are only relished. When the fit of indigestion oc- curs during the night, the patient experiences frightful dreams, or the nightmare, or spasmod- ic twitchings of the limbs, or severe pains in the stomach or bowels, or wakens with severe headache. The pulse is weak, languid, or soft; the skin cool and moist, and the extremities cold. Frequently chills, horripilations, formi- cations, or even slight shudderings, occur. Va- rious sympathetic affections often attend this state of dyspepsia, particularly headache, as described in that article, impaired or indistinct vision; muscae volitantes, noises in the ears, and dullness of hearing; disorder or impairment of the sensds of taste and smell, palpitations, and vertigo; colicky pains in the abdomen, costiveness, &c. 7. An attack of dyspepsia in an acute or sud- den form seldom appears, unless from the caus- es just alluded to. But it may proceed, partic- ularly in delicate persons or females, from other causes, as powerful mental impressions, long fasting, or deprivation of wonted stimuli. In such cases, vomitings, or even retchings, rarely occur; but nausea or disgust at food, giddiness, headache, faintness, sinking or pain at the epi- gastrium, costiveness, pallor and coldness of the surface, and inactivity, with irritability of temper, with some of the other symptoms al- ready noticed, are commonly complained of. These acute attacks are liable to pass into the more confirmed or chronic state of the complaint, next to be described, particularly when they recur frequently or are neglected. 8. B. The confirmed or chronic form of dys- pepsia may take place gradually or slowly, or as a consequence of the foregoing. In the former case, it is almost imperceptible in its progress, but it generally commences with symptoms of general as well as local debility. All the physical and mental functions betray more or less inactivity. The sleep is disturbed or unrefreshing, sometimes heavy or prolonged. The appetite in the morning is impaired and capricious, savoury articles being chiefly rel- ished, and a sense of soreness or relaxation in the throat is often complained of. A full meal is followed by heaviness, yawnings, stretchings, and an almost irresistible disposition to sleep, by sense of fulness, weight, flatulence, or by rancid or acrid eructations, &c. As the dis- order continues, the appetite is more impaired and more capricious. The bowels become cos- tive or irregular ; the discharges being scanty, offensive, discoloured, or more copious or fre- quent, and sometimes containing imperfectly digested portions of food. The biliary secretion is either insufficient or disordered. Perspira- tions are copious on exertion, often offensive, and quickly discolour the linen. Flatulence is troublesome, particularly when the stomach is empty; the mouth is clammy, and the tongue loaded or furred, especially in the morning. The countenance becomes pale or unhealthy; and the body occasionally enlarges about the INDIGESTION—With vascular Erethism. 379 trunk or abdomen. Vertigo, loss of memory, lowness of spirits, apathy, indifference; and numerous associated and sympathetic disorders supervene, according as the asthenia of the stomach extends to the duodenum and intesti- nal canal, or to the secreting collatitious vis- cera. In many cases the affection extends along the tesophagus to the pharynx and fauces, occasioning the slightest forms of angina, or simple relaxation of the uvula. 9. As dyspepsia becomes confirmed, various additional sympathetic affections appear. In- deed, there is scarcely a viscus that may not betray disorder. Irritation about the larynx, chronic cough, particularly in the morning; huskiness of the voice, or hoarseness ; copious perspirations, and eruptions on the skin ; dry and parched state of the hair, or morbid con- dition of the cuticle and of the nails ; great sen- sibility of cold, and also of heat, are very com- monly observed. Shortness of breath on slight exertion ; palpitation of the heart; intermis- sions and irregularity of the pulse ; and other sympathetic disorders about to be noticed, often also appear. This variety of indigestion, when neglected, or when its causes continue in oper- ation, sooner or later passes into one or other of the forms of the variety next to be described. 10. ii. Indigestion with vascular Erethism —Irritative Dyspepsia ; Cardialgia Injlamma- toria, Sauvages ; Gastrite Chronique, Brous- sais ; Second Stage of Indigestion, W. Philip ; Inflammatory Gastric Dyspepsia, T. J. Todd—is characterized chiefly by slow and painful diges- tion, a sense of heat and discomfort at the epi- gastrium, increased by food and by pressure, with thirst, dryness of the mouth and fauces, redness of the edges and point of the tongue, while the middle and root are white, loaded, or furred; costiveness, high-coloured urine, par- tially increased temperature and dryness of the skin, and a more frequent and sharp pulse than natural. It offers several grades of severity and various modes, according to the exciting cause, the temperament of the patient, and to the man- ner in which the organic sensibility and con- tractility, the secretions and associated viscera, are individually implicated. It may appear sud- denly in an acute form, when the cause has been active, or gradually and slowly, either primarily or consecutively, upon the variety al- ready described. 11. a. In the slighter states of irritative dys- pepsia, the appetite is often increased, occa- sionally ravenous, in some instances impaired ; thirst is generally present, particularly in the evening. The extremities are often cold ; but burning or heat of the soles of the feet and palms of the hand frequently occur, particularly in warm or temperate weather. The point and edges of the tongue are red, the papillae raised or excited, and the root more or less loaded ; the bowels are confined, and the stools dry and scanty. The pulse is somewhat excited, es- pecially in the evening, and rather sharp than hard or contracted. Headache, sometimes with slight redness of the conjunctiva and contrac- tion of the pupils, heaviness, unsound sleep, unpleasant dreams, and a feeling of fatigue and lassitude upon waking, are generally present. The symptoms referred directly to the stomach, at first, are often not more severe in this than in the preceding variety ; and pain, with tender- nes.s on pressure, is not more frequently com- plained of. As the complaint, however, be- comes more chronic, a burning pain is felt at the stomach, and is increased by a full meal and by pressure. Great discomfort and a sense of a load are referred to the region of this or- gan. Fulness or distention at the epigastrium, often extending to one or both hypochondria, is usually present. When heartburn occurs, it is characterized by a sense of heat or burning, and attended by redness and soreness of the fauces and pharynx. The tongue and throat are frequently dry, and the voice soon becomes husky on speaking, or on exerting it. Small vesications occasionally appear on the sides and points of the tongue, and more rarely ex- coriations on the fauces. In protracted cases, the tongue is often smooth, sometimes slight ly fissured or chapped, or lobulated. or even glossy. Pain is felt in the left shoulder, or in the left hypochondrium, extending to the shoul ■ der blade, or between the scapulae, and beneath the sternum. Severe headache ; irritability ol temper; depression of spirits ; impaired appe- tite ; palpitations ; a harsh, dry state of the skin, frequently with scaly eruptions; occa- sional bursts of perspirations during sleep ; in- ability to lie on the left side; burning heat in the palms of the hands and soles of the feet; increased acuteness of the senses, or obscura- tion of certain of them, and a morbid state of all the excretions, severally appear, and often divert the patient’s and practitioner’s attention from the source of disorder. In some cases pain, often increased by flatulence, shoots through the hypochondria and chest, and a symptomatic cough, with slight grayish expec- toration in the morning, is excited, owing to nervous connexion, and to the extension of ir- ritation to the pharynx and top of the larynx. In these, pectoral disease is sometimes sus- pected ; and inflammatory irritation of the lar ynx may be actually thereby occasioned. 12. b. In the more severe or acute attacks ot this variety of indigestion, particularly when produced by hurtful or indigestible food, or stim- ulating liquors, there is a total and sudden loss of appetite, with nausea, retchings, or full vom- iting, increased by, or instantly following the ingestion of substances into the stomach. Oc- casionally the contents of the organ are regur gitated without effort or nausea, but with pain or a sense of constriction at the epigastrium and hypochondria. The pulse is, at times, but little affected ; at others, quick and sharp, and the skin is harsh and hot ; but perspirations break out when free vomitings are induced. There is always thirst; pain, or a sense or burning, of scalding, or of soreness is generally felt in the stomach, and it often extends, in the course of the oesophagus, to the throat, giving rise to a similar symptomatic affection of this part, and of the larynx and chest, as just noticed (§ 11). In rare instances, however, where the retchings and vomitings are frequent and se- vere, but little pain, and no tenderness in the epigastrium are present, or much less than the severity of the symptoms indicates. The co- pious discharge from the mucous follicles and exhalants of the villous coat, in these cases, re- moves the congestion of vessels, or the morbid conditions productive of pain and tenderness in other cases. But the symptoms varv re- 380 INDIGESTION—Of certain Symptoms of# markably with the exciting cause, with the temperament and disposition of the patient, and with the previous disorder and existing state of the collatitious viscera. 13. c. In the aged, or in young persons of a phlegmatic temperament, and in cold or damp cli- mates and seasons, irritative dyspepsia assumes a form which has been denominated Anorexia pituitosa, Anorexia Catarrhalis, Catarrh of the Stomach, &c., by various writers. Dr. Todd has called it Follicular Gastric Dyspepsia; and most probably it proceeds from an inordinate and morbid secretion from the follicles of the stomach that irritates the organ ; but he has improperly confounded it with Pyrosis, which it closely resembles. It is characterized by an aching pain, by gnawing, or by a sensation of cramp, weight and uneasiness, or soreness, felt chiefly in the morning, when the stomach is empty, by loss of appetite, nausea, and some- times by vomiting of a ropy, transparent, glairy, and tasteless fluid. It is often complicated with, or consequent upon severe catarrhal af- fections of aged or phlegmatic persons, and is not infrequent in rheumatic constitutions, after errors in diet, and the use of indigestible, rich, or incongruous articles of food or drink. In this case it usually occurs in the night and fol- lowing morning. Along with indigested sub- stances, a very large quantity of this colourless glairy matter is thrown up, and often continues to be ejected for a considerable time afterward. M. Andral has seen it thrown off in very large quantities, independently of the irritation of of- fending matters; but these matters are more commonly concerned in keeping up the morbid secretion. In most of the cases I have seen the pulse was soft, languid, sometimes sharp during the attack, which was attended by a foul, loaded, or sodden state of the tongue,* a warm perspirable surface, or free perspiration, much depression of nervous power, and consti- pation ; but there was little or no thirst, nor tenderness or increase of pain on moderate pressure of the region of the stomach. Flatu- lence, eructations of an insipid or slightly acid fluid, a copious flow of saliva from the mouth, or of a watery fluid from the pharynx, and op- pression or distention of the stomach, although pain is much abated, after eating, generally accompany the disorder. This form of irrita- tive dyspepsia is often preceded or attended by severe catarrhs, by dyspnoea, or humoral asthma, or by rheumatic affections ; and it is most common in cold and wet seasons, when these are prevalent. In its slighter or less acute states, or when appearing independently of over-distention or irritation of the stomach by bulky or indigestible substances, the pulse is usually slow or §oft, the extremities cold, the evacuations scanty or mucous, and the tongue white, sodden, or loaded. As Dr. Todd re- marks, there is a frequent desire to take food, with thirst, and, as the disease continues, there is wasting of the flesh. The uneasiness caus- ed by the laborious digestion subsides as the process is finished; but before the time of taking food arrives the stomach becomes irri- tated by its own secretion, which produces all the inconvenience of a foreign indigestible sub- stance in that organ ; such as a sense of sink- ing, of dragging, of nausea, faintnoss, gnawing, or erosion, which are again, for a time, reliev- ed by the taking of food. (See art. Pyrosis.) 14. iii. Of certain Symptoms of Indigestion. —A. Cardialgia, or Heartburn, presents itself in two forms, each of which assumes various grades of severity. It is generally attended by acid or acrid eructations, exciting irritation in the throat and fauces. The acidity of the eruc- tated matters is often remarkable, occasioning the most unpleasant sensations in the mouth and pharynx, with a copious flow of fluid from those parts. The matters brought up from the stomach are sometimes rancid and alkaline, par- ticularly after a full meal of rich or fat animal food. In this case a feeling of disgust is exci- ted on each eructation, and large quantities are thus thrown off, or regurgitated from the stom- ach, without either nausea or retching. In either form, unpleasant gnawing, burning pain, and tenderness, are felt at the epigastrium, with distention, extending to the hypochondria, and with tightness or oppression in the chest. Cardialgia chiefly occurs during the period of digestion, but sometimes not until an advanced stage of the process. It may be mild, and con- sist simply of uneasy sensation, gnawing, o> burning at the cardia, sometimes with slight faintness or flatulence; or it may be severe, the uneasiness extending over the region of the stomach, attended by depression, anxiety of countenance, and faintness. This latter state has been denominated sinking heartburn. It is only when cardialgia is severe that it is accom- panied with frequent and copious, rancid, alka- line, or septic eructations. 15. B. Of the Evacuations, &c.—a. The stools furnish comparatively little information in dys- peptic ailments, when only those procured by an active purgative are examined. They are most commonly scanty, dry, and deficient in healthy odour and colour, especially in the as- thenic and simple states of the complaint. In the irritative states the discoloration is often greater, and they are occasionally mucous or watery, particularly when irritation extends along the alimentary canal. But in either va- riety they vary remarkably in colour, consist- ence, and character; being either dry, pulta- ceous, slimy, scybalous, mucous, bilious, clayey, whitish, or yeasty, and sometimes presenting several of these appearances at the same time. The calls to evacuation are commonly rare or delayed, but they are occasionally frequent and inefficient. It is chiefly when torpid or disor- dered function of the liver, duodenum, or intes- tinal canal is associated with indigestion that the states of the evacuations described by Dr. W. Philip are met with; for these states, as Dr. J. Johnson justly contends, are not com- mon in the simpler forms of the complaint. “The alvine discharge.” the former writer re- * [It is the opinion of Louis, Andral, and other pathol- ogists, that there is no direct relation existing between the state of the tongue and the state of the stomach in disease ; in other words, that the former does not afford any certain evidence of the condition of the latter. We certainly ob- serve, in some instances, a clean tongue when there are strongly marked symptoms of grave disease in the stomach ; and it is no less true that we find the tongue coated or covered with aphthous crusts, or red and smooth when there is no evidence of decided gastric affection. The lat- ter state of the tongue, moreover, exists sometimes in gas- tritis, but it often arises from a purely local affection of the tongue itself. Thus we may have a clean tongue with a diseased stomach, a diseased tongue with a healthy stom- ach, or disease coexisting in both organs, but independent of each other.] INDIGESTION—Causes of. 381 marks, “ sometimes chiefly consists of bile ; its colour at other times is too light, more fre- quently too dark, and occasionally almost black; at different times it assumes various hues, in- clining to green or to blue ; and sometimes it is mixed with, and now and then almost wholly consists of undigested bits of food.” When there is much straining it often contains mucus, sometimes in distinct masses, or substances resembling bits of membrane. “ It frequently separates from the canal with more difficulty than usual, and leaves a feeling of the bowels not having been completely emptied.” 16. b. The urine of a person in good health is perfectly clear and limpid when passed, and continues so for some time after it cools, being more or less deep in colour, according as its ingredients are concentrated or diluted. But it has been satisfactorily shown that when acidity is prevalent in the stomach and digestive canal, or when the usual acid secretion of the skin is impeded or suppressed, the urine, after stand- ing for some time, deposites a reddish sub- stance, which is found to be a coating of lithic acid, the supernatant fluid still remaining clear; but when an opposite condition to this exists in the digestive organs, the contents of the stomach being alkaline of devoid of their proper acidity, and when the function of the skin is unusually excited, the urine becomes turbid, and a whitish, or purulent white sediment is observed, consisting of lithate of ammonia, or of an amorphous deposite of phosphates and lithates. If irritation or inflammatory affection of the stomach is present, this fluid is scanty and high-coloured. In irritability of the organ it is often pale, limpid, and very copious. In several states of indigestion, it occasions smart- ing in its passage, owing to the unusual abun- dance of urea. Dr. Prout observes that in one or two cases of obstinate dyspepsia he has seen the urine not only passed of a bright pink col- our, but remain so on cooling, without deposit- ing any sediment; and he considers this pink colour to proceed from the large quantity of purpurate of ammonia present, which, from there being no lithate of ammonia with which it might be combined, was necessarily held in solution. 17. c. Pain and tenderness at the epigastrium and region of the stomach have been much in- sisted upon by Dr. W. Philip as indicative of the more inflammatory states of dyspepsia; but, as I have shown elsewhere (see Stomach —Morbid Sensibility of), the most severe pains in this organ are often felt without any inflam- matory disposition. Tenderness upon pressure is a very common symptom in the slight or more functional states of indigestion, as well as in the severe or more inflammatory, espe- cially in thin and delicate persons. It is sel- dom wanting in irritative dyspepsia. The ten- derness is often connected with fulness in this region, and also in the hypochondria; but this latter symptom is generally owing to the dis- tention caused by flatus, and by feculent and flatulent collections in the colon. When ema- ciation takes place in protracted cases the ful- ness becomes more apparent. 18. d. The pulse in dyspepsia is extremely various, but it is most commonly as I have de- scribed it. During the digestion of a full meal it is usually accelerated, and somewhat harder or sharper than usual. The hardness insisted on by Dr. W. Philip as indicative of the pas- sage of functional into inflammatory dyspepsia is seldom present. Sharpness and quickness are more frequently observed, and are symp- toms of irritation rather than of inflammation The febrile symptoms occasionally occurring, with soreness of the throat, high-coloured urine, and impaired secretions, are more prob- ably occasioned by the former than by the lat- ter pathological state. 19. C. Of the states of the associated viscera in dyspepsia.—It is obvious that indigestion will vary in form and severity, with the concomi- tance of disorder in any of the other digestive organs. The functions of the Duodenum may be deranged, as shown in that article ; and, in this case, dyspepsia will present more or less of the characters there described (§ 2). Other parts of the digestive canal may be deranged, the affection consisting either in impairment of function, or in nervous or vascular irritation, and being limited to the small intestines, or to the large bowels, or even to one only of the latter. (See arts. Ccecum and Colon.) In such cases the physician will be guided by the state of the evacuations, and by the symptoms detected on a careful examination of the abdo- men. It is not improbable that the pancreatic secretion becomes disordered, particularly in protracted cases; but of this sufficient proofs are seldom furnished: at best it can only be a probable inference. That this secretion may be diminished is not unlikely, inasmuch as there is sufficient evidence of the biliary secre- tion being deficient, retained, and altered, espe- cially in the chronic states of indigestion ; and it is reasonable to infer that, when one of the organs deriving influence from the same part of the nervous system is impaired in its func- tions, the other organs thus associated, as well as otherwise anatomically connected, will be similarly, if not co-ordinately affected. Indeed, every experienced practitioner must have no- ticed a more or less remarkable deficiency, or other disorder of the bile in dyspepsia; and not only of it, but also of the other secretions poured into the intestinal canal. That the dis- order originally induced in the stomach often extends to the other digestive organs, owing to various concomitant or consecutive circum- stances, cannot be doubted. It may be even apprehended that the consecutive disorder will become the most serious in its nature and con- sequences when these circumstances are fre- quent or continued in their operation, and that it will thereby obscure or mask the original af- fection. In many cases of dyspepsia the func- tions of the biliary apparatus are impaired, in respect not only of the quantity, but also of the qualities or properties of the secretion. In some, more or less of retention or obstruction of bile actually takes place, as shown by the state of the stools, rather than by the colour of the surface of the body. The remora of bile, also, in the biliary ducts and gall-bladder, arising from impaired function of the stomach and torpor of the liver, will farther increase the morbid state of the evacuations. 20. D. Sympathetic affections of various or- gans.—While an immense number of diseases originate in neglected or protracted indigestion, various disorders are entirely sympathetic of it. 382 Diseases of the urinary organs, of the liver and bowels, gout, rheumatism, various painful, neu- ralgic, and nervous affections, eruptions on the skfti, disorders of the catamenia, and many others often thus arise. Dr. Webster, in a treatise published in 1793, endeavoured to show this, before the appearance of the writings of Mr. Abernetiiy on the subject; but it had not been altogether neglected in the works of Whytt and others. This excellent author very justly remarks that a delicate state of the first passages, or an unnatural sensibility of their nerves, not only disposes to many com- plaints in those parts, but the whole nervous system is thereby rendered more liable to be affected by the slightest causes. “ Faintings, tremours, palpitations of the heart, convulsive motions, and great fearfulness, may be often owing more to the infirm state of the first pas- sages than to any fault either in the brain or heart. The powers which the alimentary ca- nal, w’hen its nerves are disagreeably affected, must have in producing disorders in the most distant parts of the body, cannot be doubted by those who attend to that wonderful and widely- extended sympathy which obtains between it and almost the whole system.” 21. a. The brain and organs of sense are often much affected by indigestion. Headache is one of the most common and severe affec- tions sympathetically excited by this complaint, but it has received sufficient consideration in the article on its different forms. The mani- festations of mind, both intellectual and moral, are also often more or less disordered, although but slightly or imperceptibly. Memory is some- what impaired, attention is unsteady and can- not be long continued, the disposition is more fickle, and the temper more irritable than nat- ural. There are often confusion of thought or of ideas, lowness of spirits, despondency, and vertigo, particularly in severe or protracted cases. M. Broussais has argued, with much apparent justice, that the functional disorder thus sympathetically induced in the brain may, by its frequency or continuance, pass into or- ganic change, and several recent writers in this country have adopted the opinion. 22. b. The organs of sense are not less liable to sympathetic disorder. The sight becomes weak and indistinct, the eyes impatient of light or irritable, and specks, or muse® volitantes, appear in the axis of vision. Hearing is fre- quently impaired, often from weakness of the nerves, but sometimes in consequence of the erythematic redness and inflammatory irrita- tion symptomatically produced in the throat having extended along the Eustachian tube to the internal ear, or having caused obstruction of this canal. Noises in the ear are usually present in these cases; and these, as well as the hearing, depend much upon, and vary with the state of the stomach. Care should be ta- ken, however, not to impute affections of the head and of the senses, depending upon disease within the cranium, to disorder of the digestive organs. The disorders of these parts, arising from the stomach and other digestive viscera, disappear, or are mitigated by wholesome food and drink, taken in moderate quantity ; but when they proceed from the brain they are ag- gravated, or, at least, not mitigated by the usual ingesta. INDIGESTION—The Consequences of 23. c. In the article Flatulence, I havi shown the effect produced upon the actions of the heart by this and other causes of distention of the digestive tube. Palpitations, and irreg- ularity and intermissions of the pulse, very oft- en proceed from dyspepsia, particularly when the functions of the liver and of the intestinal canal are also disordered. In such cases, the morbid sounds of the heart are usually want- ing, unless in some cases of severe palpitation, when a slight bellows sound is heard. The functional disorder, when frequent or protract- ed, may be followed by dilatation or some oth- er organic change. When structural lesion al- ready exists in this organ, the symptoms are much increased by indigestion, and by concom- itant disorder of the liver. It should, however, be recollected that lesions of the heart often occasion congestions of the liver and dyspeptic affections, and always aggravate them where they already exist. 24. d. The influence of dyspeptic complaints in producing affections of the lungs was con- tended for by Dr. W. Philip, doubted by Dr. Paris, but admitted, in a limited sense, by Dr. J. Johnson, and some others. The choice Dr. Philip made of the term “ dyspeptic phthisis" was certainly not fortunate, inasmuch as its meaning is equivocal. In protracted dyspepsia, and particularly when the liver becomes con- gested, or otherwise disordered, the respirato- ry organs also are affected ; the disorder of the digestive viscera both predisposing to affec- tions of the respiratory passages, and occasion- ally more directly causing them. The irrita- tion excited in the oesophagus, pharynx, and top of the larynx by the affection of the stom- ach is sometimes propagated along the air- passages ; and if, at the same time, the stom- ach is frequently distended and the liver con- gested, so as to impede the circulation through the lungs, disease of this latter probably will often be induced, especially if latent tubercles, or some other states of predisposition, exist. Besides, the debility caused by protracted dis- order of the digestive organs often calls latent tubercles into activity, or rapidly develops them ; and it may even be suspected that the impaired nutrition, consequent upon the debili- ty and protracted disorder of the organs of sup- ply, will sometimes even give rise to tubercu- lar productions where they did not previously exist even in a rudimental state. 25. iv. The Consequences and Termina- tions op Indigestion have been partially allu- ded to (§ 19, 20); but they require a more par- ticular notice.—(a) Dyspepsia may terminate in a restoration of the healthy function of di- gestion ; (b) It may pass into more severe functional or structural disease of the stomach ; c. It may superinduce disease of the liver, bowels, and other collatitious organs ; (d) It may give rise to affections of remote organs or parts ; (c) and, lastly, it may alter the constitu- tion of the circulating fluids, originate diseased secretions and depositions, and generate a mor- bid diathesis of the system, occasioning sev- eral serious constitutional maladies. These consequences will, however, depend much on the exciting causes, the predisposition, the temperament, the habit of body, and other cir- cumstances proper to the person aflected. 26. a. A termination in favour of healthy di- gestion seldom takes place, or if it take place, it is rarely permanent, unless the predisposing and exciting causes are avoided. Many of those causes originate in those propensities, desires, and passions which are controlled with the greatest difficulty ; and several of them de- pend upon habits which require the utmost force of character to relinquish. Hence the want of success so often experienced in the treatment of dyspeptic complaints, and the dis- satisfaction evinced by those who run from one physician to another, unreasonably expecting immediate or permanent relief, still desiring to indulge the senses—to gratify the propensities and desires, natural or acquired, without pay- ing the penalties thereby incurred. Hence, also, the frequency of the serious consequences of severe or neglected dyspepsia about to be noticed. 27. b. The forms of indigestion already de- scribed, from neglect or the continuance of their causes, may pass into the more severe affections of the stomach. In some instances, the most violent gastrodynia or gastralgia su- pervenes on them. (See Stomach—Painful Affections of.) In others, Pyrosis follows the form of irritative dyspepsia attended by the re- jection of a glairy fluid ($ 13), and seems to be an extreme condition of the same complaint, with modifications depending upon peculiarities of constitution and of functional lesion. In some cases, Vomiting (see that article) of a severer or more prolonged character than that occasionally taking place in dyspepsia, occurs, even independently, although more frequently in consequence of structural change of either the stomach or some other organ. In the lat- ter case, the source of mischief may be in the liver, or in the brain, or even in the kidneys, or uterus. More rarely, neglected cardialgia, or other dyspeptic states pass into partial or com- plete Rumination (see that article), particular- ly when the meals are taken hurriedly, in large quantity, and insufficiently masticated (see Author, in Lond. Med. and Phys. Journ. for May, 1821, p. 362). Neglected dyspepsia is very frequently followed by inflammatory ac- tion, and its consequences in the villous coat of the stomach (see Stomach—Inflammation and Organic Lesion of). This result, I am con- vinced, would more frequently take place, and when it did occur, would lead to still more se- rious effects but for the circumstance of the secretions from the villous coat favouring res- olution by unloading the capillary vessels, and for the want of appetite and nausea attending inflammatory action, preventing the ingestion of substances calculated to keep up the morbid action. 28. c. The supervention of disease, function- al or structural, in collatitious viscera, in the course even of the more simple and slight forms of indigestion, is so common, that the atten- tion should never be withdrawn from it in prac- tice. There are few cases of dyspepsia in which the functions of the Liver and Duode- num (see those articles) are not more or less disturbed. The liver becomes torpid and con- gested, and sometimes more or less tumid, from either congestion in its vessels, or accu- mulations of bile in the ducts ; this secretion being-often inspissated from absorption, during its remora, of its more watery part. It then INDIGESTION—Causes op. either obstructs, irritates, or otherwise disor- ders the canals along which it passes (see art. Gall-bladder and Ducts), and affects even the substance of the liver itself, which ulti- mately becomes inflamed, and gradually and variously changed. In protracted or severe cases of indigestion, other organs also become disordered, especially the bowels ; constipation, colic, or diarrhoea, in some one or other of their forms, frequently occurring, particularly when irritation of the digestive mucous surface is in- duced, and when the secretions poured into the intestines are deranged. 29. d. Affections of remote organs, sympa- thetically produced by dyspepsia, have been al- ready noticed ($ 20), but there are others which arise from this complaint, rather by a succes- sion of morbid changes than by any sympathy or consent of parts. When protracted or se- vere indigestion gives rise to an imperfectly elaborated chyle ; or when the impaired organ- ic nervous energy, which is chiefly manifested in the functions of the stomach in dyspepsia, extends also to the circulating, assimilating, and excreting organs, affections of the kid- neys and urinary bladder, in connexion with a morbid state of the urinary secretion, frequent- ly take place. Hence the formation of sabu- lous matter or gravel in the urine, and of cal- culi in the kidneys and bladder; and even the production of diabetes, and of slighter disorders of the excretion of urine. In females, dyspep- sia not unfrequently occasions difficult, too fre- quent, or delayed or irregular menstruation, hysteria, and painful affections of the spinal nerves in some portions or other of their dis- tribution, with tenderness in the dorsal spine. In both sexes, cutaneous eruptions either ori- ginate in, or are perpetuated by dyspeptic dis- orders, and by the state of the circulating flu- ids, and of the cutaneous exhalation conse- quent upon them. A due recognition and esti- mation of these connexions of disorder are of the utmost importance in practice. 30. e. There is every reason to infer that the pathological conditions, of which dyspepsia is an early and important indication, by altering the functions of assimilation and secretion, and weakening the processes of depuration, may give rise to a state of the circulation, produc- tive of painful affections, or of unnatural forma- tions and depositions in weak or predisposed parts ; or, in other words, to a truly morbid di- athesis, or constitutional derangement. Hence the frequency of rheumatism, of neuralgic or painful affections, of urinary calculi and gravel, and especially of gout, after protracted or se- vere indigestion. 31. II. Causes.—A. Predisposing.—Indiges- tion, although not confined to any period of life, occurs most commonly between the ages of twenty and forty-five ; and in its simple form more frequently in the female than in the male sex, The upper classes of society and the middle ranks of life are most subject to this variety of the complaint. It is more preva- lent in cold and temperate than in warm cli- mates, and in the winter than in the summer; but, whatever may be the temperature of the climate or of the season, damp weather and a moist atmosphere may be regarded as among its most active predisposing causes. The pre- disposition to this disorder is sometimes hered- 383 384 INDIGESTION—Causes op. itary, particularly in persons of a weak, relaxed fibre, with high nervous susceptibility, and gen- eral debility of constitution. Those in whom the functions of the stomach are naturally weak and feebly performed, the circulation languid, the temperature of the extremities below the natural standard, and the secretions generally disordered, or more abundant than usual, are also constitutionally predisposed to dyspepsia. Sedentary occupations, especially when carried on in close rooms and factories, indolent habits either of body or mind, long and intense study, insufficient exercise in the open air, addiction to debilitating excesses and injurious indulgen- ces, luxurious modes of living, indulgence in sleep or in bed, breathing impure air, and con- finement to close or ill-ventilated apartments, remarkably predispose to this complaint. In persons thus predisposed, the slightest excess or irregularity, or the most trivial exciting cause, is often sufficient to bring on an attack of indigestion ; while a repetition of such caus- es, or long exposure to their action, in those of a stronger habit and more vigorous constitu- tion, cannot fail to have a similar effect. 32. B. The exciting causes are divisible into two classes: (a) Those which operate imme- diately or directly upon the stomach itself; and, (h) Those which influence this organ through the medium of other parts.—(a) The causes which affect the stomach itself act either by diminishing or otherwise vitiating its secre- tions, so that the due change is no longer ef- fected in the food ; or by debilitating its mus- cular power, so that the aliment, although it may have been properly acted upon by the gas- tric juice, is not propelled into the duodenum with the natural ease and rapidity. As the admixture of the food with the gastric juice, and the passage of the chyme into the duode- num can only be accomplished by the due con- traction of the muscular fibres of the stomach, it is evident that whatever tends to weaken or to impede this action, will at once be followed by oppression or distention of the organ. In this class of agents may be included narcotics, taken habitually or in excess, as opium, hen- bane, conium, digitalis, &c., indulgence in ar- dent spirits or intoxicating liquors, and the con- stant or frequent use of the preparations of ammonia, of lavender, and of other aromatic spirits. But the most common causes of indi- gestion are, irregularity and want of due cau- tion in diet, whether as regards the quantity or the quality and congruity of the food, or the periods at which it is taken, and the use of to- bacco in any of the modes in which this nox- ious substance is so generally employed. 33. A want of due relation between the state and powers of the digestive organs and the substances upon which they are required to ex- ercise their functions, is a very frequent cause of this complaint; for whether the stomach be distended by an unusual quantity of food, or whether its secretion be compelled to act upon substances which are inappropriate or to which it is unaccustomed, the function of the organ will be equally impeded ; and if the exciting cause be powerful, or continue in operation, digestion will be altogether suspended. Hard and indigestible articles of food must therefore be productive of this disorder, and hence its frequency among the peasantry and lower or- ders. Heating and highly seasoned articles of food, hot dishes, and condiments, mushrooms, shell-fish, melons, cucumbers, nuts, and simi- lar substances ; raw, stale, or unripe fruit; rich articles of confectionery ; acid,, iced, or sweet fluids, especially when taken during the process of digestion ; large quantities of cold or of warm fluids, as of tea, relaxing slops, &e., and the habitual use of malt liquor, are among the most common causes of indigestion. The kind of aliment also exerts no small influ- ence, even in. mechanically distending, and thereby weakening the stomach ; for as most of the articles of food, when received into the organ, seem to swell in a greater or less de- gree, a bulky meal, particularly of solid or pul- taceous or vegetable substances, will not a lit- tle contribute to this effect. To the above causes may be added, irregularity in the period between the times of taking food, hasty or im- perfect mastication, frequent interruption or talking during the progress of eating, the omis- sion of an accustomed meal, abstinence or long fasting—hence its frequent occurrence during the fasts of the Catholic Church, and among the Brahmins, Fakirs, &c., in India—a sudden change in diet from animal to vegetable food, and from substances of a succulent and refresh- ing to those of a dry and heating nature, and severe and repeated vomiting. All these tend, in a greater or less degree, to debilitate the muscular fibres of the stomach ; to produce a deficiency of gastric secretion, or a secretion vitiated in its properties, and to irritate the vil- lous coat of the organ. 34. b. Among those causes which operate on the stomach through the medium of other parts may be classed those mental emotions which depress nervous power or otherwise disorder its manifestations. A due secretion of the gastric fluid depends much on the state of ner- vous influence, for a deficiency of the latter impedes or lessons the former. Any sudden intelligence, a violent fit of passion, or of great joy, sometimes instantly brings on an attack of indigestion. Grief, anxiety, envy, jealousy, indulgence in tender feelings, repeated disap- pointment, reverses of fortune, night watch- ing, &c., more slowly, but more certainly ex- ert a similar influence. Whatever exhausts the body and lowers the constitutional powers, exerts a correlative effect on the digestive functions, as venesections improperly adopted, or soon after a meal; protracted hemorrhages, menorrhagia, leucorrhea, venereal excesses, seminal weakness* and exhausting discharges of any kind. In persons particularly of a weak and delicate constitution, indigestion is easily induced by change of weather, by exposure to the night air, or to cold and humidity, by cold extremities, by a low temperature when the body is quiescent, as when travelling in an open carriage or on the outside of stages, by a fatiguing journey, by damp residences, and sim- ilar circumstances. Whatever exerts a de- pressing effect on the organic nervous power, or on any of the internal viscera, will also lower the function of the stomach, as large doses of calomel, or too long a continuance of this medicine, irritating and drastic purgatives, &c. Dyspepsia may be brought on also by the suppression of the natural and the accustomed discharges, or by the retropulsion of cutaneous INDIGESTION—Causes of. 385 eruptions, &c. It also not unfrequently ac- companies catarrhs, rheumatism, and diseases of the thoracic viscera ; it is a necessary con- sequence of disorder of any other of the ab- dominal organs, and it precedes and attends the various states of gout, &c. 35. C. The irritative states of dyspepsia are more frequently met with in the male than in the female sex, and are very prevalent in the southern countries of Europe, and among Eu- ropeans resident in tropical regions. They are common in those warm climates in which the air is dry, and the temperature subject to frequent and sudden variations ; but the caus- es acting directly on the stomach are often fre- quent and influential in those countries. In warm climates, the modes of living—the diet and regimen of Europeans—are extremely prej- udicial to the digestive functions, as shown by Hr .Anntesley and the author. — (Researches on the Diseases of India and of Warm Climates generally, &C., 4to, vol. i., p. 226.) The quan- tity and nature of the food and drink usually taken excite and irritate the stomach, liver, and intestinal canal, and exhaust their func- tions ; the states of indigestion thus induced soon passing into inflammation, or into organic changes, if neglected or injudiciously treated. 36. The irritative states of dyspepsia are, however, by no means uncommon in this coun- try in hot seasons, and even in very cold weath- er, and during the prevalence of severe or long- continued frosts, accompanied by northeaster- ly winds. They affect persons of a sanguine and bilious temperament, and of plethoric hab- it ; and in them, especially, are sometimes produced by checked perspiration, by the sup- pression of accustomed discharges, as of hajm- orrhoids, of leucorrhea, of the catamenia, &c., by the drying up of ulcers, and by the re- pulsion of cutaneous eruptions. They are, however, more commonly occasioned by the abuse of stimulants, as highly seasoned and rich food, and by addiction to spirituous and intoxicating liquors, and to opium. These states of indigestion are not so often conse- quent upon errors in diet as the other forms of the complaint; but they are most frequently met with in the habitual drunkard. They may be induced by change of diet, or change of resi- dence or climate, and hence their great preva- lence during spring and autumn; by stimula- ting medicines, as a long continuance of the use of cubebs and copaiba for gonorrhea; by drastic and irritating purgatives; by powerful or repeated emetics; by tonic, stomachic, and aromatic spirits or tinctures, taken in large do- ses or on improper occasions; by hot spices and pickles, particularly Cayenne pepper, cap- sicums, &c. ; by the frequent use of mercurial and of heating medicines ; by drinking cold and acid fluids after violent exercise, or while the body is perspiring, and by various noxious ar- ticles, used either as food or drink, or which give rise to incongruous mixtures in the stomach. [Dyspepsia is, comparatively, a very modern disease in our country, hhving been scarcely known until within the last thirty years. Our ancestors, as stated by an accurate observer,* were accustomed to much bodily exertion; there were but few pleasure or wheel carriages in the country; both males and females gen- erally rode on horseback ; professional men al- most universally had farms, on which they la- boured more or less ; mechanics were also fre- quently engaged in agricultural pursuits; the habits of living were simple and frugal; intox- icating drinks were seldom drank; religious ex- citements, so destructive to the health both of body and mind, were almost unknown ; regular and natural hours of sleeping and eating were observed; and these circumstances proved high- ly propitious in securing the general enjoyment of Dodily health and mental vigour. These salu- tary habits, however, have been gradually ex- changed for those of a more unnatural and inju- rious tendency: bodily labour, carried to the point of fatigue, is now deemed degrading, if not decidedly vulgar ; languishing in easy carriages has succeeded to pedestrian habits and equita- tion ; professional men confine themselves to the legitimate business of their calling; ex- citements of every kind, civil, religious, politi- cal, mesmeric, are the order of the day ; habits of luxurious living have become general; al- coholic drinks are more extensively used than formerly, although a great improvement has taken place in this respect within the last few years; the almost universal practice prevails of using tobacco in some form ; habits of inac- tivity, tight lacing, keeping late hours, &c., are gradually undermining the health of the female sex, and laying the foundation of gastric af- fections ; and all these causes, with numerous others that might be named, are slowly dete- riorating the health of the community, and their effects are likely to become still more evi- dent and distressing in the next and succeeding generations. Some of these causes of indigestion deserve more particular consideration. With respect to the use of tobacco, which has been lately increasing to an alarming extent, there can be no doubt that it is one of the most frequent causes of dyspepsia, notwithstanding the opin- ion sometimes advanced of its comparative harmlessness. Dr. Chapman states that a large proportion of the cases of this disease that come under his observation are produced by this drug.—(Lectures on the more important Dis- eases of the Thoracic and Abdominal Viscera. Philad., 1844.) Dr. C. refers to several striking cases to illustrate the injurious effects of this habit. In one instance, a member of Congress, of athletic frame, complained of labouring under the great- est physical and moral infirmity, and, although formerly healthy and fearless, had become so nervous and timid that he was unable to pre- sent a petition to Congress, or to say a word in its behalf, although he had long been a prac- tising lawyer and served much in legislative bod- ies. He was, moreover, tremulous and fright- ened at any sudden noise ; his appetite and di- gestion were gone ; he had painful sensations at the pit of the stomach, and laboured under constant constipation of the bowels ; his coun- tenance was wild and ghastly, and, altogeth- er, his condition most deplorable. On inquiry, it was ascertained that he used tobacco most enormously, both by chewing, snuffing, ant smoking. By discontinuing the use of this * “ A Dissertation on Chronic Debility of the Stomach, by Benjamin Wolsey Dwight, in Memoirs of the Con- necticut Academy of Arts and Sciences, vol. i., part ii. New-Haven, 1811.” 386 INDIGESTION—Pathology. poisonous weed, he entirely recovered within a few weeks. Dr. C. relates other cases equally striking where symptoms of delirium tremens, with total derangement of the digestive func- tion and the nervous system, were consequent on the use of this article. We could relate numerous instances as strongly marked of the pernicious consequences resulting from tobac- co, which have fallen under our own observa- tion, but it is unnecessary. Another very prominent cause of the preva- lence of indigestion in this country is the ex- cessive use of cathartic medicine in the form of pills. Were we to give the amount of the latter annually swallowed in the United States, the statement would not be believed ; and yet we have it from good authority, namely, that of the manufacturer himself, that one estab- lishment in this city turns out, by the aid of steam, no less than ten barrels per day; and this is by no means so extensive as some oth- ers of a similar kind. These pills, which are highly drastic, are used by immense numbers of people, not only in cases of actual illness, but in time of health, as prophylactic remedies : the consequences are easily predicted. In ad- dition to this, great quantities of bitters are used, in which brandy, wine, or some alcoholic liquor forms the principal ingredient, and on the occurrence of the least feeling of discom- fort, recourse is had to the panacea, till at length the powers of the stomach are exhaust- ed, and derangements, either functional or structural, take place. We could wish that the epitaph of the Italian count could be plac- arded so as to be seen by every man, woman, and child: “ I was well, wished to he better, took physic, and died.” Much of this evil is doubt- less owing to physicians, who have been too much in the habit of pouring down drugs em- pirically in every case of illness, slight or se- vere, in order to humour a popular notion that the materia medica must furnish a remedy for every disease, and a popular prejudice, that want of success is a sure indication of poverty of resource on the part of the practitioner. Another very frequent cause of indigestion among us is the hurried manner of taking meals, to say nothing of the great variety and incongruous nature of the articles eaten. Amer- icans have the reputation, whether deserved or not, of devoting less time to the pleasures of the table than the people of any other nation. We believe the remark to be, to a great extent, well founded ; if so, it must be a frequent cause of indigestion, and of the evils that follow in its train. Healthy digestion is only compatible with perfect mastication and insalivation, which are impracticable where there is much haste in eating. Moreover, as a people, we eat far too much hearty food, the consequence of which is that the system becomes overloaded and op- pressed ; the various organs are clogged in the performance of their several functions ; the circulating fluids become too thick and stimu- lating, and the predisposition to derangements and diseased action greatly increased. Hence arise not only frequent gastric disturbances, but a large proportion of our inflammatory and febrile diseases ; and hence it is that our acute diseases so generally require blood-letting and other active treatment; and hence the danger of trusting to medicine expectante, or homeeop- athy, which is another name for the same thing. Among students and literary men, including a large proportion of the clergy, intense appli- cation, with neglect of bodily exercise and a too stimulant diet, are very influential in bring- ing on this affection. To these may be added the perturbating or depressing passions; the anxieties and cares incident to our modes and habits of living and doing business ; dress too thin, or inappropriate to the season ; the culti- vation of the fancy and imagination at the ex- pense of the other mental faculties ; our varia- ble climate ; the abuse of mercurials ; the growing habit of opium-eating : all these caus- es appear to be operating with unrelenting force on each succeeding generation, and, un- less speedily arrested, would seem to threaten the serious deterioration of the race. The physiology of digestion will be consid- ered under the article “Stomach.” It is im- portant to bear in mind that the conditions of healthy digestion are, that the food should be thoroughly masticated, mixed with saliva, and taken into the stomach; that it should there be reduced to a semi-fluid consistence, and converted into a uniform pulp called chyme ; that the chyme should be transmitted through the pylorus into the duodenum, and there mixed with the bile, the pancreatic secretion, and the intestinal mucus, and that the chyle, or nutri- tive portion of the food, should be taken up and carried into the blood. The agent by which the food is dissolved and transformed in the stomach is the gastric juice, a secretion pecu- liar to this organ, which is only secreted while food is present in it, and which owes its solvent power to a special principle, which chemists have named pepsin.] 37. III. Pathology.—Indigestion manifestly proceeds from the following conditions of the stomach and related organs, either of which may be somewhat more prominent than the rest: 1. Impaired organic nervous power of the stomach. 2. A deficient or disordered state of the gastric juice, or a want of a due relation between the quantity and nature »f this fluid and the ingesta. 3. Impaired absorbing power of the stomach, rendering the digestion of the fluid ingesta more or less difficult, and weaken- ing the gastric fluid. 4. Diminished muscular energy of the stomach ; the motions and tonic vermicular actions of the organ being weak- ened, and the admixture of the gastric juice with the ingesta being thereby impeded or de- layed.* These pathological conditions may * As Dr. Combe observes, the first requisite to -digestion is an adequate supply of gastric juice, and its thorough ad- mixture with every particle of the food on which it is to op- erate. The second is a steady temperature of about 98° or 1(100 Fahr. The third is the gentle and continued agitation | of the alimentary mass in the stomach during the digestive process. Much light has been thrown upon the function of digestion, and, consequently, upon disorders of this function, by the experiments of Dr. Beaumont, of America, on St. Martin, a strong young Canadian, who was wounded in the left side, a fistulous opening into the stomach remaining without detriment to the general health. For some mouths after the wound the food could lie retained only by wearing a compress and bandage ; but early in winter a small fold or doubling of the villous coat began to appear, which grad- ually increased till it filled the aperture and acted a-s a valve, so as completely to prevent any efflux from within, | but to admit of being easily pushed back by the finger from without. Dr. Beaumont describes the aperture in St. Martin’s i stomach as being situated about three inches to the left of INDIGESTION—Pathology. 387 be primary, or they may be consecutive upon disease of the brain, of the liver, of the intes- tines, of the heart, of the kidneys, or of any other organ ; or they may be part only of some more general malady. Dyspepsia may thus be idiopathic or symptomatic. As presented to the physician in practice, indigestion is gener- ally owing to the above conditions, in connex- ion with the following : 1. Deficiency as to quality and quantity of the fluids derived from the liver, pancreas, and intestinal mucous mem- brane. 2. Disorder of the circulation and func- tions of this membrane ; and, 3. Disorder of the consecutive and harmonious actions of the mus- cular coat of the small and large intestines. the cardia, near the left or superior termination of the great curvature. When the stomach was nearly empty, he was able to examine its cavity, to the depth of live or six inches, by artificial distention. When it was entirely empty, the stomach was always contracted on itself, and the valve gen- erally forced through the orifice, together with a portion of the mucous membrane, equal in bulk to a hen’s egg. After sleeping for a few hours on the left side, the protruded por- tion became so much larger as to spread over the neigh- bouring integuments live or six inches in circumference, fairly exhibiting the natural rugae, villous membrane, and mucous coat lining the gastric cavity. This appearance was almost invariably exhibited in the morning before rising in bed. The first point which Dr. Beaumont conclusively settled is, that the gastric juice does not continue to be secreted between the intervals of digestion, and does not accumulate to be ready for acting upon the next meal. The next which he established isx that in health the gastric secretion al- ways bears a direct relation to the quantity of aliment nat- urally required by the system, so that if more than this be taken, there will be too small a supply of the juice for the digestion of the whole. Dr. Beaumont farther ascertained that the gastric secretion and the villous coat undergo great changes during disease. In the course of his attendance on Sr. Martin, he had opportunities of seeing what was actually going on in the organ, and of observing that when- ever a feverish state was induced by obstructed perspira- tion, or by stimulating liquors, or by overloading the stom- ach, and that when influenced by fear, anger, or other emotions depressing or disturbing the nervous system, the villous coat became sometimes red and dry, and at others pale and moist, having lost its smooth and healthy appear- ance. As a necessary consequence, the secretions became vitiated, impaired, or suppressed ; and the follicles, secreting the mucus which protects the surface of the villous coat, became flaccid, and no longer yielded this bland secretion. The nervous and vascular papilla; thus deprived of their de- fensive shield, were then subjected to undue irritation. When these diseased appearances were considerable, the system sympathized, and dryness of the mouth, thirst, quickened pulse, &c., showed themselves ; and no gastric juice could be procured or extracted, even on the applica- tion of the usual stimulus of food. The dry, irritated ap- pearance of the villous coat, and the absence of the healthy gastric secretion in the febrile state, as Dr. Combe has re- marked, not only explain at once the want of appetite, nau- sea, and uneasiness generally felt in the region of the stom- ach, but also show the folly of attempting to sustain strength by forcing the patient to eat when the food cannot be digested, and when nature instinctively refuses to receive it. The inferences, drawn from the experiments and observa- tions of Dr. Beaumont and others, that more immediately concern the subject under consideration, may be stated as follows: 1. That the. processes of mastication, insalivation, and deglutition are important, not merely as subjecting the food to the gastric juice in a state of due preparation for its ac- tion, but also as allowing time for the regular contraction of the stomach upon each individual morsel conveyed into it, as well as transmitting the food in small portions at a time, so as to prevent a too rapid or excessive and injurious distention of the organ. 2. That the gastric juice is the agent of chymification; that it is secreted from vessels distinct from the mucous follicles ; that it is a clear, transparent fluid, without odour, a little salt, and perceptibly acid ; and that it contains free hydrochloric acid, a little acetic acid, and some other active chemical principles. 3. That this juice is never found free in the stomach, but is always excited to discharge itself by food or other irri- tants ; that it is seldom obtained pure, but generally mixed with mucus, and sometimes with saliva; and that, when pure, it is capable of being kept for months, or even years. 4. That it is a solvent of food, and alters its properties ; that it checks the progress of putrefaction, corrects putrid substances, coagulates albumen and milk, and afterward dissolves the coagula; and that it commences its action on food as soon as it comes in contact with it. 5. That it is capable of combining with a certain fixed quantity of food, and when more is presented for its action than it will dissolve indigestion will ensue; and that its action is facilitated by the warmth and motions of the stom- ach, these motions taking place chiefly in two directions, transversely and longitudinally. 6. That the gastric juice is modified in quantity, and probably in its intimate constitution, so as to suit the kind of food ; and hence the occurrence of indigestion on sudden alterations of the kinds, quality, and quantity of food. 7. That the action of the stomach and of its fluids is the same on all kinds of diet; and that the motions of the stom- ach produce a constant admixture of food and gastric juice, and thereby facilitate digestion. 8. That solid food, of a certain texture, is easier of di- gestion than fluid; that animal and farinaceous aliments are more digestible than vegetable ; but that susceptibility of digestion does not depend altogether upon natural or chemical distinctions. 9. That digestion is facilitated by minuteness of division and tenderness of fibre, and retarded by opposite qualities. 10. That the ultimate principles of aliment are always the same, from whatever food they may be obtained. 11. That chyme is homogeneous, but variable in its col- our and consistence ; and that, towards the latter stages of chymification, it becomes more acid and stimulating, and passes more rapidly from the stomach. 12. That soups and other liquid food do not call into play the muscular coat of the stomach; and before the gastric juice can act upon them the fluid part must be absorbed, and the mass thickened to a proper consistence for under- going the usual churning motion ; and, consequently, that this kind of food often gives rise to acidity, particularly in weak states of the stomach. 13. That, owing to the adaptation of the gastric juice to the nature of the food, sudden or extreme changes from one kind of diet to another is injurious ; for the stomach has not had time to modify its secretions sufficiently to meet the al- tered demand upon its powers. 14. That water, ardent spirits, and most other fluids, are not affected by the gastric juice, but pass from the stomach soon after they have been received ; that heating condi- ments are injurious t.o the healthy stomach; and that the use of spirits always causes disease of this organ if perse- vered in. 15. That bulk as well as nutriment is necessary to arti- cles of diet; and that digestibility does not depend upon the quantity of nutrient principles that aliments contain. 16. That the quantity of food generally taken is more than the wants of the system require ; and that such excess, if persevered in, generally produces functional disorder, and, consecutively, organic disease. 17. That oily food is difficult of digestion, though it con- tains a large proportion of nutrient principles. 18. That bile is not usually found in the stomach, and is not necessary for the digestion of food ; but that, when oily food is used, it assists digestion. 19. That gentle exercise facilitates digestion; and that the acetic, citric, and hydrochloric acids promote this pro- cess, particularly if vegetables and indigestible substances have been taken. 20. That the time required for the stomachic digestion depends upon the quantity and kind of food, and upon the state of the stomach ; that the time required for the dispo- sal of a moderate meal, in a healthy state of the organ, va- ries from three hours to three hours and a half or four hours; and that in states of indigestion the process is de- layed much longer than this, particularly as respects the more indigestible substances. 21. That a diminution of the temperature of the stomach below 98° impedes digestion ; and that the temperature of the organ is not necessarily elevated by the process. 22. That whatever promotes organic nervous power with- out exhausting it favours digestion, as breathing a dry, pure air, hilarity of mind, moderate laughter, &c. 23. That the organic or ganglial nervous influence is more concerned in the process of digestion than the influ- ence conveyed to the stomach by the eighth pair of nerves ; and that the circulating, absorbing, and especially the se- creting functions of the organ, are under the dominion of the former, while the sensibility and muscular contractions are directed by the latter. 24. That the inferences drawn by Dr. W. Philip from his experiments as to digestion depending upon the influ- ence of the eighth pair of nerves, and as to galvanism being capable of supplying the place of this influence, are unphil- osophical, as they are formed without due consideration of all the circumstances, and as they leave out of the account the shock given to the system by the violent operations per- formed in these experiments. 388 INDIGESTION—Treatment. [Every close observer of disease must ac- knowledge that dyspepsia is symptomatic of two opposite conditions of the stomach: one of congestion, or inflammatory irritation ; the other of anaemia, or, rather, of deranged ner- vous sensibility. The latter form of indiges- tion, consisting in a purely morbid state of the sensibility of the gastric nerves, has been well described by Dr. James Johnson, in his work on the Morbid Sensibility of the Stomach and Bowels, to which the reader is referred. Now it is obvious that, for the successful treatment of this disease, we should be able to determine with some certainty whether the symptoms are dependant on nervous or vascular irritation— whether the gastric mucous membrane be in a state of active congestion, or the nervous sen- sibility of the organ only be deranged. By at- tending to the following directions, chiefly from Jolly, we shall be materially aided in arriving at a correct diagnosis. In a purely nervous af- fection of the stomach we have pain of an acute, tearing, intermittent kind, diminished by pressure, and by taking food; more fre- quently occurring in the morning. In inflam- matory affections of the stomach we have pain of a dull, obscure, constant kind, augmented by pressure and by food, increasing towards the evening. In the former (the nervous) we have the tongue sometimes coated, broad, and clean ; in the latter, almost always red, contracted, thickly coated. In the former the appetite is piorbidly increased, depraved, and there is a craving for high-seasoned dishes and alcoholic drinks; in the latter the appetite is wanting, never depraved, and there is an aversion to high-seasoned food and alcoholic stimulants. In nervous affections of the stomach the taste is metallic, or acid, and there is a vomiting of mucous secretions ; in the inflammatory affec- tions the taste is bitter or clammy, and the food is rejected. In the former the thirst is not increased, and there is a desire for warm or cold drinks indiscriminately ; in the latter there is morbid thirst, and a constant wish for cold drinks. In the former there is frequent constipation, while the stools are often natural, and not offensive; in the latter there is frequent diarrhoea, with bilious, mucous, bloody, or of- fensive stools. In the former there is frequent- ly pulsation in epigastrio, intermittent, and not synchronous with those of the heart; in the latter the pulsations in the epigastrium are natural, continuous, and synchronous with the cardiac pulsations. In the former there is ei- ther no fever, or it is of an intermittent kind ; in the latter there is fever, which is continuous. In the former there is an increase of the dis- ease early in the day, the urine is clear and abundant, and the heat of skin natural; in the latter there is apt to be an exacerbation in the evening, the urine is high-coloured and scanty, and the temperature of the surface is augment- ed. In the former there is no progressive ema- ciation, the physiognomy is natural, the temper morose, melancholy, or irritable ; in the latter there is a gradual wasting of flesh, the features are pale, sallow, sunken, or anxious, and the disposition but little altered. In the former the diagnosis is often obscure, the prognosis less dangerous, and the anatomical characters equivocal or altogether wanting ; in the latter the diagnosis is usually more clear, the prog- nosis more unfavourable, and the anatomical characters constant, but more or less varied. Occasionally, however, the symptoms of vas- cular and nervous irritation of the stomach are so similar that the most experienced practition- er is at a loss to decide upon their precise path- ological character, and we are guided in our diagnosis chiefly by the results of treatment. And there can be no doubt, moreover, that ca- ses of a complicated character often occur in which there is a blending of the symptoms above detailed, indicating a union of gastritis with exalted gastric sensibility.} 38. IV. Treatment.—There are few diseas- es which require greater attention to its causes and to its various states during treatment than this. The objects of the practitioner are, 1. To ascertain the predisposing and exciting causes ; 2. To draw a rational inference as to the path- ological states on which the complaint depends ; and, 3. To examine into its associations, and to attend to the nature and relations of its com- plications, whether primary or consecutive. Guided by these general intentions, the more special indications are, 1. To avoid the causes; 2. To give immediate relief to the more urgent symptoms, as acidity, cardialgia, flatulence, pain, costiveness, &c. ; 3. To remove the path- ological states and their consequences ; and, 4. To prevent a return of the disorder. These in- dications require to be fulfilled by means appro- priate to the particular form of the complaint. 39. i. Treatment of the Asthenic Form of Dys- pepsia.—A. In the more acute states, it is some- times necessary to remove the load by which the stomach is oppressed, or the substance by which it is irritated, by an emetic. But, unless when it is obvious that the disorder depends upon this cause, emetics are injurious, partic- ularly a repetition of them. In such circum- stances, the effect is soon produced by irrita- ting the fauces by a feather, or with the finger ; by a warm infusion of chamomile flowers; by tepid water, with common salt, or with an ape- rient salt, and by ipecacuanha. When pallor of the countenance, nausea, oppression, and the sense of a load at the epigastrium, and rancid or bitter eructations are present, emetics are indicated ; and these are the most suitable means. But after the organ is evacuated, its functions should be restored by repose, and by small quantities of Seltzer water, of iced water, or a cooling aromatic water, as spearmint, &c. Food should not be given till the appetite re- turns, when the lighter and more palatable ar- ticles may be taken. The bowels afterward require to be evacuated, either by stomachic aperients, as rhubarb, with magnesia or soda, in an aromatic water, or aloes with an alkali, as in the compound decoction, or by enemata. Most of the means recommended in the article Constipation ($ 15, et seq.), and in several of the Formula; of the Appendix, will likewise be appropriate in these circumstances. 40. When nausea continues after the stom- ach and bowels have been evacuated, or when the vomiting is protracted after offending mat- ters are removed, medicines to relieve these symptoms should be prescribed, especially the hydrocyanic acid, in camphor julep, with a little compound spirit of lavender, or tincture of car- damoms, or a drop or two of crcasote, in the form of a pill, with powdered liquorice root. INDIGESTION—Treatment. 389 Effervescing draughts, with citric acid and am- monia, this last being somewhat in excess ; or the liquor ammoniae acetatis, with camphor mixture, or with spearmint water; or calcined magnesia, in this or in any other aromatic wa- ter, will also be serviceable. If these fail of affording relief, active purgative enemata will generally be efficacious, the symptoms disap- pearing as soon as a free action of the bowels is procured. 41. Heartburn is best treated by medicines which act upon the secretions and move the bowels. Rhubarb, with magnesia, and sesqui- carbonate of ammonia, in an aromatic water ; a blue pill, with Castile soap ; and alkaline so- lutions in bitter tonic infusions, or in lime-wa- ter, are commonly employed, and are mogt use- ful when this symptom is connected with acid- ity. But when heartburn is attended by ran- cid, septic, or insipid eructations, the mineral acids, as the nitric, the hydrochloric, and the aromatic sulphuric acids, given in simple cam- phor, or aromatic water, or in suitable tonic in- fusions, will be most serviceable. Dr. Pem- berton advises lemon juice in these cases, and Dr. Todd the phosphoric acid. When there is a liability to heartburn, wine, spirits, and par- ticularly malt liquors, shoitld be avoided. Hock or old sherry may, however, be taken in great moderation in Seltzer water. [Ipecacuanha, in small doses, often proves a very efficacious remedy for heartburn ; and the following pill may be taken three times a day with decided benefit: R Pulv. Ipecac., gr. xii.; Pulv. Rhci, Sapon., aa, 3SS. M .Ft. mass, in pill, xviii. divide ; where nausea is present, a small quantity of aromatic powder, ammonia, or qui- nine, will often afford relief. The latter, com- bined with ipecacuanha, forms a very effica- cious remedy, as does also the ipecacuanha and ammonia. The sulphuret of potassa and the natural sulphur waters have formerly enjoyed a high reputation in the treatment of this affec- tion. The former may be advantageously com- bined with the extract of gentian or hop, or with rhubarb or aloes. Dr. Dick (On the Di- gestive Organs, p. 128, Phil, edit.) recommends gunpowder in cases of heartburn with eructa- tions, as tending to relieve the morbid sensa- tions, correct the secretions, preserve the bow- els in a soluble state, and to exercise a very favourable action upon the skin, kidneys, and lungs.] 42. Pain, or the slighter states of morbid sen- sibility, will be best removed by the trisnitrate of bismuth, conjoined with extract of hop, or ex- tract of hyoscyamus ; by hydrocyanic acid or cre- asote, as directed above* (§ 40); by other ano- dynes, given with aromatics and antispasmod- ics ; by the compound or foetid spirit of ammo- nia, in suitable vehicles ; by the compound gal- banum pill, or the compound rhubarb pill, with henbane and ipecacuanha; by draughts of warm water, either alone, or with an alkali, or with magnesia. If pain be severe, and if vomiting have come on spontaneously, and continued af- ter morbid matters are removed, a full dose of opium, with an aromatic, or of the acetate or hydrochlorate of morphia, similarly combined, should be prescribed. But the propriety and frequency of repeating it .will depend upon the circumstances of the case. If flatulence is troub- lesome, the means already advised may be pre- scribed, or those recommended in that article ((} 15) may be employed. Friction over the ep- igastrium, especially with a stimulating lini- ment, will also give immediate relief from both pain and flatulence. When headache is present, the treatment proposed for Dyspeptic Headache (<) 46) should be directed. For the costiveness so generally attendant upon this form of indi- gestion, the medicines already noticed, or those about to be prescribed, or a combination of mild aperients with tonics, deobstruents and altera- tives being given occasionally at night, will prove of great service. [Some writers have recommended the oil of turpentine in this form of dyspepsia, when of long duration, and the patient is exhausted by its violence, in doses of a drachm every hour or two, mixed with mucilage. We have known it employed with much benefit under such cir- cumstances, as we have also the arsenical solu- tion (Fowler’s) and the nitrate of silver, in do- ses of a sixth of a grain, gradually increased to three or four grains, three times a day, in the form of pills. We consider it important, to en- sure the full effects of this remedy, that no chlo- ride of soda or common salt should be taken either immediately before or after taking the pills. Where gastrodynia assumes a periodical character, a watery infusion of hark, or even qui- nine, will often afford relief, but alcoholic tinc- tures should be entirely proscribed. Besides the danger of creating an appetite for stimulants of this kind, they almost invariably exasperate the disease, although they often afford tempo- rary relief. In these cases, attended with cardialgia ow- ing to acidity, the following formula is recom- mended by Dr. Chapman : ft Carbonat. Sodae, vel. Carb. Potass., 3ii. ; Gum Arabic, 3ij. ; Sp. Lavend. Comp., 3i.; Tinct. Theb., gtt. xx. ; Aq. font., jiv. M. Where the stomach has lost its tone, as in the case of drunkards, the following preparation will succeed better than any other : B Aq. Ammo, pur., 3j.; Magnes. Calcin., 3ij. ; Aquae Cinnam., §ij.; Aq. font., gvj. M. Where much muriatic acid already exists in the stom- ach, ammonia is supposed to be objectionable, from its liability to form a muriate of ammo- nia, which would prove a source of irritation. Under these circumstances, the ensuing mix- ture will answer : R Liquor Potassae pur., 3j-; Magnes. Calc., 3ij.; Aq. Cinnamom., fij. ; Aq. font., jvj. The dose of this and the preceding mixtures is about repeated pro re nataf 43. After an acute attack of dyspepsia, par- ticularly when occasioned by errors of diet, it is necessary to enjoin abstinence, and thus af- ford the stomach time for repose, until its or* * [The hydrocyanic acid is an admirable remedy in this form of dyspepsia, attended with pain and cardialgia, and prepares the stomach for the reception of tonics and oth- er remedies which otherwise would be inadmissible. It has been used to a considerable extent in this country by some practitioners ; but the difficulty of preserving it of a suitable and uniform strength, the danger from differences in formulas, and its alleged uncertainty, have all tended to prevent its general introduction into practice. But these drawbacks may be guarded against by using that prepared according to the last United States Pharmacopeia (1842), which contains 2 per cent, of pure anhydrous acid, and keeping it carefully protected from the light. For the re- lief of gastralgia, even when complicated with gastritis, we know no remedy comparable with it; and between the pe- riods of its administration we may give the carbonate of iron, or quinine with ipecacuanha, or strychnine (which is an admirable remedy in many cases of dyspepsia), with the best effect.) 390 INDIGESTION—Treatment. ganic sensibility and functions begin to return. After a while, a cupful of mutton or veal broth, or of green tea, or of coffee without milk, may be given and repeated ; or a wine-glassful of Port-wine negus may, in some cases, be allow- ed. But care should be taken in returning to a full diet; and the injunctions as to diet about to be stated ought to receive attention. In gen- eral, tonics and stomachics should not be pre- scribed until the functions of the stomach are returning. 44. B. Having removed the more acute at- tack of asthenic dyspepsia, with its urgent symptoms, the remaining disorder is in all re- spects the same as the more slight and chronic states of the complaint, and requires a similar treatment to them. The third intention of cure (§ 38) should now be carried into effect; and the organic nervous energy, the secretions, and the muscular tone of the stomach be improved. This intention is to be effected chiefly by the diet and regimen hereafter to be noticed ; but a judicious recourse to medicine will also prove of great benefit. The infusion of cinchona, of columba, of gentian, chamomile, cusparia, cas- carilla, will be severally useful, with the alka- line carbonates, and small doses of stomachic tinctures. Afterward the metallic tonics, as the tincture of the sesquichloride of iron, the sul- phate of iron, the sulphate of zinc, the trisni- trate of bismuth, and the mineral acids, will generally be of service. Several of these may be given with the extract or tincture of hop, or of hyoscyamus. Lime-water may be taken with aromatics, particularly when the bowels are much relaxed; and the aerated or alkaline chalybeate waters may be used. When there is no complication contra-indicating cold bath- ing or the shower bath, it will be advantageous to resort to them frequently ; and when unea- siness at the epigastrium is often felt, a warm plaster will be worn in this situation with ben- efit. 45. The most active or varied means employ- ed to restore the functions of the stomach will be frequently inefficacious if the offices of the collatitious viscera be imperfectly performed. The biliary secretion should therefore be promo- ted or corrected by occasional doses of blue pill, or Plummer’s pill with soap ; and the bow- els preserved moderately open by mild purga- tives, or by a combination of them with bitters and tonics. With this view, rhubarb may be conjoined with aloes, guaiacum, and ipecacu- anha, or with magnesia ; the infusion of senna, with the infusion of gentian; the compound decoction of aloes, with the decoction or ex- tract of taraxacum ; the sulphate of potash with rhubarb ; the purified extract of aloes with Castile soap, &c. These and other mild purgatives may be taken in other combinations, as draughts, mixtures, or pills, as prescribed in numerous and various forms in the Appendix, and in the article Constipation. A judicious combination of bitters with mild purgatives, as of sulphate of quinine, or inspissated ox-gall with aloes (F. 562, 575); the infusion of senna with any of the bitter infusions (F. 266); and the decoction of aloes with soda and infusion of columba, will generally be extremely useful in this state of the complaint. 46. When chronic asthenic dyspepsia is at- tended, not only by a torpid state of the liver, but also by incipient cachexia, or has given rise to cutaneous eruptions, &c., much benefit will result from the simple preparations of sarsa, with liquor potassaj or Brandish’s alkaline so- lution, and extract of taraxacum. If it have occasioned difficult or impaired menstruation, or a state of incipient chlorosis, as often ob- served in females in London, the preparations of iron, particularly the mistura ferri composi- ta, the decoction of aloes being taken so as to act freely on the bowels ; or the pilula ferri composita, conjoined either with the pil. aloes cum myrrha or the pil. aloes composita, will generally remove all disorder, if sufficiently persisted in, and aided by change of air, diet, and exercise. 47. In this form of dyspepsia, the restoration Qf the digestive functions much depends upon a healthy state of the other excreting organs, as well as of the bowels. The functions of the kidneys and of the skin should be duly promo- ted and corrected. The temperature of the general surface and the exhalations from it ought to be preserved, and the urine duly ex- amined, in order to ascertain, not only its ap- pearance, but the general character of its chem- ical constituents. As these vary, or as cer- tain of them predominate, so should some of the most efficacious medicines prescribed in the complaint be varied or altogether changed ; so should tonics be conjoined with alkalies or acids; and aperients and alteratives be given with absorbents or (Jeobstruents. [In this form of dyspepsia, unattended with gastric irritation, we have found the chalybeate waters of Saratoga very beneficial, taken in moderate quantities, and at regular intervals. A tepid bath of 70°, or a shower bath of the same temperature, or colder if the impression is agreeable, should be used night and morn- ing while drinking the waters, and as much ex- ercise taken on foot as possible short of pro- ducing much fatigue. This, with a diet con- sisting of tender beefsteak or mutton chop, plain-boiled rice, stale wheat bread (or that made of the unbolted meal if the bowels are costive), and these taken in very moderate quantities, at an interval of at least six hours, will, in a large majority of cases, afford deci- ded relief, if not effect a permanent cure. Ir the treatment of this disease, in those who have been accustomed fb much intellectual exertion, it is absolutely necessary to enjoin a suspen- sion of all mental labour ; for, as this is one of the most efficient causes of indigestion in this country, so its entire suspension is essential to the removal of the malady.] 48. ii. The irritative variety of dyspepsia re- quires very different means of cure from those just advised; but the removal of the exciting causes is as necessary in the treatment of it as in that of the foregoing.—a. In the more acute states of this variety, when pain, tenderness, heat, or soreness is felt in the epigastrium, al- though the vascular disorder of the villous sur- face may not amount, it nearly approaches to inflammation; and erethism, or vascular con- gestion, at least, exists. The application of leeches to the epigastrium then becomes neces- sary. In plethoric persons, a bleeding from the arm should be preferred. In those who have suffered from haemorrhoids, or obstructions of the liver, cupping on the hypochondria, and in INDIGESTION—Treatment. 391 females whose catamenia are deficient, leeches to the groins, may be prescribed. Afterward a large rubefacient plaster, formed either of equal parts of the compound pitch and ammoniacal plasters, or of seven parts of the former with one of the cantharides plaster, should be appli- ed over the epigastrium. The blue pill, or hy- drarg. cum creta, should be taken at bedtime, and a mild aperient in the morning. Fresh cas- tor oil, assisted by cathartic enemata, will be useful in this variety. In some of the more acute cases, a full dose of calomel, either alone or with a little James’s powder, will be of ser- vice. Although calomel, when frequently ex- hibited, weakens the nervous energy, yet an occasional dose diminishes vascular action in the villous coat of the stomach, and excites the actions of the lower bowels. It should be fol- lowed by mild purgatives and active enemata ; for by increasing the organic actions of the lower portion, the morbid states of the upper parts of the digestive tube will the more readi- ly subside. When this variety of dyspepsia is attended by an erythematic redness, or soreness of the fauces and pharynx, as it frequently is, sometimes extending down along the oesopha- gus, calomel, taken in the form of powder, aid- ed by mild aperients and active enemata, will be of essential service, not only in acting in tjje mannerjust stated, but also in promoting the secretions of the liver and intestinal canal. 49. The other urgent symptoms, noticed with reference to the former variety, are generally much more severe in this, and require a some- what modified treatment. But irritation, ere- thism, congestion, or even inflammatory action of the villous coat are not the only pathological states characterizing cases of this kind. Or- ganic nervous power, the secretion of the gas- tric juices, and the tone of the coats of the stomach, are more or less weakened or disor- dered, and require to be strengthened as Well as corrected. At first, cooling medicines and diaphoretics are required, in order to remove irritation or vascular excitement; but they should afterward be conjoined with mild tonics or gentle restoratives, and aided by a light far- inaceous diet (() 72). If nausea or vomiting oc- cur in this variety, the means already prescri- bed (() 40, 41) will generally remove them. If they proceed from irritating ingesta, the gentle measures noticed above (<) 39) will procure their expulsion. Afterward, small doses of the ni- trate of potash, and of the solution of the ace- tate of ammonia, may be taken in camphor wa- ter. When this variety is caused by intemper- ance, these medicines, aided by abstinence, will prove particularly serviceable. If pain or in- ternal heat is complained of, or if vomiting con- tinues after offending matters are removed, or after vascular depletion has been practised, the warm turpentine epithem, or a mustard poul- tice, may be applied over the region of the stomach, or one of the liniments above refer- red to may be used as an embrocation in the same situation. The anodynes advised for the asthenic variety may also be taken, and ca- thartic enemata administered, until the bowels are freely evacuated. The medicines already recommended for heartburn, and for other un- pleasant symptoms, will also be appropriate after having had recourse to the means just advised. [Some cases of indigestion are attended with vomiting and diarrhoea. Under such circum- stances we should aim to allay the irritability of the mucous surfaces by mild opiates and antacid or absorbent remedies: the hyd. cum creta, gr. ij., with one grain of Dover’s powder, may be given two or three times a day; or, if acidity be present, the carbonate of soda with morphia, or a grain or two of rhubarb with the Same anodyne. The hydrocyanic acid is also a valuable remedy in these cases, combined with ■the chalk mixture; and we have derived great benefit from applying a few leeches over the epi- gastrium, and then a small blister, which should be dressed with a cerate containing three or four grains of mbrphia to the ounce. The diet, of course, should be chiefly farinaceous.] 50. b. In the chronic states of irritative dys- pepsia, local depletions are requisite only when there is evidence of plethora, or of incfeased action, or when natural secretions or accustom- ed evacuations suppressed. Small doses of mild mercurials at bedtime, the simple prep- arations of sarsa, either alone or with liquor potass®, and external derivatives, are here ex- tremely beneficial. After the secretions have been improved by these, and the excreting func- tions restored, the milder tonics, conjoined with refrigerants and diaphoretics or anodynes, will be of great service. The decoction of Ice- land moss, and various other demulcents, may be taken with hydrocyanic acid ; and a plaster, consisting of either the ammoniacal, the com- pound pitch, or the compound galbanum plas- ter, may be worn on the epigastrium. I have generally preferred aplaster consisting of equal parts of the compound pitch and of the ammo- niaco-mercurial plasters, and prescribed the fol- lowing : No. 262. It Potass® Nitratis 3ss.; Liquor. Ammonia; Acetatis Ji. ; Infusi vel Decocti Cinchona: fiii. M. Capiat Coch. ii., vel. iiii., larga bis terve in die. No. 263. It Potass® Nitratis 3i. ; Liquoris Ammoni® Acetatis gi.; Aqu® Flor. et Infusi. Aurantii Comp, 55 Jiiss. Misce. Capiat tertiam partem, ter in die. No. 264. R Acidi Hydrocyanici, M. ii., Mist. Amygdalae Dulcis ; Aqu® Flor. Aurantii, et Mistur. Camphor. 55 jss. M. Fiat Haustus ter in die sumendus. No. 265. It Infusi Lupuli, fivss.; Acidi Hydrocyanici, M. viii.; Tinct. Aurantii et Tinct. Gentian® Comp. 55 3». M. Capiat quartam partem bis terve in die. No. 266. R Liquoris Potass®, 3i#s.; Decocti Sarzae, fvii.; Extracti Sarzie, 31'ss. ; Tinctur. Hyoscyami, 3i. ; Tinct. Aurantii, 3iii.; Sirup. Sarzae, 3ii. M. Fiat Mistura, cu- jus capiat partem quartam ter quaterve in die. No. 267. R Infusi Valerian®, 3x.; Acidi Hydrocyanici Rlii. i Sod® Carbonatis, gr. x. ; Tinct. Cardamom. Comp., 3i.; Spirit. Lavand. Comp., Jss. M. Fiat Haustus ter in die sumendus. [In cases of indigestion attended with pain and constipation, Mr. Langston Parker (The Stomach in its Morbid States, &c., Phil., 1841) recommends the following formula; as afford- ing much relief: R Pulv. Rhei, gr. iv. ; Mor- phiae Muriatis, gr. TV M. Ft. pill, ter die su- mend. Cum Cochlear., iij., larg. Mistur® se- quent. R Infus. Cascarill®, f vii. ; Magnes. Sulphatis, fss. ; Magnes. Garb., 3jss. ; Tinct. Afoes, fss. ; Acidi Hydrocyanici, gtt. xv. ; Tinct. Humuli, 3ij. M. Cap. Cochlear., iij., larg. ter die. These preparations are said to act freely on the bowels, without occasioning pain. After constipation has been obviated, the following preparation will be found very useful: R. Magnes. Carb., 3J. ; Bismuth Sub- nit., gr. v.; Morphi® Muriatis, gr. I. M. Ft. pulv. ter die sumendus. The indications un- 392 INDIGESTION—Treatment. (ler this form of the malady are to remove pain and obviate constipation, by which it is always aggravated, to subdue concomitant inflamma- tory action, and to enable the stomach, when these intentions have been accomplished, to fulfil its offices again properly. As laxatives, in the treatment of indigestion attended with constipation, we have derived great benefit from the use of the following preparations: R Pulv. Rhei, 3ij.; Pulv. Ipecac., gr. x. ; Oh Carui, gtt. x. ; Sirup Commun., q. s. Ft. mass, et div. in pilul. xl. ; or, R Gum Mastic, Pulv. Aloes, aa. jj. ; Pulv. Ipecac., gr. x. ; 01. Carui, gtt. x. ; Muc. Gum Arabic, q. s. Ft. mass. ; div. in pilul. xx. Rhubarb, aloes, ipe- cacuanha, and soap make a very good prepara- tion ; as does also the following: R Pulv. Rhei, jij. ; Pulv. Gentian., 3j. ; Sodas Carbon., 3ij. ; Aq. font., Oj. M. Ft. infus.] 51. iii. Treatment of the earlier consequences of dyspepsia.—The treatment of several of these is nilly discussed in the articles Duodenum, Flatulence, Headache, Hypochondriasis, Pyrosis, and Stomach—Painful Affection# of. It will therefore be unnecessary to advance much under this head.—a. When dyspepsia, in either of its forms, causes frequent attacks of relaxation and soreness of the throat and fau- ces, or inflammatory redness of these parts with cough, the diet of the patient should be strictly regulated, and mild purgatives, aided by cathartic enemata, prescribed. These at- tacks should not be neglected in persons pre- senting any tendency to bronchitis, or to pec- toral disease. Some of the severest states of laryngitis and tracheitis have originated in ir- ritative dyspepsia, the symptomatic irritation of the pharynx and fauces extending to the larynx, and exposure to cold, to currents of air, or to other causes, heightening the affection of the respiratory passages. A predisposition to affections of the respiratory organs, or tu- bercles in a latent state, are then often called into activity by neglected dyspepsia, owing ei- ther to symptomatic irritation or to consequent debility. In females, excessive menstruation, as to either the frequency or quantity of the discharge, is often the more immediate conse- quence, or intervenes between the dyspeptic disorder and the pulmonary affection. In such cases the treatment should be directed both to the original disorder and to the consequent af- fections ; and, fortunately, much of the means, both medicinal and dietetical is appropriate to both, the more astringent and refrigerant ton- ics, and mild or cooling aperients, benefiting the disorder of the stomach as well as the su- perinduced complaints. To these medicines, ipecacuanha, camphor, and narcotics will be added with advantage. 52. b. The symptomatic disorder of the heart, consequent upon one or other of the varieties of dyspepsia, requires chiefly attention to the original complaint. When palpitation is fre- quent, or the pulse intermittent, after the bow- els have been freely evacuated and the secre- tions improved, camphor and ipecacuanha with hyoscyamus ; the sulphate of iron with extract of hop ; the decoction of senega with orange- flower water, or infusion of orange peel and hydrocyanic acid; the infusion of valerian sim- ilarly combined ; the nitrate of silver triturated with the extract of henbane, or of hop, will severally afford relief. In the irritative states of dyspepsia, particularly if signs of congestion, erethism, or inflammatory irritation of the vil- lous coat be present, the treatment advised above for this state ought to be premised. At the same time, some one of the warm plasters already prescribed may be applied to the epi- gastrium. In 1820 I first employed the nitrate of silver, combined with narcotics, for a case of dyspeptic palpitation, commencing with half a grain thrice daily, and increasing the dose to one grain. This patient, and others similarly affected, for whom I have ordered this medi- cine, perfectly recovered. Dr. J. Johnson has strongly recommended the nitrate of silver in dyspepsia; and, certainly, few medicines are more deserving adoption, when the patient is not alarmed at its use. It should, however, be very cautiously employed. This writer also insists much upon the use of the sulphate of quinine in most dyspeptic cases. In small doses, with sulphuric acid, in infusion of roses* it is an excellent medicine at that stage of the treatment when active tonics should be pre- scribed, especially when much debility is com- plained of. In order to prevent its constipating effects, it may be given with small doses of the purified extract of aloes, or with the aloes and myrrh pill; and when palpitations and other nervous symptoms exist, camphor anfl hyoscy- amus will be added to them with great benefit. In females who have long laboured under dys- pepsia, the quinine, taken in solution, is very serviceable when the catamenia are too abun- dant ; but in other circumstances, particularly when a chlorotic state of the system, and im- paired or obstructed menstruation have super- vened, the sulphate of iron with the aloetic prep- arations should be preferred. 53. c. Of all the consequences of protracted and irritative dyspepsia, disorder of the biliary functions and disease of the liver are the most common. When evidence of congestion, or fulness, or tenderness in the region of the liver exists, then the treatment should be commen- ced with general or local depletions, with cup- ping on the hypochondrium or near the right shoulder blade, or with the application of a number of leeches near the epigastrium, or around the anus. Small doses of blue pill, or of calomel, ought to be taken occasionally at bedtime, and to be followed by saline aperients in the morning. Alterative medicines, consist- ing chiefly of the alkaline carbonates, or of the liquor potassae, should be given daily, with ta- raxacum, sarsa, and such of the other remedies above recommended as may be appropriate to the case ; but the treatment of this complica- tion is fully discussed in the articles Gall- bladder and Ducts, Jaundice, and Livf.r. 54. d. Cutaneous eruptions, both acute and chronic, frequently are associated with the more protracted states of dyspepsia, and are' often consequences of these states. Yet they are seldom referred to these sources, or to these conditions of the villous surface of the stomach, of the digestive mucous surface gen- erally, and of the biliary and other excreting functions with which they are so intimately connected. In numerous instances*, heating, stimulating, and irritating medicines are pre- scribed, either prematurely, or at a time or stage of the treatment of these eruptions when INDIGESTION—Of the Diet and Regimen. 393 local or general depletions, refrigerants, evacu- ants, alteratives, and a low, cooling diet ought to have been employed. This remark is ap- plicable also to those early indications of biliary disorder, of affections of the kidneys and uri- nary bladder, and especially of gout, which so often appear in the course of chronic indiges- tion. [To these most comprehensive and judicious directions of our author but little remains to be added. From a somewhat extended experience in the treatment of the different forms of indi- gestion, we are inclined to believe that far too little attention is generally paid to restoring and maintaining the healthy functions of the skin. We can call to mind several most ob- stinate cases which had resisted the whole routine of remedies usually employed for this affection, and which readily yielded to the daily employment of the vapour bath, friction with the hair glove and the flesh brush, and other means to restore cutaneous action. We be- lieve, therefore, with Professor Chapman, who has laid down most admirable precepts on the management of dyspeptic maladies (Lectures on the more important Diseases of the Thoracic and Abdominal Viscera, Phil., 1844), that it is, for the most part, well to let the stomach alone, or, forbearing the use of every sort of internal medicament, and particularly of any activity, to endeavour to abate and draw away the irri- tation to the exterior surface by a combination of depletory and revellent means, as local bleed- ing, rubefacients, sinapisms, vesicatories, the vapour, tepid, and warm baths, or the Croton oil, so as to induce pustulation. When the latter is employed, if the irritation seems to be seated in the ganglionic nerves, it is preferable to make the application to the epigastrium, but over the spine when the irritation seems to proceed from the rachidian axis. Dr. C. rec- ommends to cup the spine and counter-irritate the epigastrium. “ By this simple plan,” says he, “ aided by the regimen hereafter to be pointed out, I have met with no difficulty in arresting the progress of the disease, and am persuaded, from ample experience, that it is the one which only will be found productive of any uniformity of success. As corroborative of the correctness of this view, in theory and practice, it may be remarked, that whenever a metastasis of the irritation takes place to the surface, as an efflorescence or any other form of eruption, relief is ordinarily afforded. Nor to the other and rarer form of the disease, depend- ant principally on a want of muscular contrac- tility alone, from ipperfect innervation, have I found this plan less applicable. It might, in- deed, be affirmed to be more prompt and effec- tual under such circumstances. Cases without number have I known with a permanently dis- tended stomach, and the indescribable wretch- edness of this state, which, after refusing to yield to every variety of internal remedy, were very speedily cured by the topical applications to the exterior already enumerated.”—(Loc. cit., p. 224.)] 55. Of the Diet and Regimen in Dyspep- sia.—Unless the diet of the dyspeptic be duly regulated, medical means will be employed in vain. On the subject of diet with reference to indigestion, Dr. Paris, Dr. A. Combe, Dr. Rob- ertson, Dr. Ticknor, Dr. T. J. Todd, and Mr. Mayo have furnished much information of the best kind, and conveyed it in the most agree- able manner. It is impossible to adduce any- thing on this topic which has not been already stated and illustrated by these able writers.—■ i. In considering diet icith reference to indigestion generally, there are various circumstances re- quiring particular notice : 1st. The kinds and quality of the food ; 2d. The quantity and con- gruity of the food ; 3d. The times of eating, or the periods which should intervene between meals ; 4th. The kind and quantity of drinks ; and, 5th. The conditions deserving notice in connexion with eating and drinking. 56. A. The kinds and quality of food.—a. Dr. Combe justly remarks that a direct relation ought always to subsist between the qualities of the food and the nature of the constitution which it is intended to support. The highly concentrated and stimulating food necessary for the support of those who take very active exercise will prove too exciting to the irritable constitution of persons possessed of great ac- tivity of the brain and nervous system ; and the generous diet which suffices to rouse or sup- port a phlegmatic system will prove too nutri- tive for a person of a florid and sanguine tem- perament. For persons of a florid complexion, with great activity of the circulation, and a consequent liability to inflammatory diseases, the food ought to be calculated to soothe rather than to stimulate. Red meat, spices, wines, and fermented liquors ought to be used spa- ringly, and the principal support derived from soups, fish, mucilaginous vegetables, acidulous fruits, and diluting drinks. In lymphatic per- sons, on the other hand, where the circulation is weak and slow, and the functions feeble, benefit is derived from a larger proportion of animal food, while vegetables, soups, and fluids prove relaxing. To these persons, wine in moderation and spices are useful, if much ex- ercise be taken. Persons of a highly nervous temperament, of great excitability and sensi- bility to impressions, are injured by heating or stimulating diet. White meats, as fowl and fish, farinaceous and mucilaginous aliments, and ripe fruits, are most appropriate to them. Where the bilious temperament predominates, and much active exercise is taken in the open air, a full supply of animal food is necessary, and a moderate allowance of wine or other stimulus is borne with less detriment, if not with more advantage, than in the sanguine and nervous temperaments. Where the constitu- tion is of a mixed nature, a diet composed of animal and vegetable substances, in nearly equal proportions, is, under ordinary circum- stances, the best. The food, also, should be adapted to the age, state of health, and mode of life of the individual, and to the climate and season of the year. A diet which would be quite sufficient to a person of sedentary occu- pations would be inadequate to support an in dividual subjected to frequent or constant ex- ertion ; and in warm climates and seasons, a smaller supply of food, particularly of a heating or stimulating kind, is necessary than in cold and temperate countries. In the former but little animal food is requisite ; in the latter, especially in very cold regions an-d in rigorous seasons, an abundant supply of this kind of diet I becomes indispensable. 394 INDIGESTION—Of the Diet and Regimen. 57. 1. Although there are few articles of diet which a healthy person, leading a sufficiently active life, may not eat with impunity, there are many which ought to be preferred, and others which should be avoided by the dyspep- tic. Vegetables are slower of digestion than animal and farinaceous aliments, and more lia- ble to undergo the acetous fermentation in weak stomachs, and to occasion acidity and flatulence. Fat and oily meats are also very indigestible, and give rise to acid or rancid eructations and heartburn. Soups and liquid food are acted upon by the stomach with great difficulty; and if the diet consist chiefly of them, they furnish insufficient nourishment, and never fail of producing the more severe forms of dyspepsia, and the diseases of debili- ty. Soups are hurtful when taken at the com- mencement of a full meal ;* but when little or no animal food is eaten along with them, and rice or bread is taken with them, so as to pro- mote their consistency, they are digested with greater ease. Pastry, puddings, rich cakes, and articles containing fatty or oily matter, are the most indigestible of all kinds of food. Plain, well-cooked animal food, particularly venison and game, kept a due time after it has been killed, and eaten in moderate quantity with bread, or with roasted, mashed, or dry mealy potatoes, or with rice, is one of the most digestible meals that can be taken by the dys- peptic. The kind, however, of animal food, and the modes of dressing it, should depend much upon the state of disorder, and the age and constitution of the patient. 58. c. Fish holds an intermediate rank be- tween the flesh of warm-blooded animals and vegetable food, as respects digestibility. It is less nutritious than mutton or beef; and a lar- ger quantity is requisite to satisfy the appetite. Whiting, haddock, and skate are the most di- gestible of salt-water, and perch of fresh-wTater fish. Gurnard, cod, soles, and turbot are suc- cessively richer and heavier, but easier of di- gestion than mackerel, herrings, eels, or sal- mon. Eels are, however, more digestible when they are stewed. Salmon is very indigestible, as usually obtained from the London fishmon- gers, for the reasons stated in the article Dis- ease ($ 46); but it is not indigestible when quite fresh and properly cooked. The same obser- vation applies to mackerel and herrings. Fish is most digestible when boiled; it is less so when broiled; and the least so when fried. The dyspeptic should eat it dressed only in the first of these ways. Shell-fish is slow of digestion ; some much more than others. Raw oysters are more digestible than crabs or lobsters ; but oysters, when stewed or otherwise cooked, are heavier than either. Fish is often rendered indigestible by the sauces, &c., taken with it. Vinegar, however, and lemon juice promote the digestion of it. Malt liquor ought not to be drank with fish. Fruit should not be eaten with it; and milk, likewise, should be avoided. 59. B. The quantity of food should always be proportioned to the digestive powers of the stomach and the wants of the system. Where waste is great, and growth active, an abundant supply of food is requisite, and the desire for it is commensurate with the demand. Those who lead sedentary lives, and whose circum- stances admit of free living, are peculiarly lia- ble to dyspeptic complaints, owing chiefly to the quantity of food indulged in. It is indis- pensable to a due and natural supply of aliment to the stomach, that attention be paid to the preliminary processes of mastication and deglu- tition. If these be performed too hastily, too much food will be received in a short time, in a state of insufficient preparation, and the stom- ach will be overloaded before the sensation of hunger can be completely allayed. As the dilatation of the stomach by the ingesta should be gradual, and ought not to exceed a certain limit, and as a definite quantity of gastric juice is secreted, according to the wants of the sys- tem and the habits of the individual, if more than the usual quantity of food be taken, the organ will be over-distended and a part of it will remain undissolved, producing the usual symptoms of indigestion. Such being the case even with the healthy, how much greater will be the disorder when excesses are committed by the dyspeptic. Sir F. Head very justly re- marks “ that almost every malady to which the human frame is liable is either by high-ways or by-ways connected with the stomach ; and I must own I never see a fashionable physician mysteriously counting the pulse of a plethoric patient, or, with a silver spoon on his tongue, importantly looking down his red, inflamed gul- let, but I feel a desire to exclaim, ‘ Why not tell the poor gentleman at once, Sir, you’ve eaten too much, you've drunk too much, and you've not taken exercise enough !’ ” Dr. Ab- ercrombie observes, “ when we consider the manner in which diet is generally conducted in regard to the quantity and variety of food and drink, instead of being astonished at the preva- lence of indigestion, the wonder should be that any stomach, having such duties imposed on it, is capable of digesting at all.” Much, cer- tainly, is to be done in dyspepsia by attention to the quality of the articles of food, but much more depends upon the quantity; indeed, the dys- peptic might almost be independent of attention to the former if he rigidly observed the latter. This opinion is supported by the experiments of Dr. Beaumont, showing that the power of digestion is limited by the amount of gastric juice provided by the stomach—an amount va- rying with the modes of life and the wants of the system. It is superfluous to remark that second courses, served up to gratify the pride of the host, overcome the stomach, paralyze digestion, and occasion acute attacks of indi- gestion. 60. It is impossible to assign any rules re- specting the quantity of food that should be taken, as it depends upon so many circumstan- ces. Mixtures of different kinds of food are in- jurious to digestion, chiefly by the inducement to excess in quantity which the variety affords, and by the incongruity of many of the articles. When only one dish is partaken of, Dr. Combe remarks, there is less temptation to exceed the quantity than when several are tried. The first intimations of a satisfied appetite are warnings to stop eating, which should never be neglected by dyspeptics. If these be passed by, indigestion, or an aggravation of it where it is already present, will always result. The quantity of food should also have reference to the amount of exercise. When little or no waste is excited by exercise, the supply should INDIGESTION—Of the Diet and Regimen. 395 be remarkably moderate, as well as digestible. Persons who have removed from the country, where they have enjoyed active exercise in the open air, and have consequently digested well a full diet, generally become dyspeptic when they have removed to large towns, and are sub- jected to very different circumstances, espe- cially if they continue the same quantity of food, or if they increase it. 61. C. The times of eating.—In general, five or six hours should elapse between one meal and another. Even in healthy persons, diges- tion of a full meal is seldom over in less than four hours; and in dyspeptics it is seldom dis- posed of until a much longer period has passed. The stomach, also, requires an interval of rest after the process is finished, in order to enable it to enter upon the vigorous digestion of the next meal. If food be taken before the organ has recovered itself from its previous exertion, the secretion of the gastric juices and the muscular contractions will be imperfect. The whole of the gastric juice which the stomach can secrete in a given time being engaged in the digestion of the first meal, the one taken too closely upon it will be insufficiently acted upon, and thereby undergo fermentation. The intervals between meals should be in relation to the quantity eaten, and the habits of the individual as to air and exercise. When the latter are enjoyed, the periods may be much shorter than when the habits are sedentary. 62. For dyspeptics, as well as for healthy persons, the meals should be regulated accord- ing to the necessary occupations and habits of the individual. For those, observes Dr. Combe, who work by day and sleep by night an early breakfast, an early dinner, and an early evening meal will be most conducive to health ; but for those who, against the laws of nature, keep late hours, late breakfasts and dinners are preferable. Persons who eat suppers ought not to breakfast till one or two hours after ri- sing ; but those who dine late, and eat nothing afterward, require breakfast sooner. As a gen- eral rule, breakfast about half an hour or an hour after rising will be found most beneficial. Those who are obliged to rise very early should take a cup of coffee or tea, with a biscuit, soon after getting up, and a more substantial break- fast about three hours afterward. If exposure to cold, to the morning dews, or to unwhole- some air, or to'any other cause of infection, be incurred in the morning, the stomach should be fortified by coffee or by breakfast. The dys- peptic, especially, ought never to travel, or to enter upon any exertion with an empty stom- ach, and never with an overloaded one. 63. As a general rule, not more than five or six hours should elapse from breakfast till din- ner. For youth and convalescents, and for persons taking active exercise in the open air, the interval may be somewhat shortened ; but for sedentary persons it may be much prolong- ed. Much, however, should depend upon the appetite, which ought to have returned some time before dinner is taken. According to this, the most suitable time for this meal is about two o’clock. As many dyspeptics as well as others cannot dine until much later in the day, ought nothing to be taken till five, six, or seven o’clock \ or ought a light repast to be taken at one or two o’clock, and the appetite be chiefly reserved for a substantial meal at a much later hourl When dinner cannot be taken until eight or nine hours after breakfast, it will be necessary to have some refreshment in the mean time ; but it should be in relation to the time that will elapse until dinner, and to the ex- ercise taken. For persons of sedentary habits, a biscuit and a glass of water will be sufficient; but for the active and the young, especially if the interval be long, a more substantial lunch- eon is necessary. The habit of resorting to pastry-cooks for refreshment, and of taking wine with it, is generally prejudicial, and par- ticularly in dyspepsia. When dinner cannot be taken until a late hour, it should always be postponed for half an hour or an hour, until ex- citement or fatigue has subsided. 64. When the dinner is early—from one to three o’clock—a light meal of tea or coffee and bread is necessary ; but when the dinner is late, or little exercise is taken after it, tea or coffee should be used merely as a diluent, and no food ought to be eaten. After an early dinner, ad- mitting of time for its digestion and a return of the appetite before a late hour, a third meal, of light aliments, and in moderate quantity, should be taken, particularly by persons enga- ged in the open air. When ultra-temperance is practised by the dyspeptic, particularly when he lives actively, and retires to bed with an entirely empty stomach, he is quite as likely to have disturbed sleep and unpleasant dreams as if he had his stomach loaded. He may even be wakeful and irritable, or experience a sense of unpleasant emptiness or gnawing at the stom- ach. All these may be removed by a basin of arrow-root or sago about an hour before bedtime. A light supper may, therefore, be ta- ken when the dinner is early; but it should be at least an hour or two before retiring to rest. 65. D. The dyspeptic, as well as other vale- tudinarians, inquire, What ought we to drink ? but they rarely follow the question by the next important one, When should we drink 1 And they never inquire as to the temperature at which fluid should be taken.—a. Respecting the first of these questions, it may be stated that water— either spring water or toast-water—is the safest if it be taken only according to the dictates of thirst. Whey, fresh small beer, soda water, and Seltzer water, are of service in many cases, as will be noticed hereafter; but fermented liquors and wines require greater restrictions. The young dyspeptic ought never to drink any- thing but water, toast-water, or whey. The more stimulating beverages will be prejudicial to him, unless during states of debility, for which it may be necessary to prescribe them medicinally. Of all these, spirituous liquors are the most injurious, and ought never to be taken in any form, nor in any variety of indi- gestion. Some of the asthenic states of the complaint, which are benefited by a moderate use of wine, are exasperated by spirits, or even by malt liquors. Dr. Beaumont found, on ex- amining St. Martin’s stomach after a free in- dulgence in ardent spirits for several days, the villous surface covered with erythematic and aphthous patches, the secretions vitiated, and the gastric juice diminished in quantity, viscid, and unhealthy, although he complained of no- thing, not even of impaired appetite. Two days later, when matters were aggravated, the 396 INDIGESTION—Of the Diet and Regimen. erythematic appearance was more extensive, the spots more livid, and from the surface of some of them small drops of grumous blood exuded. The aphthous patches were larger and more numerous, the mucous covering thicker than usual, and the gastric secretions much more vitiated. The fluids extracted from the organ were mixed with much thicker ropy mucus and muco-purulent discharges, slightly tinged with blood. Yet St. Martin complain- ed only of an uneasy sensation, and a tender- ness at the pit of the stomach, with vertigo and dimness of vision on stooping. The tongue was covered with a yellowish brown coating, and the countenance was somewhat sallow. After a few days of low diet, with mild diluents, the inner surface of the stomach assumed its healthy state, the gastric juice became clear and abundant, the secretions natural, and the appetite voracious. Dr. Beaumont adds that the free use of ardent spirits, wine, beer, or any intoxicating liquor, when continued for some days, invariably produced these morbid states. Eating voraciously or to excess, and swallow- ing food imperfectly masticated, or too fast, produced the same effects when repeated fre- quently in close succession. (Exper. and Ob- serv., &c., p. 237.) He often observed that, when stomachic disorder, with febrile symp- toms, was present, or when influenced by vio- lent mental emotions, the villous coat of the stomach became red, irritable, and dry; and that but little gastric juice was secreted on the food being taken, digestion being very much prolonged. No more wine, therefore, nor more of any other fermented liquor, should be taken, than may be found sufficient to support the strength and ameliorate the symptoms of the dyspeptic without quickening the circulation. 66. b. As a general rule, the desire for fluids is the chief indication of the time at which they ought to be taken; but large draughts should be avoided, as the stomach becomes suddenly distended, the juices diluted, and the muscular coat weakened by them. Besides, much more fluid may be thus taken than is necessary for the wants of the system. The dyspeptic ought never *o drink largely, either during or soon after a meal. Frequent sipping, or drinking by mouthfuls, will be much more beneficial, and, ultimately, more quenching of thirst. Mild drinks are best taken about three or four hours after a solid meal. It is then that tea and cof- fee are used as beverages. These are always injurious when made too strong, or taken in large quantity, especially to the dyspeptic. Soda water drank at the time of dinner is hurt- ful, by distending and over-exciting the stom- ach. Seltzer water is less so ; but it is often of service some time after a meal, when there is much thirst. Soda water is then sometimes also of use. 67. c. The temperature at which fluids should be taken is of the utmost importance to the dys- peptic. Extremes of temperature are injurious even to the healthy, and not only to the stomach, but also to the collatitious viscera, and to the teeth. The bad effects of the ingestion of large quantities of cold water into the stomach have been often demonstrated ; but the subject has been very superficially considered. Dr. Beau- mont remarked that a gill of water, at the tem- perature of 55°, received into St. Martin’s stomach when empty, reduced the heat of the organ from 99° to 70°, at which it stood for a few minutes, and then rose very slowly. This experiment explains the injurious effects pro- duced upon weak stomachs by cold fluids taken during digestion, and the fatal effects of very copious draughts of cold water while the body is fatigued and perspiring; the shock which the constitution receives from having the tem- perature of the most vital and central organ suddenly and remarkably depressed paralyzing the other vital movements. It having been de- monstrated that a temperature of 98° is re- quisite to healthy digestion, it must follow that the use of ices, and particularly iced creams after dinner, or when digestion is proceeding, will be most injurious. A fit of indigestion is often caused by them ; and they seldom fail of lowering the vital tone of the stomach during the digestive process. The moderate use, how- ever, of cold or iced water, or of water ices, when this process is completed, and when there is no exhaustion, is beneficial, by indu- cing a salutary reaction in the organ. Ices can be only taken slowly, and in small quanti- ties at a time ; hence they produce a much less sudden fall of temperature of the stomach than draughts of cold fluids. Dr. Dunglison states that labourers in Virginia were frequently kill- ed by drinking copiously of spring water when overheated ; but that such accidents have rare- ly occurred since they have been supplied with ice. The proper temperature at which soups, tea, coffee, chocolate, &c„ should be taken may be stated at about 100° ; and at this grade of heat liquids will be found more quenching to thirst than at a higher or lower temperature. 68. E. The conditions necessary to promote a healthy digestion require a brief notice. The determination of the circulating fluids to the digestive mucous surface and collatitious vis- cera, and the copious secretion from these vis- cera during digestion, require that the function should not be disturbed by moral or physical perturbation or exertion. Rest of body and tranquillity of mind for a short time before and after, but particularly after eating, are hence conducive to digestion. Whatever derives the nervous energy and the circulating fluids from the digestive viscera, or causes oppression of these viscera, by overloading the large veins, is injurious during digestion. Hence blood- letting, hot or cold bathing, mental shocks, ex- ertions of any kind, and other circumstances which operate in this way, are more or less hurtful. As the quantity of gastric juice re- quisite to the digestion of a full meal is gener- ally secreted in an hour or an hour and a half after it is taken, or, at least, within two hours, even in the dyspeptic, bodily and mental re- pose is beneficial during this time. It is thus that a siesta after dinner is found so servicea- ble to the dyspeptic. But, by promoting diges- tion, it favours supply, diminishes waste, and consequently induces vascular plethora, and the usual consequences of this state, particu- larly in respect of the brain and liver. In dys- pepsia, the desire for rest after a repast is great in proportion to the quantity eaten, the ner- vous energy being concentrated in the digest- ive viscera in order to dispose of the ingesta. The state of the mind has a powerful influence on digestion: hilarity and ease of mind pro- INDIGESTION—Of the Diet and Regimen. 397 mote this function ; while care, anxiety, envy, and dissatisfaction impede it. Dr. Caldwell remarks that dyspepsia commences perhaps as often in the brain as in the stomach. It is al- most exclusively a complaint of the studious, the scheming, the daring adventurer, the stock- jobber, and the speculator, and of those who, over-exerting their brains, thereby injure them. 69. ii. Of the diet and regimen with reference to the different states of dyspepsia. The observa- tions of Dr. Todd as to the diet suitable to the different states of dyspepsia are extremely just and precise. I shall therefore avail my- self of some of them.—A. During the asthenic forms of indigestion, the quantity of food should be reduced to the power of disposing of it; such articles as are difficult of digestion and weaken the stomach being altogether with- drawn.—a. The patient should be confined to a spare diet of animal food, and to a restricted use of fluids. A bulky meal ought always to be avoided; and when the appetite is impaired, abstinence will be frequently preferable to the use of stomachics. When the appetite does not fail, which is often the case when dyspep- sia is produced by mental exertion, the patient should cease eating before the appetite is alto- gether allayed. The tea or coffee at breakfast should be taken with very little milk and sugar, and very little butter ought to be used. An egg, lightly boiled, may be eaten by those who take sufficient exercise. The dinner should consist of lean animal food, particularly mut- ton, poultry, game, and venison, which ought to be roasted or broiled. Bulky vegetables should be avoided ; but mealy potatoes, yams, or rice, mixed with the gravy of the meat, young summer turnips, cauliflower, or French beans, may be taken sparingly. The least hurt- ful fruits are strawberries, morel cherries, and mulberries ; but they should be eaten as a part of the luncheon, rather than after dinner. Flu- ids, even when there is thirst, should be taken slowly, and in small quantity, and always after a meal. If the digestion or habit require the stimulus of wine, old sherry, or old port, with an equal part of water, should be preferred; but the quantity of either, or of both, should not exceed two or three glasses. Twice-dress- ed meat, rechauffecs, and made dishes ought not to be eaten ; and the food should be masti- cated slowly and thoroughly. 70. b. The kinds of food most injurious in this variety of dyspepsia, and therefore to be avoid- ed, are sweet, mucilaginous, or acid fluids, and such as contain much milk ; puddings, com- pound dishes, and meat pies ; new bread, or heavy unfermented bread ; compact or fat dumplings, and pultaceous articles ; creams, curds, custards, cheese, and all preparations of milk; fat meat, particularly pork or bacon, young meat, all gelatinous parts of meat, and salted or smoked meat; the less digestible spe- cies of fish, and all shell-fish; strong broths, gelatinous soups, or concentrated dishes ; melted butter, oil, sauces, spices, condiments, and pickles ; bulky or flatulent vegetables, es- pecially cabbages, waxy potatoes, pot-herbs, beans, pease, cucumbers, &c. ; most fruits, whether fresh or preserved ; currants, goose- berries, apples, plums, melons, all kinds of nuts or kernels, and preserves or jellies. Malt li- quors, particularly ale, perry, cider, home- made wines, punch, and shrub, should also be avoided. 71. c. Regular exercise ought to be taken in the open air ; and the kinds of exercise that bring the greatest number of muscles into mod- erate action should be preferred. Celsus very justly advises persons subject to stomach com- plaints to exercise the upper extremities and parts of the body. There are several amuse- ments which have this effect, especially bill- iards, fencing, rowing, cricket, &c. For fe- males, singing, dancing, skipping, battledore, dumb-bells, and the exercises recommended by Mr. D. Walker, will be found very servicea- ble, especially when confined to the house by weather, or when exercise on horseback or on foot cannot be taken. 72. B. The diet and. regimen most suited for the irritative states of indigestion differ considerably from those now recommended. In this varie- ty, bland, farinaceous, and semi-fluid food, in small or moderate quantity, is the most appro- priate, until vascular disorder of the villous coat of the stomach is removed by treatment. Saccharine, farinaceous, feculent, mucilagin- ous, and acidulous articles of food are most ea- sily digested in this condition of the organ. Gentle exercise, as gestation in a carriage or on horseback, sailing, swinging, and walking, is preferable to the more exciting kinds of ex- ercise. After digestion is completed, tepid or warm bathing, and frictions of the surface are generally beneficial. When vascular excite- ment is removed, the patient may gradually adopt the diet advised for the preceding varie- ty, beginning with light chicken, mutton, or veal broth, with toast or rice; and afterward the more digestible kinds of solid food may be used. 73. C. The wines and leverages best suited for indigestion are old sherry or port, diluted with equal parts of water, the finer kinds of claret, hock, white hermitage, and Sauterne; but these should not be taken in the irrita- tive forms of dyspepsia until vascular excite- ment of the villous coat of the stomach is re- moved. The diluents most beneficial are Selt- zer water with a small quantity of hock, or Selt- zer water with milk or whey, or limewater with milk or black tea, according to the pecu- liarity of the case. In the more irritable states of the stomach, whey, goat’s whey, small quan- tities of Seltzer water, or the imperial drink, should be preferred. When the state of the urine indicates the impropriety of using vege- table or mineral acids, the alkaline carbonates may be substituted ; but, when indigestion has induced a torpid or disordered state of the bil- iary organs, not connected with inflammation, beverages slightly acidulated with the nitro-hy- drochloric acids wall be found serviceable. 74. D. Several mineral waters, both natural and factitious, are most excellent aids in the treatment of the several forms of indigestion. —a. In the asthenic variety, the mineral springs of Clifton, Malvern, Bath, and Tunbridge Wells, and the carbonated chalybeate waters of Spa, Pyrmont, Carlsbad, Marienbad, Swelbach, and Eger, on the Continent ; or their imitations prepared by Dr. Struve, are generally benefi- cial.—b. In the irritative states of dyspepsia, the springs of Harrowgate, of Ems, Plombieres, Vichy, and of Marienbad, or other alkaline 398 BIBLIOGRAPHY AND REFERENCES. mineral waters, will be used with advantage. When the functions of the liver are disordered, the wraters of Cheltenham or Leamington, or of the Beulah Spa, and the springs of Seid- schutz and Pnllna, may be preferred ; but when excitement of the villous coat of the stomach, and when the functions of the excreting vis- cera are restored, the aerated chalybeate wa- ters already mentioned will be most service- able. [With respect to the use of the natural min- eral waters in this disease, Dr. Chapman gives the preference to the sulphur waters of Virginia, “ as well from superiority of climate as the greater diversity of qualities. Imbosomed within a mountainous region,” he adds, “where the heats of summer never penetrate, and from which the diseases of the season are excluded, there is, within a very limited space, a group of some ten or fifteen of these waters, of deci- ded activity, including natural baths of every gradation of temperature and difference of med- ication. Not a little is to be ascribed to their medical properties, though, in a just apprecia- tion of them, we must also include the advan- tage of the change of scene, a purer air, a more cheerful society, and the interruption of perni- cious habits and associations. It is in these modes that a long journey over a delightful district of country, or a visit to a European metropolis, or a residence in some of the ge- nial climates of that section of the world proves so effectual.”—(Loc. cit., p. 252.) We have little doubt that it is generally owing to these latter influences, and not to the qualities of the waters, that dyspeptic invalids are so often in- debted for an amelioration of their sufferings, although, under circumstances already indica- ted, the chalybeate waters are decidedly bene- ficial.] Biblioo. and Refer. — J. P. de Lignamine, De TTno- quoque Cibo et Potu Utili et Nocivo. Rom., 4to, 1474.—C. Apicius, De Arte Coquinaria. Mediol., 4to, 1498.—B. Fiera, Coena, de ea Mediae Artis qute in Victus Ratione Consistit. Argent., 8vo, 1530.—B. Platina, De Honesta Voluptate, de Ratione Victns, &c. Par., 12mo, 1530.—Albengnefith, De Virtutibus Ciborum et Medicain. Argent., fol., 1533.— C. Lang than, an Introd. into Physike wyth an Universal Diet. Lond., 8vo, 1550.—L. Cornaro, De Vit.se Sobrise Commodis. Padua, 4to, 1558.—J. 11. Champier, De Re Cibaria, lib. xxii. Lugd. Bat., 8vo, 1560. — G. Gratarotus, De Regitnine iter Agentium, lib. ii. Basil, 8vo, 1561.—A. Fracantianus, in Libro Hippocratis de Alim. Coinmentarius. Venet., 4to, 1566. —M. Sybillinus, De Medicam. Stomachieis quse Ven- triculi medentur Imbecillitatibus. Basil, 4to, 1580.—B. A. Ferrioli, Von den Magensehwachkeiten, Myua, rf/Jyyaota, Gr. Inflammatio, Phlogo- sis, Phlegmone, Phlegmasia, Lat. Entzundung, Germ. Inflammation, Phlegmasie, Fr. In- Jlammazione, Ital. Classif.—1. Class, Febrile Diseases ; 2. Order, Inflammations {Cullen). 3. Class, Diseases of the Sanguineous Function ; 2. Order, Inflammations {Good). III. Class, I. Order (Author in Preface). 1. Defin.—Alteration of the vital actions of a part, manifested by morbid sensibility or pain, by redness, increased temperature, and swelling, gen- erally with more or less febrile commotion of the system. 2. Inflammations or phlegmasia constitute one of the most numerous classes of disease, and appear the most frequently in practice. They are the most common sources of structural le- sions, while they are, in their developed states, themselves lesions of organization, yet origina- ting in changes which are not at first, although they rapidly become more and more manifes'" They are thus intermediate states between dis ordered vital action and change of structure j retaining, however, the characteristics of the former condition, even when they have super- induced the latter. They may be seated in any organ of the body, and in any tissue, ex- cepting the cuticle, hair, and nails ; but certain structures or parts are much more frequently affected by them than others. The phenomena characterizing inflammations ; the changes in the circulating and secreted fluids attending them ; the effects produced by them locally and constitutionally; the remarkable variations these effects present, with the state of the sys- tem, and with the exciting causes ; and the al- most universal liability of the tissues and organs to their invasion, combine to impart the utmost interest and importance to the investigation of their nature and treatment. 3. In treating of this subject, I shall describe, first, the •phenomena, local and general, constitu- ting inflammation of a sthenic form, or as observ- ed in a previously healthy person, with their course and terminations, or consequences; sec- ondly, the varieties or states inflammation assumes, owing to certain predisposing, exciting, and concurrent causes, to the previous condition of the patient, to morbid associations, and to the tissues affected ; thirdly, the causes and pathol- ogy, or rational theory of inflammation; and, fourthly, the treatment, with reference to the different forms, states, and complications of the disease. Under one or other of these heads I hope appropriately to introduce everything of importance connected with the causes, nature, and treatment of this most important, most com- mon, and but imperfectly understood deviation from the healthy state. 4.1. Of the Phenomena constituting Sthen- ic Inflammation, and of their Course and Terminations.—It is necessary, in order to form a satisfactory view of inflammation, to consider, first, its phenomena, as manifested in a previously healthy constitution. It then pre- sents characters which have been variously de- nominated, in order to distinguish them from those which attend inflammation occurring in previously disordered frames, as the adhesive, phlegmonous, healthy, reparative, sthenic, &c. I have preferred the last of these terms, as it is more appropriate to most of the states in which this species of the disease presents itself. As sthenic inflammation occurs both in acute or active, and in slighter or more chronic forms, I shall describe it accordingly, but with due reference to the succession of one to the other, to the usual procession of the morbid phenom- ena of each, to the effects upon the circulation and secretions, and to the ultimate results. 5. i. Of Acute Sthenic Inflammation.—A. Local Characters.—In this, which may be de- nominated the truest, or the most unequivocal form of inflammation, there is an increase of the vital actions; but this increase must be of a certain duration, and the vital actions must be altered in character as well as in degree, must be truly morbid, as I have contended in the ar- ticle Disease (§ 87, et scq.), to constitute in- flammation, and to distinguish it from the vital turgescence, which is temporarily produced by local stimuli, or even by mental excitement. The true seat of inflammation is always the ganglionic nervous system and J;lie capillary vessels of the part affected ; the. primary change, as will hereafter be more fully shown, originating with the former, but more fully ex- pressed in the latter constituent of the organi- zation.* 6. Acute sthenic inflammation commences with increased or altered sensibility or pain of the part, to which soon succeeds redness, from in- creased vascularity, from the enlargement of * I may here state, that this and other views connected with the pathology of inflammation were published by me, first, in 1815, and subsequently in 1820, 1822, and 1824, in the works referred to in the Bibliography. It is the more necessary to state this, as several of these views have been adopted by later writers, and brought forward with an air of originality to which they have no claim. INFLAMMATION—Phenomena constituting Sthenic. 427 vessels. The temperature of the part is raised, the functions disturbed, the secretions at first interrupted, and subsequently changed; and swelling takes place. These phenomena are always present in a more or less remarkable manner, or in different proportions, and are much augmented when the system sympathizes and febrile action is developed. Neither of these constitutes inflammation when existing singly, and but four of them have generally been considered requisite to its existence, namely, pain, redness, heat, and swelling. Dis- turbance, however, of the functions, and disorder of the secretions of the part are constantly pres- ent, and are as much constituents of the dis- ease as are those more generally conceded to it. To these, the local symptoms, it will be ne- cessary more particularly to advert before the constitutional disorder, consequent upon the local affection, is considered. 7. a. Uneasy sensation, from its lowest grade, until it amounts to acute pain, is the primary symptom following the operation of the exci- ting cause, or characterizes that kind of excite- ment, or deranged influence of the ganglionic nerves forming the first series of the changes in the affected part, and it is heightened or kept up by the alteration thereby induced in the action of the capillaries. When the uneasy sensation amounts to pain, it is owing either to the de- gree of change in the organic nervous fibrillae, or to the communication of the morbid excite- ment, originating in these nerves, to the ter- minations of the cerebro-spinal nerves, with which they are associated in the tissues. The pain, therefore, of inflammation originates in, or arises from a change in the state .of the par- ticular influence exerted by the organic nervous fibrillae of the part; this change deranging the action of the capillaries supplied by these fibril- lae, and often exciting or otherwise disturbing the sensibility of the associated cerebro-spinal nerves. That the extension, however, of the morbid change to the latter nerves is merely contingent, is shown by the slightness of the pain, or by the absence of acute pain in many cases of severe inflammation of internal visce- ra, particularly those which are not supplied by these nerves ; and that the morbid sensation originates in the organic or ganglial nerves, and not in the cerebro-spinal, is rendered prob- able by the circumstance of the most acute pains which are clearly referrible to the latter class of nerves, as those of neuralgia, trismus, and other spasmodic affections, not being at- tended by inflammation. 8. The uneasy sensation is the sensible mani- festation of the primary change in the organic nerves of the part; of that change which indu- ces the vital expansion or turgescence of the capillary vessels, and the consequent increased influx of blood. The morbid sensation is after- ward increased to actual pain by the circum- stances just stated (§ 7), and by the excessive expansion and tension taking place in that part. It differs in severity and character according to the degree of inflammation, and to the sensi- bility and structure of the affected part. It often consists of soreness or aching ; of prick- ing, itching, tickling, tension, heat, or burning; of painful throbbing, tearing, darting, gnawing, &c. ; and in parts abundantly supplied with nerves, particularly with the nerves of sensa- tion, it is most acute. In mucous, cellular, and parenchymatous structures the pain is rarely very severe. The substance of the brain, or of the lungs, or of the liver, or of the kid- neys is often acutely inflamed without sensibil- ity being materially excited. Severe pain in these diseases is owing either to the extension of inflammation to the serous or fibrous struc- tures, or to the tension of these tissues, caused by the swelling of the parts they enclose. Un- yielding and dense textures, as the fibrous, se- rous, and fibro-cartilaginous, are generally the most painful when acutely inflamed. Pain does not always represent the true seat of the disease. In cases of partial inflammation of the substance of the brain, pain may be felt only in some remote part of a limb, or in a part of the scalp. During the inflammation of the substance either of the lungs, or of the liver, or of the kidneys, or of the uterus, pain may be felt only in those ramifications of the cerebro- spinal nerves which are most intimately related to the organic nerves of the affected part, as in the vicinity of the clavicle or shoulders, in the limbs, &c. 9. It is necessary to study, not only the se- verity and character of pain, with reference to the existence of inflammation, but also its types or modes. The uneasy sensation attending inflammation is generally constant; and, al- though often exasperated at times, it is never altogether absent. Even when no pain is com- plained of, as often occurs in inflammations of internal viscera, tenderness to the touch, or to pressure, is generally present. When, with continued pain, or with a sense of soreness, aching, or of throbbing synchronous with the pulse, or of heat, more or less constant, there are tenderness on pressure, and increase of the morbid sensation on exercising the functions of the part, inflammation may be inferred, even when other indications of it are absent. But the most severe pains, without tenderness, or with perfect tolerance of pressure, and espe- cially if they are paroxysmal, and attended by complete intermissions, furnish no evidence of inflammation. 10. b. Redness, of itself, is not sufficient to indicate inflammation. It may arise from ac- tive congestion of the capillaries, or from a vi- tal turgescence of only temporary duration On the application of an irritant, redness of the part is not manifested immediately, although uneasy sensation is induced ; but it soon is de- veloped, owing to the morbid excitement of the nervous fibrillse, and, like this morbid state, it is more or less permanent. The redness which has thus arisen is caused by the vital expansion of the capillaries, and by the admis- sion of a larger current of blood .into them, and of the colouring globules into a series of ves- sels which did not formerly admit them. The blood, also, during the sthenic state of inflam- mation, becomes somewhat more florid than usual in the capillary vessels. The redness is generally greatest in the centre of the inflamed part, or in that spot in which the irritation ori- ginated ; but it spreads more or less, and is gradually lost in the surrounding tissues. The colour varies in depth or hue with the progress and form of inflammation ; but, in the species now being considered, it is more or less florid or deep. In very vascular, or highly organized 428 INFLAMMATION—Phenomena constituting Sthenic. parts, the tint is deepest, owing to the more intense state of action. 11. Increased redness of a part may exist, as just stated, without inflammation. In order to impart to it essentially inflammatory characters, the vascular action, from which the redness proceeds, must not only be excited, but also otherwise changed from the healthy state. It must be rendered truly morbid. Stimuli or mental emotions will produce redness, but this redness is not inflammatory ; it soon disap- pears, and gives rise to no consequences or lesions. The excitant or irritant must, from either its continued or its peculiar action, change or vitiate, as well as excite the organic nerves of the part; must impart to them a truly morbid state or influence, which similarly affects the vital actions of the capillaries, not merely exciting, but also modifying that action, so as to give rise to effects very different from those observed in health. In this respect, ehiefly, the redness of inflammation differs from simple vascular excitement, or injection, or congestion. In this latter state the vessels are distended, and contain more than their usual quantity of blood, the circulation through them varying in activity, either rising above or sinking below the common grade of celerity. This state, to which only the very loose and often inappropriately employed term, hyper amia, recently introduced into pathological discus- sions, is applicable, is, however, very different from true inflammation, although it may be readily converted into some one of the varie- ties of inflammation. It is unattended by that morbid state of the organic nerves of the part upon which the true inflammatory action of the capillaries depends. However denominated, Whether congestion or hypercemia, or however qualified by the prefix active or passive, it forms no essential part, and constitutes no particular stage of sthenic inflammation, as supposed by some recent writers. 12. If we trace the course of the vascular dis- turbance, we shall find that a contraction of the capillaries of the part follows upon the applica- tion of an irritant, and upon the change pro- duced in the organic nerves of the part. The contraction is soon followed by a reaction or vital expansion of these vessels, an increased afflux of blood, and the other phenomena of the excited vital process. The veins receive the blood from the minutest ramifications of the capillaries, in such a manner as naturally to retard the capillary circulation in them. Con- sequently, when the action of the capillaries is morbidly increased, expansion of these vessels, and an excessive accumulation of blood in them, must necessarily follow; for the veins are in- capable of receiving and carrying onward with sufficient rapidity the quantity of blood sent to them. Owing to this circumstance, vessels previously admitting only the colourless blood, become expanded, so as to admit the red glob- ules ; and as the morbid process goes on, new vessels are probably developed, the blood also becoming, and continuing to be more florid as long as the sthenic action persists. 13. c. Increased heat, as well as augmented redness, is the result of the morbidly excited action. Experiments, however, with the ther- mometer show that the warmth of inflamed parts is not so great as the sensations usually indicate. Some writers, as Hunter, Aber- nethy, Mayo, and others, contend there is ac- tually no increase of the temperature above the healthy standard, but such is not the case. The temperature of an inflamed part upon or near the surface is usually several degrees higher than that of parts at some distance from it; and even the deep-seated viscera experi- ence a rise of two or three degrees, and often much more, above the healthy temperature of 98°. The existence of heat, even with in- creased redness, is not an unequivocal symp- tom of inflammation, for it may depend upon temporary or healthy excitement merely. It is necessary to be continued to indicate a mor- bid state of action. Moreover, it may be so slightly augmented as to escape notice. 14. As to the source of heat in inflamed parts, some difference of opinion has existed. Since Crawford proposed the theory of the depend- ance of animal heat upon the different capaci- ties of venous and arterial blood for caloric, the warmth of these parts has been imputed by many to the quantity of blood circulating through them, and passing from the arterial to the ve- nous state. Without occupying my limits with the opinions and discussions as to animal heat, I may remark that Sir B. Brodie considered, from his experiments, that the cerebro-spinal nervous system was instrumental in its produc- tion. This opinion, however, was not confirm- ed by the researches of Legallois, W. Philip, and Hastings. In 1820, 1822, and 1824 I pub- lished my views on the subject (see Lond. Med. Repos., vol. xvii., p. 370, and Appendix to Rich- erand’s Elements of Physiology, p. 630), and contended that animal heat is not the result of the difference of capacity existing between ve- nous and arterial blood ; for, as Dr. Davy has shown, this difference is not sufficient to ex- plain the phenomenon, although it may be sub- concerned in producing it. I then stated that the various causes which modify the production of animal heat act, 1st, immedi- ately upon the organic system of nerves ; 2dly, upon the blood ; and, 3dly, through the medium of the cerebro-spinal system, modifying the in- fluence which this system imparts to the gan- glial. I then viewed animal heat more as a vi- tal secretion than as a chemical phenomenon, as proceeding from, and as being controlled by, the influence exerted by the ganglial system ot nerves upon the vascular system and blood ; and the subsequent researches of Chossat and Ed- wards obviously confirm this opinion. Con- formably with this view, I have stated, in the works referred to, that the increased heat of inflammation is derived from the same source, from the influence of the organic nerves upon the vessels of the affected part, aided by the increased circulation through the capillaries; the nervous influence enlarging these vessels, or occasioning an erectile state of them, and thereby soliciting an afflux of blood to the part. The increased temperature of erectile tissues, consequent upon irritation of their nerves and expansion of their vessels, fully illustrates this theory of animal heat, and particularly with reference to inflammation. 15. d. Swelling has been assigned above as one of the changes constituting inflammation. But, from what I have already stated, it should be viewed rather as a consequence of this act than as an essential part of it. Besides, swell- ing is not always present, owing to circum- stances about to be noticed. The morbid state of the organic nerves and the expansion of the capillaries are the earliest causes of swelling. But, as the diseased action proceeds, a more or less copious exudation of serum into the areolar tissue takes place ; a portion of the se- rum, and' even of the red particles of the blood, passes through the pores or distended walls of the capillary canals, especially in cellular or mu- cous tissues, distending, tumefying, and thick- ening the inflamed part. Hence the areolae of cellular structures are found filled with a se- rous, sero-albuminous, and often with a san- guineous fluid, in which flocculi are sometimes seen floating, or adhering to the parietes of the areolae or cells, these parietes being often thickened. 16. The nature of the swelling entirely de- pends upon the state or kind of fluid thus exu- ded from the inflamed capillaries. The state ojf the fluid depends upon the kind of disorder of the organic nervous influence of the part, and of the constitution generally, and upon the de- gree of vital power exerted by the system. In the sthenic species of inflammation, this power, however much it may deviate from the healthy condition, is at least not depressed below this condition. The fluid exuded is therefore a product of increased or sthenic vascular action, excited and kept up by the influence exerted on the capillaries by the nerves in which the disorder originated. Hence it is generally sero-albuminous, or a mixture of serum and coagulating lymph, sometimes containing col- ouring particles when the morbid action is in- tense ; and the consequent swelling is firm, tense, and limited as to extent. The sero-al- buminous or coagulating character of the effu- sed fluid entirely depends upon the sthenic na- ture of the inflammation, and is of the utmost importance as respects the subsequent changes. When the organic nervous or -vital power, lo- cally or generally, is depressed or otherwise vitiated, as well as depressed, the effused fluid is not albuminous, and does not coagulate. It is then either serous or sanguineous, or even sanious, and does not possess the characters of coagulable lymph. The consequent swell- ing is cedematous, soft, diffusive, or spreading, owing to the fluid state of the exudation, and its more ready infiltration into the surrounding parts. While organic nervous or vital power is unreduced, the exuded matter occasioning the swelling in the advanced stage of inflam- mation at least partially coagulates, and limits the extension of tumefaction. But when this power is much reduced, or greatly vitiated, as in the different forms of asthenic inflammation, this matter retains its fluidity, infiltrating and infecting the surrounding tissues. 17. The existence and amount of swelling chiefly depends upon the nature of the inflamed tissue. It is neither so early nor so obviously present in inflammation of dense structures as in that of soft and yielding parts. It is incon- siderable in fibrous, fibro-cartilaginous, and se- rous tissues, and is hardly apparent until the morbid action has continued for some time. In cellular, mucous, and parenchymatous tis- sues, the swelling is early and considerable. In certain parts, as in cellular tissue bound INFLAMMATION—Phenomena constituting Sthenic. down by aponeurotic expansions, and in the in- ternal structure of organs surrounded by fibrous or unyielding membranes, the swelling is less, or more slowly developed ; the pressure thus occasioned restraining the effusion and the ex- pansion of the capillaries. But, where the morbid action is intense, the pressure gives rise to a most distressing sense of tension, in- terrupts the functions of the organ, and some- times even the circulation in it, thereby de- stroying its vitality and occasioning dissolution. When the substance of the brain is inflamed, the nature of its circulation, the great division and tenuity of its capillaries, and the unyield- ing nature of its surrounding structures com- bine to prevent it from becoming much swol- len. Yet there is every reason to believe that more or less swelling actually occurs (see art Apoplexy, and Brain—Inflammation of), and that the pressure on the inflamed organ, occa sioned by the unyielding parts surrounding it. gives rise to the more dangerous symptoms ob- served in the advanced progress of the disease 18. e. The functions of an inflamed organ, tissue, or part, are, as Mr. Morgan has very justly contended, more or less disordered ; and I may add that the disorder is one of the earli- est phenomena or constituents of the morbid action, being nearly coetaneous with the change in the organic nervous power, on which this action depends. The disturbance of the func- tions is generally in proportion to the violence of the disease. If the inflamed part performs a secreting function, the secretion is either di- minished, increased, or altered in character. Diminution of this function is observed, when the cutaneous surface is inflamed, at the com- mencement of acute inflammation of serous and mucous membranes, and when the morbid action in glandular secreting organs is sudden or intense. When parts near the surface are inflamed, perspiration is obstructed, and the temperature is thereby increased. It is onlj at the commencement of inflammatory actior in serous and mucous surfaces that their secre tions are diminished: as the disease proceed?- their secretions become increased, but, at th same time, changed in their characters; the change varying with the intensity, form, and duration of morbid action, and with the state of the patient. Inflammation of glanduh.r or- gans is generally attended by suspension or diminution of their secretions, as in hepatitis, nephritis, &c. But in many cases, one kidney only, or a portion of the liver, may be inflamed, the secretion being only diminished or some- what altered. It should, however, be recol- lected that the secretions of an organ may be suspended, increased, or morbidly affected oth- erwise than by inflammatory action. 19. The lesion of function attending the com- mencement of inflammation obviously depends upon the primary affection of the organic nerves. That accompanying the advanced progress of the morbid action proceeds not only from this source, but also from the alteration in the ca pillary circulation, from the consequent effusion of lymph in the inflamed tissue, and from the swelling and mechanical obstruction thereby produced. 20. The throbbing is connected with the ob- struction to the return of blood, particularly from the expanded capillaries into the veins. 429 430 It is synchronous with the pulse, and is caused by the injection of blood into the part on each contraction of the left ventricle of the heart. It increases and renders the pain pulsatile; when it occurs at an advanced stage of inflam- mation, it is usually soon followed by suppura- tion. It is increased by a depending position of the inflamed part, and by whatever either obstructs the return of blood from, or favours the flow of it to, the seat of disease. 21. B. Op the Local Appearances after Death.—Certain of the preceding local charac- ters of inflammation necessarily disappear with the termination of life; and the rest, as red- ness and swelling, either vanish, or remain for some time afterward. Redness does not al- ways continue after death ; its absence, there- fore, is no proof that inflammation had not ex- isted during life. Its presence also, post mor- tem, is not sufficient evidence of its dependance upon this cause. At an early stage of inflam- mation, and before the capillaries have lost their vital tone or contractility, and before much serum or lymph has been effused, red- ness generally disappears after death. Even when much effusion of fluid, and other changes consequent upon the morbid vascular action, have taken place, the blood may have entirely forsaken the vessels before the parts have been examined. Where redness actually exists, much discrimination is necessary to determine whether or not it has proceeded from inflam- mation, or from a dependant position, or from transudation of the colouring matter of the blood from the vessels, or from incipient de- composition. It may arise from either of these. In many cases, two or more combine to pro- duce it: a depending position favours both the gravitation of the fluids in the vessels, and the exudation of' the colouring particles in the lower parts. The injection caused by position more readily occurs in parts which have been inflamed than in those previously sound. Much, however, depends upon the seat and form of inflammation, and upon the circumstances con- nected with dissolution. Next to position, ob- structed circulation through the heart or lungs, or obstruction to the return of blood in the veins, most frequently occasions non-inflamma- tory injection and redness, particularly in mu- cous surfaces ; but, in such instances, the red- ness is more or less general or diffused in these parts, or exists in situations remote from each other, and is not attended by the usual products of inflammation. Attention to the circumstan- ces causing redness of parts after death will generally enable the practitioner to infer with accuracy its dependance upon inflammation. When it is associated with any of the usual products or consequences of this disease, as the effusion of lymph, or of a sero-albuminous fluid, with softening, swelling, &c., then no doubt as to its origin need be entertained. (See Diagnosis.) 22. C. Of the Constitutional Symptoms or Effects of Sthenic Inflammation.—The con- stitutional phenomena vary remarkably with the exciting causes, the intensity, and the seat of inflammation ; and they are farther modified by age, habit of body, diathesis, and epidemic constitution. When inflammatory action takes place in a previously healthy person, and from causes which do not materially vitiate or de- INFLAMMATION—Constitutional Symptoms of Sthenic. press the vital powers, or contaminate the cir- culating fluids, the constitutional effect pre- sents certain features which are r ’.rely want- ing. It has been variously denominated as Symptomatic Inflammatory Fever, Sympathetic Synocha, General vascular Reaction, Inflammato- ry Fever, &c., and has been improperly descri- bed in connexion with, or, rather, as a species of true fever. Indeed, some writers, as I have shown in the article Fever ($ 91), particularly Clutterbuck, Marcus, and Broussais, have contended that the constitutional affection, pro- duced by the local changes constituting inflam- mation, is in no respects different from idio- pathic fever. In the article just referred to, I have stated sufficient to prove the very remark- able differences between the two ($ 26-30), and I shall hereafter succinctly notice the subject. Indeed, the former is altogether distinct from the latter, and should not be considered in con- nexion with it, farther than to point out the di- agnosis. 23. In some constitutions, particularly the sanguineous, the irritable, and the nervous, the local lesions described above (<) 6), very soon af- ter their commencement, create more or less constitutional disturbance and febrile commo- tion ; while in others, as the phlegmatic or lymphatic, the melancholic or bilious, these lesions may have been of some continuance, or have proceeded far before general disorder is developed or becomes severe. The local change being the same, the constitutional ef- fect will vary remarkably in grade, form, and course, according to these and other circum- stances just mentioned. In some it will be rapidly developed; in others slowly, or after a precursory period of longer or shorter dura- tion, or after several efforts to produce it. The earlier constitutional symptoms are often neg- lected by the patient, and are seldom subjected to the physician. Occasionally the patient ex- periences chills or rigours, more or less severe, almost immediately after sensations of pain or uneasiness. In rarer cases, morbid sensation is not produced until either during or after the rigours. This is observed most frequently in inflammations of internal organs. More com- monly the patient complains, in connexion with pain, of uneasiness, or other morbid states of sensation referrible to a particular part, of weakness of the limbs, lassitude, general un- easiness, or lowness of spirits, of slight chills, formication, or of an alternation of slight chills and flushings. These may be the only precur- sors ; or they may be attended by disturbed sleep, a whitish or loaded tongue, a clammy state of the mouth, with vitiated taste, want of appetite, constipation, &c. With these, the local symptoms are aggravated, and severe rig- ours or shudderings are more or less rapidly pro- duced. The rigours are sometimes accompa- nied with nausea or vomiting. The counte- nance, general surface, and extremities, which were pale, harsh, or cold during the rigours and chills, soon afterward become warm; and the pulse, which was previously small or constrict- ed, and but little accelerated, increases in quickness and volume. The consequent phe- nomena appear with a rapidity and severity varying with the intensity and extent of the local action. The secretions and excretions are diminished, and subsequently vitiated. The INFLAMMATION—Changes observed in the Blood in Sthenic. 431 skin is hot and burning, the face flushed; the tongue is white, furred, or loaded, and, with the mouth, somewhat dry or clammy ; the appetite is gone ; thirst is urgent; the bowels are con- stipated ; the urine is scanty, high-coloured, clear, and emits a strong odour ; and pains are often felt in the back, or loins, limbs, or head, in addition to those referred to the inflamed organ. The symptoms indicate general vas- cular excitement and its usual consequences, unconnected with depression of vital power or contamination of the fluids. When they are severe or intense, and when the energies of life become exhausted, delirium sometimes takes place, particularly at night; but it rarely appears early, unless the brain is the seat of inflammation, or readily sympathizes with the , local affection, as in inflammation of the dia- phragm or of fibrinous parts. 24. The acuteness of the general symptoms is not always in relation to the severity of the local changes; but, according to the intensity of either, or of both, will the type of the for- mer be more manifestly continued. Th'e less severe states of constitutional affection, and particularly when the local morbid action is neither extensive nor very acute, are charac- terized by exacerbations in the evening or night, during which the local symptoms are more or less exasperated, restlessness and want of sleep being generally present. In the morning the symptoms are ameliorated, and a tendency to perspiration appears. The course and duration of the constitutional affection vary with the severity and the seat of the local disease, and with the circumstances proper to the individual affected. The symptoms usual- ly increase either gradually or rapidly, accord- ing to the nature of the exciting causes, the acuteness of the attack, and the circumstances just alluded to, until they arrive at a certain pitch or acme, from which they decline more or less rapidly in some cases, and slowly in others. This change, whether taking place gradually and slowly, or suddenly and rapidly, depends entirely upon the state of the local af- fection. If the local symptoms gradually de- cline, the general disturbance subsides in a similar manner ; and if any of the more unfa- vourable terminations of the local disease about to be noticed occurs, the system evinces the change, as will be hereafter stated. 25. D. Of the Changes observed in the Blood in Sthenic Inflammation.—These vary remarkably with the circumstances determin- ing the severity, seat, and course of the dis- ease. I have described them so fully in the article Blood (§ 96, et seq.), that little more need be here adduced upon the subject. Much importance has been attached to the existence of a buffy coal, and of a cupped appearance of the coagulum. These states of the blood are most frequently observed in the species of in- flammation now being considered. But they are not always, nor even very generally pres- ent, nor at all stages of the disease in which they occur. They are even more commonly met with in some complaints which, although nearly allied to inflammation, are not purely inflammatory, as rheumatism. They have fre- quently a marked reference to the stage and seat of inflammation. In acute rheumatism they are very remarkable, and often become more so as depletions are repeated. I once witnessed a case of the internal metastasis of rheumatism, for which venaesection was re- peated several times. The buffed and cupped appearances became more and more remark- able ; and yet, upon examination after death, no signs of inflammation could be detected, and the internal viscera were quite bloodless. When, however, serous and fibrous structures are inflamed, these states of the coagulum very generally exist. During acute inflammation of cellular and mucous tissues they are much less frequently observed. When compound or parenchymatous structures are inflamed, they are met with chiefly in certain stages and states of the disease. When an important or vital organ is inflamed, and especially when the patient is plethoric and the circulation op- pressed, these appearances often do not take place until the vascular load and oppression are removed, and the circulation is rendered free. There are various other circumstances which affect the state of the coagulum in acute sthenic inflammations, but they are noticed in the article just referred to. It is chiefly in the venous blood that cupped and buffed appear- ances have been seen ; for the occasions of noticing them in arterial blood are compara- tively rare, and unfavourable to their occur- rence. They have, however, been met with in arterial blood by Gordon, Gendrin, and others. [Mr. Addison claims to have established the following conclusions as connected with the blood : “1. That the colourless corpuscles exist in the blood of man under all circumstances, and are constantly circulating through the capillary vessels, to the walls of which they have a ten- dency to adhere. “ 2. That they exist in great numbers in the blood of inflamed parts ; and that they may be seen accumulating in the irritated vessels of a frog’s foot, and showing an increased tendency to adhere to their walls. “ 3. That they exist in great numbers in the buffy coat of the blood. “ 4. That the liquor sanguinis, especially that of inflammatory blood, jibrillates in coagulating, so that a thin film of it presents all the structu- ral characteristics and physical properties of fibrous or membranous tissue. “ 5. That lymph and pus globules, exudation cells, and epithelium, are altered forms of the colourless corpuscles.” (The Actual Process of Nutrition in the Living Structure demonstrated by the Microscope, &c., by William Addison, F.L.S. Lond., 1844, p. 76, with 2 plates.) Dr. A. also maintains that neither the fibrin noi albumen of the circulating blood is diffused through its fluid portion, or liquor sanguinis; but that they are both contained in the colour- less corpuscles : of these he supposes that a large proportion burst or become ruptured as soon as the blood is drawn from a vein, owing to the sudden change of temperature to which they are exposed, or from other causes; and that they set free the liquor sanguinis, which rises to the surface, drawing up with it the colourless corpuscles which have hitherto pre- served their integrity. These views, however, appear to us hypothetical, and, considering the variety of appearances described by different microscopical observers, require farther con- 432 INFLAMMATION'-Changes observed in the Blood in Sthenic. firmation. It is now well established, by the researches of Andral, Gavarret, and others, that an excess of fibrin and of the colourless or lymph globules exists in inflammatory dis- eases, especially those of a sthenic character, and acute rheumatism. In some cases fibrin has been observed in the proportion of 10 parts in 1000, the natural ratio being from 22 to 32. It is found in excess in tuberculous diseases, pneumonia, rheumatism, cellular inflammation, or simple phlegmon, phlegmasia; of the mucous membrane of the respiratory and digestive ap- paratus, mercurial stomatitis, acute cystitis, acute inflammation of the skin, as in burns, erysipelas, &c' ; also, of all serous membranes, lymphatic glands, and softening of the brain. As soon as inflammation begins, an increase in the fibrinous constituent of the blood is mani- fested. M. Andral supposes that the disease of the solid precedes the change in the blood; and that the occurrence of this latter explains, and is proof of inflammation being a general and constitutional disease. The sympathetic fever in the phlegmasiae is, he thinks, due to the alteration in the blood by excess of its fibrin. —(Williams’s Principles of Medicine, ed. by J. Bell. Phil., 1844.) The increase of fibrin is so constant a phe- nomenon as to be regarded as a pathognomon- ic sign of inflammation, distinguishing it from other conditions that simulate it, and thus en- abling us to detect it at an earlier period than could be done by either general or local signs, the degree of increase bearing a constant pro- portion to the extent of the inflamed part and to the intensity of the morbid action. But it is to be observed that there is not only an ex- cess of fibrin, but an increase in its plasticity, or tendency to become organized; thence ari- ses the rapid production of false membranes from fibrinous effusions, as well as from the more complete fibrous arrangement seen in the buffy coat, than that which the ordinary coagu- lum of blood displays. The increased propor- tion of the white or colourless corpuscles in inflammatory blood, and their special accumu- lation in the vessels of the inflamed part, has been abundantly shown by the independent ob- servations of Gendkin, Gulliver, Addison, and Williams. There is every reason to sup- pose that the white corpuscles are newly formed immediately upon the application of an irritant; and Mr. Addison has shown that they have the character of true cells. The above facts seem to prove very conclusively that the increase of fibrin, and its more contractile and separating quality, originate in the vessels of the inflamed part, and must be regarded as an augmentation of the vital process of nutrition developed by inflammation.] 26. The coagulation of the Hood, and the ori- gin of the buffy coat of the coagulum, have been so fully considered elsewhere (see art. Blood, and my Appendix to Richerand’s Elements of Physiology, p. 638), that I need adduce but lit- tle farther on the subject than to state the facts ascertained, and the inferences deduced from my investigations, and published in 1824, in the first edition of the Appendix just mentioned. The blood during life consists of serum, hold- ing in suspension small, regular, and insoluble globules, each of which is composed of a cen- tral, colourless spheroid corpuscle, and a col- oured envelope. The latter always continue* to surround the former during life ; but. as life departs, and as the motion to which it gives rise ceases, the attraction between the central corpuscles and their coloured envelopes no long- er exists, the one completely separating from the other. The central corpuscles then obey the force which tends to unite them, and form a net-work, in whose meshes the liberated col- ouring matter, now detached from these cor- puscles, becomes enclosed, and thus the coagu- lum is formed. These central corpuscles, in uniting into filaments or other forms, consti- tute the fibrin, which, as respects its consti- tution, is probably only a modified or more high- ly animalized albumen, which abounds more or less in the serum. When the coagulum of the blood is exposed to a stream of water, the colouring matter, detached from the central corpuscles, is washed away, while the corpus- cles themselves remain aggregated in the form of fibrinous filaments. It is the various forms assumed by the aggregation or mutual attrac- tion of the central corpuscles, in relation to the separation, deposition, or entanglement of the colouring matter, and to the appearances of the serum in which these changes take place, which constitute the phenomena of coagulation, and give rise to the appearances of the blood char- acteristic of inflammatory action. In addition to these facts, the following inferences as to the causes of the phenomena of coagulation may be abridged from my notes above refer- red to : 27. 1. The globules of the blood possess a rotatory motion during life, this motion contin- uing until shortly before coagulation takes place. 2. This motion is the consequence chiefly of the organic nervous or vital influence which is exerted by the ganglionic system on the heart and blood-vessels, and which is par- tially imparted to the globules. 3. This influ- ence thus preserves the blood in a state of due fluidity. 4. The fluidity of the blood is hence a vital phenomena, or property derived, from, and depending upon the vital conditions of the vessels in which, and the organs through which it circulates; the vital conditions of the ves- sels and organs depending, as shown elsewhere, chiefly upon the organic nervous influence. 5. The cause of the coagulation of the blood is not to be found in external agencies, but in the loss of the vital influence and motion of the globules, proceeding from the sources just assigned, the power exerted by the ganglionic upon the vas- cular system. 6. The presence of air, particu- larly the oxygenous portion of it, and several physical and chemical agents, hasten coagula- tion, while others delay or altogether prevent it. 7. When coagulation commences at any point of a mass of blood, it is rapidly propaga- ted throughout the whole : rest favouring co- agulation, while motion delays or prevents it. 8. The heat of the body and the strength of the circulation are not causes of the blood’s fluidity, but are both results of the same cause, namely, the vital energy of the vessels, and vi- tal endowment of the globules of the blood: both are co-ordinate, and both, as well as the phenomena connected with coagulation, are de- pendant on this source. 9. Coagulation occurs sooner in venous than in arterial blood ; and coagulation of arterial blood is still longer do- INFLAMMATION—Changes observed in the Blood in Sthenic. 433 layed if it be prevented from leaving the arter- ies. 10. Coagulation takes place the sooner after the blood is removed from the vital sphere of the system, the weaker the vital energy to which it was subjected while circulating in the system. 11. The weaker the vital energy, and, consequently, the quicker the coagulation, the more lax is the coagulum which is formed. 12. Coagulation is more slow, and the coag- ulum more firm, the more energetic the vital action of the vessels. 13. As the central cor- puscles lose their coloured envelopes soon af- ter their removal beyond the sphere of the vital influence of the vessels, and as this is the first part of the act of coagulation following the loss of motion of the globules, so it may be inferred that the colouring matter continues to surround the central corpuscles in consequence of the vitality emanating from the interior of the ves- sels and endowing the globules ; and that the separation of the colouring envelope from the central corpuscle is the result of the loss of a portion or of the whole of that vitality, and of the rotatory (1) motion which it occasions; and, as the loss of vitality may be reasonably supposed to be quickest where it has existed in the lowest grade, the separation of the coloured envelopes, and the attraction of the central corpuscles forming the fibrin, will be the quick- er, the weaker the vital energy, and vice versa; but the coagulum will be the more lax or im- perfect, as shown by the facts already stated (10,11). 14. Although the loss of the rotatory motion and of the colouring envelopes of the globules disposes the central corpuscles to at- tract each other, yet the attraction is weak in proportion to the depression of organic nervous or vital power endowing the vascular system at the time when the blood is abstracted ; and in some inflammations, as well as in some other diseases, the depression may be so ex- treme as to deprive the central corpuscles of all power of uniting in the form of fibrinous filaments. In such cases these corpuscles merely mix with the serum like a gelatinous or albuminous matter, and either suspend the col- ouring substance, or allow its deposition to the bottom of the vessel; the central corpuscles separating imperfectly from the serum or com- bining with its albumen, or forming merely an almost colourless gelatinous mass in the upper parts of the coagulum. 15. The firmness of the coagulum is in proportion to the degree of organic nervous influence endowing the vascu- lar system, and to the emanation which the globules themselves derive from this influence.* 28. From what is now advanced, the appear- ances of the blood in inflammatory and other diseases will be readily explained. When the organic nervous power is depressed or exhaust- ed—as in asthenic inflammations, in typhoid and adynamic fevers, in the true infectious pu- erperal fever, and puerperal mania, in the worst forms of erysipelas and diffusive inflammation of the cellular structures, and in several other diseases, particularly when epidemic, or occur- ring in hospitals, the air of which is vitiated by crowding of the sick, and the decomposition of the discharges and secretions, as in lying-in hospitals—the blood taken from a vein will often not separate into a distinct coagulum and serous fluid, but will assume the appearance either of a black, grumous, sanious, semi-gelat- inous mass, or of a straw-coloured jelly, at the bottom of which jelly the colouring matter forms a loose reddish brown, or blackish stratum. In such cases the blood, participating in the deficiency of the vital energy of the body, and being also, perhaps, deranged from the admix- ture of hurtful materials with it, which are not duly eliminated by the various emunctories, evinces the lowest grades of vital endowment, the attraction between the central corpuscles of the globules being too weak to form a coag- ulum and to exclude the serum, the colouring envelopes separating speedily from the central corpuscles, and forming a loose stratum at the bottom of the vessel. 29. It may be inferred, as corollaries from the foregoing, that the appearances which the blood exhibits have always an intimate relation to the vital conditions of the system, and to the excitement of the heart and blood-vessels; that the buffy coat is merely one of the manifesta- tions furnished by the blood, indicating reaction of the powers of life, or excitement of the vas- cular system; that the blood participates in the vitality of the body, through the medium of the vessels and organs in which it circulates and that, according to the degree or condition of this vital endowment, coagulation and the coagulum are modified in their phenomena and appearances, and the production of the buffy coat promoted or altogether prevented. (See art. Blood, § 81, et seq.)* tution, since its contractile power is diminished by whatev- er impedes the function of respiration, as in phthisis, asth- ma, disease of the heart, the cold stage of fever, and all maladies of long standing, by which the powers of life are greatly reduced” (vol. ii., p. 648). The work above quoted is one of the most remarkable of the age, for the great learning and ability it displays ; being characterized by a deep philosophical spirit, profound sagacity, and immense research, there can be no doubt that it is yet destined to exert a most important influence upon medical science, and modify many existing opinions on physiology, pathology, and practical medicine.) * [The changes observed in the blood in sthenic inflam- mation are thus ably summed up, in the Brit, and For. Med. Rev., July, 1844, p. 103 : “ I. a. The quantity of fibrin in the blood undergoes a decided increase ; the plasticity of the whole mass, therefore, but especially that of the liquor sanguinis, is greatly augmented, b. There is a correspond- ing increase in the proportion of white corpuscles, which are present in large amount in the vessels of the inflamed tissues, and have a great disposition to adhere to their walls ; but which are also present, to an unusual amount, in the entire mass of the circulating blood, c. The increase in the proportion of fibrin is chiefly a local action, exerted on the blood during its passage through an inflamed part, and probably effected by the instrumentality of the white corpuscles, d. There is usually an increase, not only in the quantity of fibrin, but in its plasticity or tendency to be- come organized, ns shown by the greater perfection of the fibrous structure into which it passes in coagulating. Thi9 * [Dr. S. L. Metcalfe has reduced the leading facts connected with the theory of coagulation to the following propositions (Caloric, its Mechanical, Chemical, and Vital Agencies in the Phenomena of Nature, 2 vols., 8vo, p. 1100. Lond., 1843) : “1. That the contractile power of the blood when re- moved from the body, like that of the muscular fibres, is in proportion to the quantity of respiration, mean healthy tem- perature, and aggregate vital energy in the different orders of animals ; being greater in birds than in mammalia, and greater in the latter than in reptiles and fishes. « 2. That, as the temperature of arterial is higher than that of venous blood, so does the former coagulate more quickly and firmer than the latter. “ 3. That, as the vital energy of animals is always dimin- ished by reducing their temperature below their natural standard, so is the coagulation of the blood retarded by the same means, and wholly prevented by long-continued cold. “4. That the blood of individuals belonging to the san- guine or dynamic temperament coagulates sooner and more firmly than in such as are of a weak or phlegmatic consti- 434 INFLAMMATION—Che onic. 30. ii. Of Chronic Inflammation.—Inflam- mation may affect any tissue or organ in so mild and obscure a form from the commence- ment as to proceed for a long and indetermi- nate period ; and, in many cases, to escape detection for a long time, owing to the slight- ness and gradual progress of the phenomena constituting the inflammatory act. This may be termed Primary Chronic Inflammation. The chronic form of inflammatory action is, how- ever, frequently observed to follow the acute disease; the latter, owing to diathesis, treat- ment, premature exposure, and to the operation of injurious agents before recovery had taken place, only partially disappearing, or degenera- ting into a milder and more prolonged state of action. This state may be called Consccutivi Chronic Inflammation. 31. A. The Local Symptoms vary remarkably with the mildness or severity of the morbid ac- tion ; for, as the term chronic, as well as acute, is merely conventional or relative, both mark- ing extremes of action, between which every intermediate grade is to be found, each of the phenomena already described, as characterizing sthenic inflammatory action, appears in differ- ent states of development in different cases and circumstances. Generally speaking, how- ever, all the local symptoms are much less se- vere than in the acute disease, and sometimes so slight as to escape detection. Pain is occa- sionally absent, or is so slight as not to excite attention. Redness is also sometimes slight, or not very remarkable. The temperature is not much elevated ; it is often not above the natural standard. Swelling is frequently slight, but it is sometimes very considerable; and throbbing is seldom complained of. The func- tions of the organ or part affected are generally more or less disordered ; but in some instances the disorder is slight, or even escapes detec- tion. This is especially the case when a por- tion only of an organ or part is chronically in- flamed. When an internal organ is thus affect- ed, it is chiefly by the presence of disordered function, and by the constitutional or sympa- thetic effects of the morbid action that the na- ture and seat of the disease can be detected. 32. B. The Constitutional Symptoms are often slight and obscure, sometimes prominent and characteristic. Febrile Symptoms are not al- ways present; and, even when most manifest, they are rarely of a continued type. They are generally remittent, or almost intermittent, the exacerbations being preceded by languor, un- easiness, or slight chills, followed by increased frequency of the pulse, by thirst, dryness of the mouth, and heat of skin. These symptoms come on in the evening, impair the rest, and subside in the morning, either with or without perspiration. The general health is more and more impaired, the strength fails, the flesh wastes, and the complexion waxes pale, sal- low, or unhealthy. If the generative or urina- ry organs are the seat of the disease, various nervous or sympathetic symptoms are present; and if matter forms, or ulceration takes place, the chills become more severe, the febrile exa- cerbations terminate in copious perspirations ; the urine is thick after standing, or deposites a sediment; emaciation proceeds more rapidly, and hectic fever is established. 33. iii. Progress and Duration.—The prog- may consist in an increased attraction between its particles, which continues to operate for some time, causing contrac- tion of the fibrous net-work, subsequently to its first produc- tion. e. There is also an increased attraction between the red particles of blood, causing them to adhere together in rolls more firmly and for a longer period than they do in healthy blood. /. To these two causes, usually aided in their operation by the slowness of the coagulation, all con- curring to produce an increased tendency to separation be- tween the red corpuscles and the liquor sanguinis, we may ascribe the production of the huffy coat of inflammatory blood, g. The increased plasticity of the blood is so con- stant a phenomenon of inflammation, that it maybe regard- ed as essential to the presence of that state. “ II. a. On the other hand, the formative power of the in- flamed tissues appears to be diminished ; their usual functions, whether of nutrition or secretion, being com- pletely checked, or insufficiently performed, or perverted in their character, b. While, therefore, an over-production of fibrin is taking place in the blood, there is diminished con- sumption or appropriation of it in the tissues, c. If the in- flammation be severe in its character, the vitality of the tissues is so diminished as to cause, not only a cessation of their formative actions, but also an increased tendency to disintegration, as shown in suppuration and ulceration; or positive death of a large part, as in gangrene, d. The de- pression of the vitality of the tissues sometimes appears to result from a previous over-excitement of it, as when in- flammation follows excessive use of a part, or the applica- tion of stimulants to it; but it is sometimes the consequence of some directly sedative action, as that of cold. e. Hence both determination of blood and congestion have a tendency to produce inflammation; the one being a state of over-ex- citement, which is very prone to occasion subsequent de- pression, while there is at the same time a tendency to in- creased production of fibrin in the blood, the other being itself a state of depression of formative power in the solids, but not passing into inflammation, unless there be at the same time an increased plasticity of the blood. “ III. a. The motion of the blood in the capillaries of the inflamed part is greatly retarded, as we might have anticipated from the impairment of the functional operations of the solids. There may even be a total stagnation of the blood in the capillaries of a considerable portion of the tis- sue, which will be followed by its death and disintegration. The degree of stagnation will depend upon the amount of the depression of the vitality of the surrounding parts, b. The motion of blood through the vessels in the neighbour- hood, however, is more rapid than usual, and these vessels are themselves enlarged ; so that the total quantity which passes through an inflamed member in a given time is great- er than usual, c. The vessels are enlarged both m and around the inflamed part, in consequence of a diminution of the tonic contractility of their walls, which causes them to admit of abnormal distention by the impulse which the blood receives from the heart. This diminution is another evidence of the depression of the vital properties of the solid tissues in an inflamed part. “IV. a. The products of inflammation differ from those of the ordinary processes of nutrition and secretion, not so much in their materials as in the nature of the change which these have undergone, b. When the intensity of the inflammatory process is moderate, the liquor sanguinis, con- taining an unusual proportion of fibrin, and possessing a high degree of plasticity, is effused into the neighbouring tissues or upon the neighbouring surfaces, being generated, by the local actions of the part, faster than it can be with- drawn by its formative processes. By the organization of which it is susceptible, when in contact with the living solids, it spontaneously assumes the form of simple fibrous tissue, constituting false membranes on the surface, or con- solidating the substance into which it is effused, c. If the inflammatory process goes no farther there is no disintegra- tion of the original tissue ; but if its vitality be too far de- pressed it dies ; and the changes which it consequently un- dergoes impress themselves upon the fibrinous effusion. The fibrin loses its vital power of coagulation, and in this aplastic state becomes the chief ingredient in the liquor pu- ris; while the cells (pus-corpuscles), which are found float- ing in it, resemble the white corpuscles of the blood in a degenerated form. d. When the inflammation is very se- vere, and the stagnation of blood in the capillaries of the part is complete, an entire loss of vitality in the whole tis- sue at once, or gangrene, is the result. Gangrene does not originate, however, in inflammation alone, since any other cause, such as the long-continued action of cold or pressure, interrupting the capillary circulation, or obstruction to the supply of blood through the arterial trunks, will equally produce it, by the suspension of the formative processes thus occasioned. But unless some degree of inflammatory action, that is, an increase in the plasticity of the blood, be set up at the same time, there is an indisposition to the for- rnation of the line of demarcation between the sound and the dying parts, and the gangrene has a tendency to spread.”] INFLAMMATION—Sthenic—Complications—Terminations. 435 ress and duration of sthenic inflammation are influenced by the constitution or diathesis, hab- its of life, age, and sex of the patient; by the structure or organ affected, and by the treat- ment and influences to which the disease is subjected. The sanguine and irritable temper- aments, a full and robust habit of body, and youth or the vigour of age, not only impart a sthenic character to inflammation, but also cause it to assume an acute or active form, or to run its course rapidly. A similar effect is favoured by parts which are naturally vascular, and supplied abundantly with nerves, or en- dowed with high sensibility, and especially if they be placed near the centre of the circula- tion. On the other hand, the melancholic, leu- cophlegmatic, and nervous temperaments, the scrofulous diathesis, an advanced period of life, and the female sex, prolong the progress of in- flammatory action, and cause it to assume, either primarily or consecutively, a latent, lan- guid, or mild and chronic form. Structures endowed with little vascularity, and with a low grade of sensibility, as tendons, ligaments, fas- cia?, and bones; also parts far removed from the centre of vitality and of circulation, as the extremities, are most prone to inflammation of a slow and chronic character. 34. The patient's habits of life have a re- markable influence in determining the charac- ter of inflammation from the commencement, in favouring the passage of the acute into chron- ic disease, and in disposing the latter to assume the former state. Full living, and the use of much animal food, or of exciting and intoxica- ting liquors, have these effects especially, and not only prolong or aggravate the morbid ac- tion, but also cause its unfavourable termina- tion. Similar results are also produced by in- judicious treatment; by exposure to a close, miasmatous, foul, or unhealthy atmosphere ; by certain epidemic constitutions of the air, depending upon electrical conditions, or other circumstances; by mental anxieties and per- turbations, and improper or premature exercise or excitement of the functions of the part af- fected. These not only prolong or aggravate acute inflammation, but also render its termi- nations more unfavourable than they otherwise would have been, and cause slight or chronic inflammatory action to pass into the acute and active state. 35. The circumstances just alluded to render the duration of sthenic inflammations quite in- determinate. The active and acute states may continue but a short period, but two or three days, or even not so long, until one or other of the terminations about to be described takes place ; and the slight or chronic state may en- dure months, or even years. Between these extremes, every intermediate term of duration, as well as grade of action, may be seen. The duration depends chiefly upon the organ affect- ed, acute inflammation in vital parts, especially the stomach and bowels, terminating most rap- idly. 36. iv. The Complications of sthenic inflam- mations deserve some notice, although hither- to the subject has received no attention from pathological and practical writers, owing mani- festly to the “ verba magistri,” the dictum of Hunter, that two diseases cannot co-exist in the same frame. This, however, does not ap- ply to inflammations, and hardly to other dis- eases, not excepting even specific contagions. The one morbid action may mask or absorb the other, but the one that predominates has its principal features somewhat modified by the association. In cases of chronic inflammation, particularly in females, and in young or ner- vous subjects, the sympathetic disturbance pro- duced by it will often attract the chief attention of the patient, and also of the physician ; and a disease, truly depending upon inflammatory action, in some one of its grades, may be view- ed as nervous, spasmodic, or functional. This most frequently applies to inflammations of the uterine and urinary organs, of the cerebro-spi- nal masses, and of the digestive mucous sur- face ; and is fully illustrated in the articles Hysteria, Hypochondriasis, &c. 37. When a vital organ is inflamed, either acutely or chronically, other parts sympathize more or less; and when the inflammatory ac- tion is slight, the affected organ may not man- ifest the disorder by characteristic phenomena, the sympathizing parts actually presenting the chief disturbance. Parts, also, which Were at first only sympathetically affected in their func- tions or sensibility, may either, from the sever- ity, or from the continuance of such affection, become more and more seriously diseased, un- til the structure is changed, and thus what was merely a symptom increases to a morbid asso- ciation, and, lastly, to a true complication, or even, ultimately, becomes the principal disease, the primary inflammation subsiding, or entirely disappearing, as the consecutive complication is developed. Instances of this are. not infre- quent in respect of inflammations of the lungs, pleura, pericardium,, and heart, the disease ori- ginating in either, and extending to the others, the primary affection being masked by the con- secutive disorder, and sometimes ultimately absorbed by it. Such occurrences still more frequently take place when any one of the ab- dominal viscera is inflamed; two or more of them becoming consecutively affected, the dis- ease either continuing for a time to co-exist in them, or disappearing from the one as it is de- veloped in the others. 38. The complication of inflammations with each other, or with nervous, spasmodic, or con- vulsive disorders, or even with haemorrhage, is much more common than is usually supposed, the latter often depending upon the former, particularly when the inflammation is chronic, slight, or latent. In such cases, the passage of the disease into a more acute or active form becomes an advantage, by disclosing its nature. Such complications are frequent in childhood, and in females, particularly during the puer- peral states. Many of the convulsive affections of the former derive their origin, in a large pro- portion of cases, from inflammatory action; and most of the nervous, spasmodic, painful, and hysterical disorders of the latter arise from inflammatory action of a slight and chronic form in the uterus, ovaria, or urinary organs. 39. v. Terminations and Consequences.— Inflammation, correctly speaking, terminates only in two ways : in resolution, or the recovery of the healthy state of action ; and in gangrene, or the death of the inflamed part. The other morbid conditions, improperly ranked as termi- nations, are merely consequences of inflamma- 436 INFLAMMATION—Sthenic—Terminations and Consequences. tion, the morbid vascular action giving rise to them still subsisting in most instances in some one or other of its forms.—A. When inflamma- tory action terminates in resolution, the phe- nomena subside very nearly in the order in which they appeared. Pain ceases, the red- ness and heat diminish, the swelling subsides gradually, and the functions slowly return. In many cases, however, the swelling continues with little diminution for a considerable time, and the functions of the part are restored with equal slowness ; the recovery of the impaired tone of the capillary vessels, and the absorption of the sero-albuminous fluid effused in the are- olae of the tissues, being necessary to the sub- sidence of the swelling, and to the restoration of function. This termination may be looked for when the inflammation does not proceed too rapidly ; when the pains are neither acute, lancinating, nor throbbing; when the sympto- matic fever gives rise to a general and copious perspiration, and when the urine deposites a sediment.—B. The termination of inflamma- tion in gangrene is so fully discussed in that article that nothing farther need be advanced respecting it at this place. (See art. Gangrene, § 3, et seq.) 40. C. Of the consequences or results of in- flammation, the most important are, exudation, softening, suppuration, ulceration, induration, thickening, and probably other organic changes. Several of these are treated of in separate ar- ticles, a simple reference to which, at this place, will be sufficient.—a. Exudation or effu- sion is the earliest and most common conse- quence of inflammatory action, the swelling, constituting one of the chief characters of in- flammation, being caused by it chiefly. Exu- dation is the deposition in the areolar tissue, in the parenchyma of an organ, in a cavity, or upon some surface, in consequence of excited vascular action, of a fluid consisting chiefly of the natural secretion of the part, greatly in- creased in quantity, and remarkably altered in its properties and appearances. This exuda- tion sometimes commences at a comparatively early stage, but most commonly it becomes abundant at an advanced period, or even to- wards the close of the morbid action; and it occasionally favours a resolution of this action, but not infrequently some degree of inflamma- tion still subsists with it. The fluid which is exuded or effused varies in its characters with the structure affected, and with the degree or activity of the morbid action producing it. Something, also, depends upon the function of absorption in the part; for when it is active, and the more fluid parts of the exudation are thus removed, the state of the remaining parts will be thereby much modified. Hence the fluid is serous, sero-albuminous, flocculent, tur- bid, liquid, thick, or partially consistent, ropy or glairy, coagulated, adherent, albuminous, or even membranous or fibrinous. The fluid ex- uded in inflamed cellular or parenchymatous structures is generally serous, turbid, sero-albu- minous, or flocculent, but becoming more con- sistent, albuminous, or otherwise changed as ab- sorption proceeds. That which is exuded from inflamed serous surfaces is eitherfluid and trans- parent, or turbid and flocculent, or thick, semi- coagulated, and albuminous ; films or layers of lymph, or of albuminous matter, covering the af- fected surface, or agglutinating opposite parts. The fluid exuded from mucous surfaces varies in different situations, and as the follicles or the mucous membrane itself is principally affected. Hence the morbid secretion is watery or thin ; or mucous, thick, and opaque or glairy, ropy, gelatinous, and transparent ; or muco-puri- form, or sanguineous ; or muco-albuminous, or consisting chiefly of an albuminous lymph. 41. The intensity or activity of inflammatory action influences not only the quantity, but also the nature of the effused fluid. When this action is weak or slight, the fluid is chiefly se- rous ; and in proportion as it is more active or severe, the effusion is more albuminous, and presents the characters of coagulable lymph. But the effused fluid is also much modified by the constitution, diathesis, and habit of body of the patient, and by the vital and physical in- fluences to which it is exposed for a time after its effusion. When the fluid is retained for some time in contact with surfaces which ex- uded it, the more watery portion is absorbed, and the albuminous part or the lymph becomes more plastic and solid, and, ultimately, even organized. This is shown especially in chron- ic and sub-acute inflammations of serous mem- branes. Even in mucous surfaces, as in the fauces, larynx, and trachea, the albuminous fluid exuded during inflammation is changed, not only by a partial absorption, but also by the evaporation during the constant passage of the air over the parts during respiration. The scrof- ulous, the gouty, and the rheumatic diatheses farther affect the quality of the fluids effused from inflamed surfaces ; but still more depends upon the intensity of the general vascular dis- turbance, in connexion with the state of vital power. When the former is energetic and the latter unimpaired, then the effused fluid is al- buminous, and abounds in coagulable lymph, a formative as well as a reparative process fre- quently resulting therefrom ; a formative pro- cess often appearing from inflammation of se- rous membranes, and a reparative process af- ter the division or wounds of parts. When the febrile and vascular disturbance is great and organic nervous or vital power is mucn impaired, the fluid effused is watery, sanious, turbid, septic, offensive, &c., the morbid action being incapable of effusing a fluid sufficiently coagulable to be the medium of adhesion be- tween opposing surfaces, or to limit the spread of the morbid action to surrounding parts. Hence inflammation, in these circumstances, assumes the asthenic, spreading and disorgan- izing characters about to be considered. One of the chief and most important features of sthenic inflammation is its disposition to ex- ude a fluid more or less coagulable, by which parts adhere and unite, and which even be- comes organized, and arrests the extension of the inflammation, as well as limits the destruc- tion or disorganization of the parts in which it commenced. 42. Albuminous or coagulable matter exists in the fluids effused or exuded by sthenic in- flammation in various proportions. In the more liquid effusion, it is in small quantity, and is separated from the serum which suspends it, or holds it in solution by heat and by the min- eral acids; but of the more solid or consistent exudation, it constitutes the principal part. Be- INFLAMMATION—Terminations and Consequences. 437 Uveen these extremes it is found in every pro- portion. In puriform matter and pure pus al- bumen exists in the form of minute corpuscles, or globules, swimming in a turbid serous fluid. In this, as well as in the more fluid states in which albumen presents itself, it is incapable of organization ; but, in the more solid or plas- tic state, it xfften becomes organized, and is the bond of union between divided parts, when the powers of the constitution and the condi- tion of the circulating fluids admit of its pro- duction. Salutary or reparative effects, from the effusion of coagulable lymph, are evinced also by its effusion around abscesses, by its ag- glutinating serous membranes, when morbid formations, ulceration, and purulent matter are about to perforate them ; and by its obliterating arteries or veins, after ligatures or in circum- stances where dangerous haemorrhage would otherwise occur. (See Abscess and Adhe- sions.) 43. b. Softening is a very general conse- quence of inflammation, and one of the earliest which attends it. Indeed, inflammatory ac- tion seldom continues long, particularly in an acute form, without impairing more or less the vital cohesion of the tissues affected. It often precedes suppuration, and it generally increas- es the disposition to effusion. It is most re- markable in mucous and cellular parts, and in parenchymatous organs, particularly the brain, lungs, liver, &e., these becoming more friable as well as softer than natural. But softening from this, as well as from other morbid condi- tions, is fully considered in the article devoted to the subject. 44. c. Suppuration is the natural result of in- flammation when it is allowed to attain a high degree of intensity, especially in cellular, pa- renchymatous, and mucous structures. Pus, the product of the suppurative act, is apparent- ly produced from the albuminous part of the blood by an altered state of the vital condition of the capillaries. It is very difficult to show satisfactorily in what this alteration consists ; but it probably is impaired tone, or deficient vital contractility of the capillary vessels, the arterial branches supplying them being still morp or less excited. Suppuration may be viewed as a true act of secretion; although pus, as it usually appears, is somewhat changed in the course of its production by absorption, by the vitality of the parts with which it re- mains in contact, by temperature, and by evap- oration. The small, whitish flocculent masses often found in the purulent matter consist chiefly of a more concrete albumen secreted by the inflamed part. Although suppuration chiefly takes place in the structures mentioned above, yet it sometimes is seen in other parts, especially in the cavities of joints, and more rarely in serous surfaces. In these situations, particularly in serous membranes, it is general- ly a result of intense action in connexion with deficient power. 45. Mr. Hunter was the first who recog- nised with any degree of accuracy the changes which take place in the blood and in the capil- laries of an inflamed part during suppuration, inasmuch as he considered that pus was a re- move farther from the nature of the blood than the matter formed by adhesive inflammation— than coagulable lymph; and M. Gendrin is of the same opinion. The formation of pus in an inflamed surface or tissue takes place as fol- lows, according to the observations of Kal- tenbrunner, Gendrin, Carswell, and the au- thor. In the field of a microscope the inflamed capillaries seem uniformly red, and the circu- lation in them is retarded or has ceased. Se- rum and coagulable lymph are effused in the areola of the tissue ; and, if the inflammation is very intense, the exuded fluid is more or less coloured by the exudation of red globules or of blood. The whole of the inflamed part is quite opaque. As soon as suppuration commences, the red colour begins to disappear in various points, giving place to a yellowish granular- like matter in the capillaries, and connecting cellular tissue. In the centre of the inflamed tissue, several of the capillary vessels, which were obscured by the accumulated blood, reap- pear, some containing red, others yellowish- gray globules, which gradually become more distinct, increase in number and size, begin to move slowly, and, traversing the capillaries, arrive at the surface of the tissue, or at the edges of the solution of continuity, if this has occurred, in the form of globules of pus (Cars- well). Gendrin states that he has distinctly seen the globules of blood, after stagnating in the capillaries of the inflamed part, losing their colouring envelopes, becoming opaque, and as- suming a grayish yellow colour, approaching to that of pus; and that he has traced them mo- ving slowly in the capillaries, and, as they ad- vanced to the suppurating surface, gradually acquiring all the characters of pus. The ob- servations of Kaltenbrunner agree with those of Gendrin as to the transformation of the blood-globules into the globules of pus, and as to this taking place within the capillaries ; but they also seem to prove, what I have observed in several instances, that the red globules, or blood, exuded in an intense state of inflamma- tion into the areolae of the tissue, undergo a similar change to that which takes place with- in the capillaries when the circulation becomes stagnant in them ; and that pus may thus be formed without, as well as within, the capilla- ries of an inflamed part, the fluid portion of the secretion consisting of the serum of the blood. Kaltenbrunner even supposes that not only the blood of the inflamed tissue, but likewise a part of the tissue itself is converted into pus- globules. But I believe that this takes place only where suppuration is followed by ulcera- tion ($ 48), or where an ulcerated surface se- cretes a puriform fluid. 46. From these facts it is evident that, in an inflamed part, certain changes precede the formation of pus : 1st. A loss of the vital tone, or a change of vital action in the extreme ca- pillaries 2d. A retardation or stagnation of the circulation, and partial coagulation of the blood in them. 3d. A change of the blood- globules into pus-globules, and the discharge of the latter with a portion of serum on the suppurating surface. 4th. A similar change of the globules of blood extravasated in the in- flamed part, these globules losing their colour- ing envelopes, and becoming the globules of pus. As connected with the subject of suppu- ration, some notice might be taken of the pres- ence of pus in the general circulation, or in situations remote from the seat of inflamma- 438 INFLAMMATION—Varieties ok Modifications tion ; but as this belongs rather to the trans- lation and metastasis of inflammation—to con- secutive inflammation, it will be considered hereafter. 47. Pus, or purulent matter—the product of suppuration—is a slightly unctuous fluid, of the consistence of thin cream, which it otherwise resembles. It is generally of a whitish or pale yellowish colour, and of a mawkish or sweet- ish taste. It is nearly inodorous when cold, but when heated it emits a faint, sickly, and unpleasant odour. Under the microscope it presents corpuscles or particles swimming in a serous fluid. These corpuscles resemble the central corpuscles of the globules of the blood, deprived of their colouring envelopes, and con- sist of a highly animalized albumen.* The se- rous part of the secretion differs but little from the serum of the blood. In many situations, pus is mixed with the more natural secretions of the part, the latter being either altered in their characters or increased in quantity. This is especially the case in acute inflammations of mucous surfaces, the fluid excreted consisting of pus and mucus in variable proportions. The other relations of suppuration are fully consid- ered in the article Abscess. 48. d. Ulceration is distinguished from suppu- ration chiefly in its being attended by a loss of substance—by a destruction of parts, and by a more or less abundant secretion of a puriform, ichorous, fretid, sanious, and variously-coloured fluid. It may immediately result from inflam- mation, or be consequent upon suppuration, or the formation of an abscess. It depends chief- ly upon causes connected with the treatment of the part in the earlier stages of inflamma- tion ; upon the diathesis, habit of body, or ex- isting constitutional vice, as scrofula, scurvy, syphilis, and upon the state of the digestive and excreting functions. Ulceration is always preceded by softening ■ by a loss of the vital cohesion of the tissue inflamed, at the surface or part most remote from the centre of circu- lation, or at the termination of the capillary vessels. Along with the softening there is also a more or less copious effusion or exudation of a serous fluid, in which the organic molecules, which have lost their vital cohesion, are lique- fied or suspended. Hence the discharge is ichorous, offensive, sanious, or coloured. In the more rapid or phagedenic states of ulcera- tion, and when the discharge is scanty, and in parts covpring abscesses, very probably the or- ganic molecules are absorbed nearly as fast as they lose that degree of vital attraction neces- sary to their cohesion in the diseased surface. From this, the relation of ulceration to sphace- lation and gangrene, particularly hospital gan- grene, is apparent. (See art. Gangrene.) 49. When an ulcerated part begins to return to a healthy state of action, the diseased se- cretion becomes more puriform or albuminous, and an attempt is made to restore the loss of structure by a process called granulation. The vessels of the ulcerated surface acquire a more sthenic action; the disposition in the tissues to lose their vital attraction or cohesion is ar- rested ; and the secretion assumes at first a puriform, and afterward an albumino-puriform character; the albuminous or coagulable por- tion of the secretion coating the inflamed sur- face protecting it, and ultimately becoming or- ganized or partially identified with it. These changes in the ulcerated surface are evidently brought about by an improvement in the -or- ganic nervous influence of the part; and hence the success of a treatment, general and local, calculated to restore or to promote the energy of this influence, especially through the me- dium of the digestive and respiratory organs. 50. e. Induration and thickening, or hypertro- phy of structures, consequent upon inflamma- tion, are discussed in the articles on these le- sions. It is unnecessary to offer any farther remark respecting them, than that they are gen- erally consequences of chronic inflammation, and of acute or sub-acute inflammations which have passed into the chronic state. They may also be referred to the exudation, into the areo- lar tissue, of a sero-albuminous fluid, the more serous parts having been absorbed, and the al- buminous parts organized or assimilated to the structure including them. From this source other organic lesions may arise, according as the exuded matters undergo a more or less complete organization, or according as they are retained in the state of merely minute amorphous masses disseminated in the areolae of the structures, and are preserved from dis- solution or change by the vitality of the sur- rounding parts. See arts. Induration and Hy- pertrophy ; also Disease.) 51. II. Varieties o* Modifications.—Hav- ing described inflammation as occurring in a previously healthy constitution, or in its sthen- ic form, and having viewed this as the more usual and standard condition of the disease, whether appearing in the acute, chronic, or in- termediate states, it becomes necessary to con- sider the alterations or deflections from sthenic in- flammatory action, occasioned by the' previous health or the existing constitution of the pa- tient, and by the nature of the predisposing, the exciting, and the concurrent causes. Many of the lesions of vascular action arising from these sources are so different from the true sthenic condition now discussed, as to admit of doubts as to the propriety of viewing them as inflammations; yet they have intimate re- lations to the sthenic disease, inasmuch as they possess nearly the same local characters as it, and often in a very remarkable degree— as they differ from it merely in kind, and often by slight shades only—as they may be con- verted into it by a general and local restora- * [These globules are obviously a modification of the ex- udation corpuscles ; each consists of a fluid, with granules and molecules contained within a thin cell, which some- times has granules also on its surface. The granules ren- der the appearance of the investing cyst or cell obscure ; but its existence is clear from the action of distilled water, which causes the cell to dilate (by endosmosis) to double its for- mer size ; and what is curious, the contained granules swell also, which shows their vesicular nature (Williams). Pus globules are larger than the general size of exudation corpus- cles, and exceed in size the blood discs (Gulliver). Ac- cording to Mr. Addison, they measure from toTxV?r of an inch ; besides, in size they differ from other exudation corpuscles in beingmore distinctly vesicular, and containing a fluid as well as granules. Their more readily swelling, bursting, and shedding their contents under the influence of water or the solution of potass, may be referred to the same difference. This probably imitates the process by which the exudation corpuscle is converted into a pus globule. From a peculiar constitution, either of the corpuscles or of the adjoining fluids, the disposition to endosmosis is increased, and the corpuscles, and even their contained nuclei, swell into vesicles, instead of remaining in the gelatino-s condi- tion which characterizes the corpuscles within the blood- vessels and in coagulable lymph (Williams).] five treatment, and as the sthenic disease may be reduced to some one ofi these lesions by va- rious depressing influences or contaminating agents. 52. In the view just taken of sthenic inflam- mation, we have seen merely different grades of action, the disease being acute or chronic, or some intermediate state, usually called sub- acute, according to the degree of severity or of activity presented by the morbid action, rela- tively to the constitution and powers of the pa- tient. While the term active has been applied by many to the more acute states of sthenic inflammation, the word passive has been used as synonymous with the chronic conditions. To the former of these appellations, and to its application, little objection need be urged ; but the latter is by no means applicable to any state of inflammation, neither to the chronic states of sthenic inflammation, nor to the asthenic va- rieties about to be considered. 53. With the increased local and general vascular action, constituting the states of in- flammation above described, the constitutional powers are not much reduced or otherwise al- tered, nor are the depurating functions impair- ed, nor is the blood materially vitiated or dete- riorated, in the early stages at least, or until the disease approaches an unfavourable termi- nation. But in the varieties about to be no- ticed, the powers of life are much depressed or otherwise deranged from the commencement, the depurating or excreting functions are inter- rupted, the blood more or less altered, and the nervous sensibilities increased. Hence vital resistance to the changes consequent upon in- creased susceptibility and diseased vascular ac- tion is greatly impaired, and disorganization rapidly supervenes, and as speedily proceeds, unless arrested by the most efficient means. To these circumstances, however produced, are to be imputed those alterations or deflec- tions, from the sthenic or true form of inflam- mation, that frequently present themselves in practice, with characters varying with the cause and seat of the disease, and with the pe- culiarities of the patient. As the inflamma- tions already described present no obvious loss of power in their earlier stages, or until their terminations, and are therefore justly termed sthenic, so those about to be considered may be generally denominated asthenic, from the want of organic nervous energy and the loss of vital resistance to the progress of disorganization which they usually present, unless controlled by judicious treatment. They have also been denominated typhoid, venous, erylhematic, and erysipelatous ; but these are chiefly specific terms, the generic appellations, spreading, dif- fusive, disorganizing, or asthenic, being more ap- propriate. 54. i. Of Asthenic Inflammations.—A. Of the Local Alterations, or Characters.—a. Uneasy sensation, or pain, is the earliest, and some- times the most remarkable symptom, particu- larly when serous membranes or circulating vessels are affected. When the disease is caused by external injury, by the inoculation of morbid matters, as in punctures during dis- section, the pain is often early and acutely felt, even in cellular parts, although no other change has yet appeared. In nervous, susceptible, and weakened persons, the pain is so acute as to INFLAMMATION—Asthenic—Characters. accelerate or increase the restlessness or de- lirium consequent upon the constitutional symp- toms, which are often remarkably severe com- pared with the apparent small extent of the lo- cal disease, especially when caused by an animal poison. Pain, however, is frequently not very severe in certain forms of asthenic inflamma- tion, particularly when parenchymatous organs are their seat, and when they are consequent upon some disease which has lowered or ex- hausted organic nervous power and sensibility. The inflammations which complicate or appeal in the course of continued fevers are illustra- tions of this ; and the metastasis of erysipelas, or the transference of inflammation from an external part to an internal organ, seldom gives rise to much pain. The amount of uneasy sen- sation depends chiefly upon the tissue implica- ted, upon the exciting cause, upon the consti- tutional susceptibility of the patient, and upon the state of the blood. In cellular, mucous, and yielding structures, it is sometimes slight, particularly if the purity of the blood is impair- ed by imperfect excretion, unless the inflamed and turgid parts be partially strangulated by aponeurotic expansions, or other unyielding textures, as in diffusive inflammation of the cellular tissue, and in various states of erysipe- las. In this latter, and in inflammation of the lymphatics, the pain is generally tensive, burn- ing, or stinging, and occasionally remittent. 'Inhere are always great tenderness and sensi- bility to the touch, unless the affected parts are deeply seated. 55. b. Redness and vascular injection are al- ways very remarkable. The former often ei- ther rapidly passes into a deep, dark, brownish- red, livid, or purplish hue, or presents more or less of either of these from the commence- ment. It is sometimes of a pale or yellowish red tint. The vessels are injected and dis- tended, and the current of circulation through them is slow or impeded. The already dark hue of the blood is farther deepened by this congestion, and the exudation of the serous portion of it is facilitated by the weakened state of the vital cohesion of the tissues, by the impaired tone of the capillaries, by the increas- ed frequency of the heart’s contractions, and by the diminished crasis of the blood itself. The discoloration and injection of the part in the various asthenic states of inflammation are generally indices of the extent to which the vital tone of the vessels and tissues is exhaust- ed, and the blood, especially that circulating in the part, is altered. 56. c. Increased temperature is present chiefly at the commencement of asthenic inflamma tion, and when membranous tissues and circu- lating vessels are attacked. Even in these cases, at an early period, the actual rise of temperature in the affected part is often not greater than on the surface of the body gen- erally. Where the febrile disturbance is great, the pulse very quick and the skin dry, the heat of the general surface and of the diseased part is very considerable ; but it is also peculiar, as observed in typhoid and malignant fevers; it seems to be greater than it really is, and is at- tended by a stinging, harsh, and unpleasant sensation. As effusion into the areolar tissue of the part proceeds, and as the swelling ex- tends, little or no increase of heat is usually 439 observed ; and sometimes the temperature of the part may even be lower than that of the surface of the trunk, or even lower than natural. 57. d. Swelling is considerable, and some- times very great when cellular or parenchyma- tous tissues are affected. It is caused at first by the relaxation of the vital tone of the capil- laries and tissues, and by the injection of the former; but consecutively, and chiefly by the effusion of serum from the diseased vessels. The swelling is always diffused, is disposed to extend itself, and is never acuminated or con- vex. It is generally soft, sometimes boggy or oedematous, and never elastic or hard, unless from the tension occasioned by aponeurotic or unyielding structures stretched over the swoll- en part. In mucous and serous membranes it is much less manifest, although existing more or less ; and, in them, it is owing chiefly to the distention of the capillary vessels, and to the relaxation of the tissues themselves. 58. e. The secretions and functions are always disordered by asthenic inflammation : the for- mer are altered and generally increased in quantity; the latter are remarkably impaired. When a secreting membrane or surface is at- tacked by it, the discharge is variously changed from the healthy state, the change obviously arising from the impaired state of vital power, the morbid condition of the blood, and the ac- celeration of the circulation. The effusion generally consists of a foul, dark, turbid, ioh- orous, septic, sometimes whey-like fluid. In puerperal females it is often remarkably abun- dant, and contains much curd-like or semi-coag- ulated matter, partially separated from a turbid or whey-like serum. This watery, serous, or ichorous fluid is also abundantly effused in the areola of the asthenically inflamed cellular tis- sue (see Diffusive Inflammation of 'Cellular Tissue) ; and, owing to the deficiency or ab- sence of coagulable lymph or albumen, it readi- ly spreads to, and infects or contaminates the surrounding tissues. This is one of the diief characters of asthenic inflammation, its spread- ing or diffusive nature, especially, resulting from the states of general or local vital power, and of vascular action, which are insufficient for the formation of coagulable lymph, by Avhich the local disease may be limited. 59. The secretions from glandular organs are also remarkably altered in quality as Avell as in quantity; but their quantity is as often diminished as increased. Sometimes they are nearly or altogether suppressed, particularly in extreme cases of the disease, manifestly ow- ing to the loss of organic nervous influence or vital power in connexion with the distention of the capillaries. When the substance of the liver is the seat of asthenic or diffusive inflam- mation, bile is either not secreted, or is ab- sorbed as soon as it is secreted, giving rise to one or other of the forms of Jaundice ($ 28) described in that article as consequent thereon. The swelling, also, caused by the distention of the diseased vessels, and by the effusion into the parenchyma of the organ, is so great as to press upon the ramifications of the ducts, and to prevent the passage of the fluid along them as it is secreted. This is especially the case when the secreting organ is enclosed in an en- velope or membrane, which does not readily vield to the distention thus occasioned. 440 INFLAMMATION—Asthenic—Symptoms. 60. B. The Constitutional Symptoms.—Asthen- ic inflammations derive their peculiar charac- ters, local as well as general, from either pre- existing disorder or the poisonous nature of the exciting cause. The former consists chiefly of debility, as manifested in the assimilating, cir- culating, and excreting functions (see Debili- ty, § 13, et. seq.). The vital powers are im- paired throughout the frame, and especially in the organs of digestion, circulation, and depura- tion. Hence, with increased sensibility and susceptibility of the nervous system, the blood soon becomes affected, and is less suited for the production of a healthy secretion, and for the formation of coagulable lymph or albumen in the seat of inflammation, than in persons otherwise circumstanced. When asthenic in- flammation depends upon the exciting causes, it will generally be found that they possess poi- sonous or contaminating properties which in- fect the frame, while they produce inflamma- tory action in certain structures by their spe- cific operation, as in the infection of erysipe- las ; or which contaminate the system by act- ing directly upon the part with which they come in contact., as when a septic animal fluid or an animal poison is applied to a wounded or abraded surface. Very frequently asthenic in- flammations derive their constitutional as well as their local peculiarities from both these sour- ces ; from the previous state of health as well as from the nature of the exciting cause. In sur- gical practice, they not infrequently depend upon the severity of the shock sustained by the sys- tem in cases of very severe local injury, as in extensive bruises and crushing wounds, or after operations. In all cases of asthenic inflamma- tion, although the states of constitutional or vi- tal power and of the circulating fluid are chiefly concerned in modifying the character of the lo- cal disease, yet the local generally reacts upon the general affection, the one aggravating the other reciprocally and progressively, until ei- ther a fatal disorganization or arrest of func- tion takes place, or a favourable change is brought about by energetic means. This is evinced especially in the diffusive visceral in- flammations occurring in diseased or cachectic habits of body, or in the course of continued fevers, and in certain forms of erysipelas, and of inflammation of the cellular tissue 61. The severity of the constitutional symp- toms frequently has but little apparent relation to the extent of the local inflammation, the lat- ter being comparatively slight, and presenting but little of the spreading, diffusive, or disor- ganizing characters usually observed in con- nexion with remarkable febrile commotion and vital depression. A person may experience a slight abrasion or puncture of the integuments, followed by inflammation to no great extent, Avith a more or less foul discharge, or with a discharge not materially different from that fol- lowing sthenic inflammation ; and yet the con- stitutional affection may be of the most violent description, and characterized by excessive vascular action, by great excitement and mor- bid sensibility of the nervous system, and by remarkable depression of nervous power and ot vital resistance. It is this state of disease es- pecially which Mr. Travers has so well de- scribed under the terms Direct and Reflected Constitutional Irritation—terms which, in the INFLAMMATION—Asthenic—Symptoms. 441 present state of our knowledge,, convey as sat- isfactory an idea of the nature of these caus- es as any other that can be employed. The remarkable constitutional disturbance charac- terizing them has been ascribed to sympathy ; and probably it may be produced in some in- stances by the absorption of a morbid or poi- sonous secretion or fluid into the circulation ; but the majority, and these the most severe and the most marked, as to all the peculiarities of these maladies, can be ascribed only to a morbid impression or lesion of the organic ner- vous system that is soon propagated through- out the frame, implicating, not only the vascu- lar system, but also the cerebro-spinal func- tions and all the vital manifestations. So in- tense a disease, produced by so slight a cause, and depending, apparently, upon so small a lo- cal lesion, is, it is true, very inadequately ex- plained by the terms irritative fever and consti- tutional irritation, and far less by that of consti- tutional sympathy; but the difficulty is, to de- nominate them by any other name which shall be in every respect appropriate. 62. The constitutional symptoms attending upon asthenic, foul, or spreading inflammations appear variously grouped or characterized ; but they may be referred chiefly to the following types or varieties : 1st. General and remark- able depression of organic nervous or vital power, without vascular reaction ; 2d. General depression of vital power, with vascular reac- tion or excitement; 3d. Vital depression, with acute nervous sensibility and cerebral disor- der ; and, 4th. Vital depression, with remark- able nervous excitement and vascular reaction. Although the constitutional commotion usually appears in one or other of these forms, yet it must be admitted that the arrangement is some- what conventional; that there are often inter- mediate or mixed states of disturbance; and that the general affection may commence in either of these forms and pass into another, owing to the influences to which the patient is subjected in its course. Nay, fever attending sthenic or adhesive inflammation may be con- verted into either of these low types of fever by the more powerful depressing or contami- nating influences ; and the latter may be chan- ged into the former by agents of an opposite nature, similar alterations taking place, from the same causes, in the characters, consequen- ces, and terminations pf the local affection. 63. a. General vital depression, without reac- tion, is not of frequent occurrence, and is pro- duced only by a very sedative or poisonous cause, relatively to the power of vital resist- ance, when depending upon a slight local le- sion. It is very frequently observed after se- vere shocks, crushing injuries, and operations. However induced, it usually commences with a sense of general coldness, sinking, anxiety at the epigastrium, nausea, occasional vomit- ing, and remarkable despondency or depression of spirits. The skin is of the natural or of a diminished temperature, and there is generally little or no thirst. The mental faculties become obscured or stupified, and the countenance collapsed ; and convulsive motions or twitches frequently occur. The pulse is weak, irregu- lar, small, or compressible; sometimes quick or intermittent, but always deficient in power. Vomiting is often attended by little retching, matters being brought up with a species of sin- gultus ; and the alvine excretions are always morbid and offensive. As the powers of life sink, low delirium, coma, the supine posture, hiccough, complete physical prostration, sharp- ened features, and a cold, clammy state of the surface supervene ; the local disease either be- coriring more deeply discoloured or extending towards the centre of the body, or passing into gangrenous disorganization. 64. b. Vital depression, with general vascular excitement and reaction, is much more common than the preceding variety of constitutional af- fection. It is generally ushered in by chills or rigours—sometimes with nausea, and even vomiting. The skin soon becomes hot, dry, burning, or harsh ; but occasionally the affect- ed part is hot and burning, while the tempera- ture of the surface is very little elevated. The pulse is generally above 110°, and sometimes it is 120°, or even upwrard; it is compressible, open, broad, quick, and irritable, becoming more so, and smaller or weaker, as the disease proceeds. The tongue is foul or loaded, some- times glossy, and afterward dry and mahogany coloured. The evacuations are offensive and otherwise disordered. Medicines, or substan- ces taken into the stomach, are soon thrown off; and there is generally thirst, which is at first urgent, but becomes less so, and is at last not complained of, particularly when delirium takes place. Delirium first appears at night, and either remits in the morning or continues, and is often followed by coma. In some in- stances the vascular excitement is most rapid- ly developed, or reaction speedily follows the rigours, and all the symptoms soon become se- vere ; violent headache, with anxious, collap- sed countenance, succeeded by delirium, ap- pearing early. In other cases the general ex- citement is more slowly and more moderately produced, and not until several rigours and at- tempts at reaction have taken place. In either case exhaustion speedily occurs, and all the symptoms of the advanced stage of the prece- ding variety supervene. The disease is rapid in its progress, if it be not early arrested by treatment; and the local alteration extends more or less, assumes a more livid or dark hue, or more aggravated form, or becomes more dis- organized. When pus has been formed at an early stage of the local affection, and is con- fined in deep-seated parts, or beneath fasciae, it is often offensive, discoloured, and different from that discharged after sthenic inflamma- tion. In many instances the local alteration is apparently slight in relation to the severity of the constitutional affection ; but in others it has extended to a very considerable distance along the absorbents, veins, or cellular tissue's from its primary seat, and has thus either been overlooked or has infected the blood. (See ar- ticles Cellular Tissue—Diffusive Inflammation of; Erysipelas ; Lymphatics, and Veins.) 65. c. Vital depression, with acute nervous sen- sibility and cerebral disorder, is very often ob- served to accompany asthenic inflammations caused by animal poisons and septic animal se- cretions, especially by the inoculation of either of them during the dissection of dead bodies. In all these the pain felt in the seat of injury is most excruciating, and is attended by gen- eral irritability and impatience; by irregular 442 INFLAMMATION—Progress and Duration. chills, loss of appetite, intense headache, white tongue, thirst, anxious countenance, nausea, and sometimes vomiting ; a frequent, small, quick, or irritable pulse; hot and dry skin ; sleeplessness, followed by delirium ; and, last- ly, a dry, brown state of the tongue ; vomiting, singultus, coma, subsultus tendinum, collapsed features, cold, clammy perspirations, and quick, laborious respiration. The febrile commotion often commences insidiously, and without rig- ours or chills, and proceeds with much rapidity. In this variety, particularly when produced by the causes just stated, morbid sensibility, gen- eral irritability, violent headache, and want of sleep, early delirium, and suppressed, imper- fect, or weak vascular reaction, are character- istic phenomena, the other symptoms being less constant. The local alterations generally con- sist of early and remarkably intense pain, ex- cessive and spreading tumefaction, and of pur- ulent formations, first on the seat of injury, but extending, successively, to parts nearer to the centre of the body, until the trunk and large cavities are reached. The cellular tissue, in the course of veins and absorbents, or around the glands of the latter, is most commonly at- tacked ; and, ultimately, the serous envelopes on internal organs, or even these organs them- selves, occasionally become implicated ; but other parts, particularly the lymphatics, fasciae, and veins, are often also affected. 66. d. Vital depression, excessive irritability, violent pain, and vascular excitement often attend cases of asthenic inflammation, arising from similar causes to those inducing either of the former varieties of constitutional commotion ; the difference in the degree of vital depression in the one, of nervous disorder in the other, and of vascular excitement in a third, depend- ing chiefly upon the temperament, habit of body, vital power, age, and previous health of the individual, and upon the nature of the ex- citing cause. In proportion as the cause is of a poisonous, depressing, septic, or contamina- ting nature, relatively to nervous susceptibility and vascular activity, will the local affection be diffusive, spreading, or disorganizing, and the constitutional disturbance be characterized by a predominance of the symptoms marking ex- cessive vital depression, or acute nervous suf- fering, or tumultuous vascular excitement, de- void of the power of resistance. When the impression of the cause, or the subsequent in- fluence of the local disease, depresses the vital energies beyond recovery, or the power of re- action, the extension of disorganization and the sinking of the manifestations of life through- out the economy are remarkably prominent. Where either the cause or the local disease is less overwhelming, relatively to the state of constitutional power, reaction takes place, and efforts are thereby made to resist the progress of the local and general mischief. Violent pain and other severe nervous symptoms, whether occasioned by the nature of the exciting cause or depending upon the state of the system, may attend any of the varieties of constitutional af- fection, either that of continued depression or that of vascular reaction. Where the nervous sufferings are extreme, the vascular system usually evinces some degree of excitement; but it is often slight and without power. In certain cases the reaction is as excessive as that marking the second variety of constitu- tional affection (§ 63), is accompanied with the same symptoms, and runs a similar course, the only difference being in the greater affection of the nervous system than in it. In other cases vascular excitement is not sensibly raised, un- less in so far as the great rapidity of the pulse may indicate it, as in the third variety (<) 65). In either case the cerebral disturbance is great, and the disease tends rapidly to an unfavour- able issue, if not arrested by active means. 67. If blood be taken in any of the varieties of asthenic inflammation, it either does not co- agulate, assuming a treacly appearance, or it coagulates imperfectly, the crassamentum being loose; or the imperfect coagulum consists, in its upper half, of a mass resembling jelly in colour and consistence, the lower half contain- ing the colouring matter. The blood, however, may present other appearances, particularly those already noticed, and those described in the article Blood (§ 110, et scq.). Vensesection, in these states of disease, is generally prejudi- cial, although, in some of the cases, where the vascular reaction is great, local depletions are often serviceable by unloading the distended capillaries, and diminishing local tension. 68. ii. Progress and Duration.—A. The course of asthenic inflammations is usually acute; and, unless controlled by salutary agents, is generally to an unfavourable termination. While these inflammations most frequently originate in causes which are septic or poison- ous, and depressing relatively to the power of the constitution, they also sometimes follow the more sthenic forms of morbid vascular ac- tion, in consequence either of the exhaustion following excessive reaction, or of the opera- tion of sedative influences or contaminating agents. Hence, persons affected with sthenic inflammation, especially of a part exposed to the air, will have it changed to the asthenic form, soon after removal to the crowded wards of an hospital, or to any impure or unhealthy situation; and a similar change will also occur in visceral or internal inflammations, from any depressing influence, moral or physical. On the other hand, asthenic inflammations are often converted into the sthenic, by restorative means acting upon either the respiratory or the digest- ive functions. Indeed, the principal indica- tion of cure in the former is to change them to the latter by such means ; but, in order that this end should be accomplished, they must be energetically and appropriately employed. Re- peated efforts at restoration, in respect both of the local lesion and the constitutional disturb- ance, are often made during the course of as- thenic inflammation, especially when the treat- ment is only partially calculated to attain its objects ; and the disease thus assumes a remit- tent appearance, and is much prolonged. When a morbid secretion, or foetid pus, collects in a part which is deep-seated, although a favoura- ble change may seem to have taken place from the treatment, all the symptoms, local and con- stitutional, are sometimes speedily and unex- pectedly aggravated, and the patient ultimately sinks. Occasionally, efforts at restoration re- cur oftener than once, before either recovery takes place or death ensues. This is especially the case when the disease is caused by the in- oculation of an animal secretion or poison ; the INFLAMMATION—Complications—Terminations and Consequences. 443 inflammation extending along the cellular tis- sue, lymphatics, or veins, sometimes with oc- casional interruptions to its course, and with short ameliorations of the nervous and general disturbance, until the trunk of the body is reached, when all the symptoms become sud- denly aggravated : vomiting, delirium, lurid and collapsed countenance, exhaustion of vas- cular and nervous power, laboured respiration, clammy perspiration, singultus, &c., appear, and the patient sinks. Upon dissection, collections of foetid pus, disorganization of the cellular tis- sue, and lesions of the lymphatic and circula- ting vessels are found extending to the central parts of the frame. The neighbouring cavities also contain effused fluid of various appearan- ces, and the parenchymatous viscera purulent collections, the serous membranes being more or less inflamed, or partially adherent. 69. B. The duration of asthenic inflamma- tions varies from a day or two to several weeks. It may not be longer than the former period in the puerperal state, and it may be prolonged to the latter in the recurring or remitting form of the disease. It is also often of very short du- ration, when caused by septic or contaminating animal matters. In many cases, however, when the spreading characters of the local dis- ease, and the adynamic type of the sympto- matic fever have been arrested, a suppurative state of action continues for a considerable time, until more or less complete reparation of the affected part is accomplished. Indeed, this is generally the case when much disorganiza- tion has taken place before the disease is ar- rested. 70. iii. Complications.—Asthenic inflamma- tions frequently occur in the course of other diseases, particularly of exanthematic, contin- ued, and adynamic fevers. It is chiefly when exanthematic fevers assume an adynamic form that the inflammations which complicate them are truly asthenic. In the inflammatory type of these fevers, the associated local alterations possess more of the sthenic characters. The same applies to continued fevers, the adynamic species being those in which the asthenic states of local action and of structural change are chiefly observed. Indeed, asthenic inflamma- tions frequently appear in the course, and even constitute a principal part of all infectious, ma- lignant, and contagious maladies. In these, they present, generally, modified or aggravated characters ; but still they are merely varieties of this state of local morbid action, depending upon the specific nature of the cause, and of the constitutional affection. This is exempli- fied by scarlatina, smallpox, plague, &c. The course of most of these specific forms of asthen- ic inflammation is very acute, the complication often accelerating a fatal issue. 71. iv. Terminations and Consequences.— A. Asthenic inflammations terminate, 1st, in a return to a healthy state of action; 2dly, in sphacelation or disorganization ; and, 3dly, in dissolution without sphacelation, or without disorganization so extensive as to be of itself productive of death.—a. A return of the healthy state of action is generally brought about by constitutional or local means—by the former especially, or by both—which are calculated to restore the vital powers, to impart tone to the relaxed capillaries and tissues, and to enable the part to secrete a more healthy pus, and to form coagulable lymph, by which the extension of the morbid action may be prevented. Thus it i3 necessary that the asthenic state should be changed into the sthenic before restoration can be accomplished ; and this can be affected only by such means as will change the constitution- al commotion from the adynamic type, as will give energy to the organic nervous system, at the same time that they restrain excessive vascular action. As soon as the local disease and accompanying fever assume the sthen- ic conditions, reparation commences, and re- covery takes place, as in these inflammations ($ 39). 72. b. Sphacelation or disorganization of the affected part may take place in very various grades. After the occurrence of either, the in- flammation and disorganization may cease to extend ; the local action and febrile commotion may gradually or quickly assume a more sthen- ic character, particularly under restorative influences ; the sphacelated portion may be thrown off, the disorganized part repaired, a suppurative action set up, and coagulable lymph thrown out around the seat of suppuration, whereby the surrounding structures will be pro- tected, and the diseased parts more or less re- stored. Very frequently, however, when as- thenic inflammations terminate in this way, the local mischief increases rapidly, and the general disturbance is aggravated, until life is at last extinguished. In these cases, the de- struction of parts, either by sphacelation, or by phagedenic or sloughing ulceration, is generally so- extensive as to be incompatible with the continuance of life ; but in those next to be no- ticed the destruction of parts is not of itself sufficient to produce death. 73. c. Dissolution, without sphacelation, or dis- organization, so extensive as to account for the occurrence, is not an infrequent termination of asthenic inflammations. In such cases, the lo- cal affection is either merely the local manifes- tation of a severe constitutional malady, or is attended by a state of vital depression or ex- haustion so extreme as to terminate life before it had advanced to the changes constituting actual disorganization. In some of these cases the result depends chiefly upon the morbid im- pression first made upon, and continuing to in- fluence the organic nervous energy, and in others it is partly owing to the morbid state of the blood, arising either from the same source, or from contingent circumstances or changes. When serous or mucous membranes are the seat of asthenic inflammation, a fatal termina- tion is owing rather to the vital depression con- sequent upon the extent of surface to which the morbid action has been extended than to the amount of disorganization. This is evinced in many cases of general peritonitis. When a mucous surface, engaged in the performance of vital actions, is the seat of the disease, the powers of life often sink rapidly, both from the extent of surface affected, and from the inter- ruption to the functions performed by it. This is shown in general bronchitis, and in certain states of influenza. Illustrations, moreover, of this termination of asthenic inflammations are often furnished by certain of the forms of dis- ease caused by poisoned wounds, or by local injuries, and by some cases of puerperal discaset 444 INFLAMMATION—Asthenic—Terminations and Consequences. and even of erysipelas,* particularly when oc- curring in an infectious or epidemic form. 74. B. Consequences. — Asthenic inflamma- tions give rise to certain changes which differ, in some respects, from those attending the sthenic form of the disease. It is necessary, in practice, to be fully acquainted with the dif- ferences between the results of both states of inflammation, especially as they are often so slight as to be overlooked, and as these results are generally essentially the same, but modified in character and in the period of their appear- ance.—a. Effusion of serous fluid is a very early consequence of asthenic inflammations. In parenchymatous or cellular parts it produces the extreme swelling (which is, in some cases and situations, cedematous or quaggy) attend- ing the disease ; and, in serous membranes, it often takes place to a great extent, and is in all respects an effusion rather than an exudation. The appearance of the effused fluid varies much with the state of the disease, and with the de- gree of vital power and vascular reaction. In proportion as power is depressed is the effused fluid ichorous, foul, abundant, and dark or dis- coloured ; probably from some of the blood globules, or of the colouring matter, having been effused with the serum. Hence it is, in some instances, almost sanguineous. As vas- cular reaction is increased, the fluid is turbid, flocculent, sero-albuminous, or sero-puriform, the situation and other circumstances attending upon the effusion modifying its character. The puerperal state, and the persistence or suppres- sion of the discharges and secretions attending this state, modify remarkably the characters of the effused fluid, as in the asthenic peritonitis associated with adynamic puerperal fever. The fluid effused from the mucous surfaces is also much modified from that exuded during sthen- ic inflammatory action; it is usually less mu- cous and less albuminous, and more watery, serous, ichorous, or sero-sanguineous, as in cases of adynamic Dysentery (see § 26, 27). It is sometimes glairy as well as watery ; and when vital power is extremely depressed, it is very dark-coloured, offensive, and sanious. When sthenic inflammation passes into the as- thenic state, owing to failure of the powers of life, or to morbid states of the blood, the ef- fused fluids also pass from a consistent and co- agulable to a fluid and ichorous state. The fluid effused during asthenic inflammation of cellular parts also partakes more or less of the characters just mentioned. It is deficient in albumen or coagulable lymph, and hence more readily infiltrates the surrounding tissues ; and when it is of an ichorous nature it seems to contaminate the parts to which it extends. Thus, asthenic inflammation of cellular tissues is never limited by the effusion of coagulable lymph, unless a change be produced in the gen- eral and local disease by means hereafter to be pointed out; and then lymph is formed around the seat of morbid action, agglutinating the areolae of the tissue, and becoming a barrier between the morbid matters effused in the central diseased parts and the healthy stiuo* ture. 75. b. Softening is the next early consequence of asthenic inflammation, and one of the most remarkable. It is evidently owing to the ex- treme prostration of vital power in the part, causing a loss of the vital cohesion of the tis- sues, progressive with the disease. I have seen the softening so extreme that the struc- tures have been torn with the utmost ease af- ter death, although the examination was made while the body was still warm. When this state of morbid action affects cellular and mu- cous parts, the softening and want of cohesion are equal to that of wet bibulous paper. They are often also very remarkable when the serous membranes have been implicated. In some cases of infectious puerperal fevers, complica- ted with asthenic peritonitis and hysteritis, I have found the peritoneum, and even the sub- stances of the uterus, not only discoloured, but so softened as to be torn with the utmost ease. 76. c. Suppuration of a truly restorative na- ture is met with chiefly when the morbid ac- tion verges towards the sthenic type. Puru- lent matter is frequently found in parts asthen- ically inflamed, and is often secreted from sur- faces thus affected ; but it is generally offen- sive, and otherwise modified from that described above (§ 47). It is often tinged, particularly in cellular and mucous parts, with the colouring substance of the blood. As the puriform mat- ter secreted by this state of action is not con- fined from the adjoining structures by the effu- sion of coagulating lymph, and by the cysts thereby formed, it is frequently partially ab- sorbed into the circulation. It thus contami- nates the blood, and aggravates both the con- stitutional and the local disease, rendering still more morbid the secretions and excretions, as well as the discharge from the seat of inflam- mation. When the matter passes to a more perfect pus, the change depends upon an im- provement in the local and general action, and is an indication of commencing restoration, if unfavourable influences do not come into oper- ation. Mucous and serous membranes often secrete a puriform fluid, presenting characters varying with the states of vital power and of vascular action, when asthenically inflamed, and generally in a very large quantity. The asthenic bronchitis attending severe cases of influenza generally give rise to a copious secre- tion of a thin muco-puriform fluid ; and the ef- fusions into shut cavities, in some cases of complicated erysipelas, of puerperal fever, &c., consist of a sero-puriform matter, occasionally tinged with blood, or otherwise modified. 77. d. Ulceration from asthenic inflammation is characterized by a rapid loss of substance, and its consequent extension. The edges and bottom of the ulcers are softened ; sometimes not materially, if at all, elevated ; and occa- sionally not much discoloured, or even infla- med. In other instances they are foul, dark, phagedenic, or sloughing. The discharge from the ulcers is usually ichorous, sanious, some- times slimy and watery, and always offensive. The loss of substance is in them more owing to deprivation of the vital cohesion of the tis- sues at the diseased surface, and to the lique- faction or admixture of the dead molecules in * In 1836, erysipelas prevailed most generally and fatally In the Orkney Islands. Its infectious nature was fully dem- Jnstrhted on many occasions. It assumed a low or ady- aamic form, and the deaths from it were more numerous, for the period of its continuance, than from any other dis- ease that had prevailed within the memory of the oldest sractitioner. INFLAMMATION—Modification of, by Structure. 445 the fluid discharge, than to absorption, which, however, takes place to some extent. When the ulceration is sloughy or gangrenous, and the discharge copious and very offensive, it is chiefly owing to the former. In some of these cases the loss of vital power and cohesion is much more rapid than the solution of the mole- cules in the discharge, and then large sloughs cover the ulcerated parts. In some instances the sloughy appearance proceeds from the more consistent or albuminous portion of the dis- charge having attached itself to the surface, while the fluid part either is dissipated by evaporation, or has passed off. This, howev- er, is observed chiefly when a change to a more sthenic action takes place in the inflamed tissues. When absorption proceeds rapidly on the ulcerated surface the constitutional symp- toms are thereby greatly aggravated, and an unfavourable termination accelerated. Asthen- ic inflammations of the mucous surface, and particularly of that of the bowels, are often fol- lowed by ulceration, which occasionally pre- sents a sloughing or phagedenic appearance. (See Dysentery, § 54, 56.) [When the inflammation is of a low charac- ter, or when the blood is poor in red particles, and especially when these two conditions are combined, the solid products of inflammation are less capable of organization, and therefore may be called cacoplastic. As the process of organization varies in degree, so these prod- ucts may attain to different degrees of struc- ture, forming membranes of a denser, less pli- ant texture, and less vascular than the serous membranes to which they are attached, and which they therefore shackle. Thus, patches of a kind of fibro-cellular or fibro-cartilaginous membrane are formed on the lungs, the heart, and the intestines, sometimes with the effect of materially impeding the functions of these several organs. Where the effusion of lymph is scanty and slow, its granular mode of de- posite is more obvious than in the more acute disease ; for, being less ductile, it is less readi- ly spread or stretched by the motion of the parts. This is well seen in chronic inflamma- tions of the peritoneum and arachnoid, in which the deposite is almost entirely in granules or flattened patches, commonly called tubercles. These are generally of a buff or skin colour, of firm consistence, and sometimes exhibit slight traces of blood-vessels in them ; but sometimes their colour is more yellow and opaque, their texture uniform and tough, and they are total- ly destitute of vascularity. These constitute the formations described under the names cir- rhosis and crude yellow tubercle, and are the lowest of the organized products. Being, in organization and consistency, dissimilar to the membranes on which they are formed, they prove a source of irritation and constriction ; and, being liable to ulterior changes (shrinking and contraction in the case of cirrhosis, farther degeneration and softening in the case of yel- low tubercle), they may bring farther mischief in contiguous parts. In some cases, again, more or less of the product of inflammation is aplastic, or totally incapable of organization, and is thrown off with the liquid in separate large globules filled with granules and molecules, constituting pus, or in detached flakes or curds, consisting of aggregations of irregular opaque corpuscles and molecules held together by a few fragments of fibrils : such effusions are exemplified in the sero-purulent liquid and curdy matter of low pleurisy, pericarditis, and peritonitis. It is ob- vious that such lifeless products must act prej- udicially on the containing structures, and the fact might be anticipated that they are little susceptible of absorption. I have mentioned a low form of inflamma- tion, and an unhealthy condition of the blood, as causing the cacoplastic character of the products of inflammation. It may be added, that the long continuance of any inflammation, and its occurrence in subjects in whose blood fibrin abounds, while the red particles are scan- ty, wilf pretty surely render the products caco- plastic or aplastic. At the onset of inflamma- tion its products may be plastic, and the pro- cess of vascular organization may commence ; but if the inflammation continues, its product either is thrown beyond the reach of vascular communication or displaces that already ef- fused, and thus the outer layer will be in a de- generating condition. Added to this, the press- ure of the liquid effusion may impede the con- struction and injection of the new membrane, which, therefore, is degraded into one of the cacoplastic or aplastic matters above descri- bed. Again, in scrofulous or cachectic sub- jects, the blood, although scanty in red par- ticles, abounds in fibrin, and this is readily ef- fused in inflammation ; but is of low vitality, and susceptible of little or no organization. There is yet another circumstance tending to lower the plasticity of lymph (although, from the observation of Mr. Dalrymple, it some- times accelerates its organization), that is, the admixture of the colouring matter of the blood with it. Laennec supposed that contraction of the chest had its origin in heemorrhagic pleu- risy only. This is not correct; but I have many times remarked, after death, that lymph on the pleura and pericardium, in cachectic subjects, is much stained with blood ; and where patients with similar symptoms have recovered from inflammation, they have been affected with structural disease. So far as we yet know, the colouring matter does not form a material for organization; and, farther, it is very probable that in such cases the colouring matter is itself diseased.]—Select Medical Li- brary, p. 252. 78. III. Modification of Inflammation by Structure.—Inflammation has been consider- ed above chiefly with reference to vital power and vascular action, without, however, over- looking the modifications depending upon struc- ture. On this latter part of the subject a very few general remarks may yet be added. Dr. C. Smyth first ascribed the differences of in- flammation to differences of tissue ; and the writings of Bichat, Pinel, Beclard, Gendrin, and others have tended to give very general currency to these view's, and to carry them much beyond their legitimate value. Struc- ture certainly modifies, not only the course and terminations, but also the results or products of inflammation ; but still the chief sources of difference are the states of vital power and of vascular action. Besides, inflammation of an organ or part is not limited to a single constit- uent tissue of that organ, although it may have 446 INFLAMMATION—Diagnosis. originated in one tissue only. It usually im- plicates two or more, although the cellular tis- sue, being, as it were, the matrix of the rest, is that chiefly affected. When inflammation thus extends to different textures, its charac- ters, terminations, and consequences are mod- ified more by the vital conditions above insist- ed upon than by differences of structure ; and, even when very differently organized parts are affected, the consequences of the morbid ac- tion in all of them are often very nearly the same, and are obviously owing chiefly to the states of vital power and vascular action. Even when mucous or serous surfaces are inflamed, the morbid action is seldom confined to them, the connecting cellular tissue being more or less implicated, and frequently also the Adjoin- ing structures ; but the results and termina- tions of this action chiefly depend upon the constitutional affection; or, rather, the local and the general disease are both consequences mef'J!y of the morbid states to which they have been just ascribed, and are hence more inti- mately dependant upon them than upon other circumstances. In the present day, so much has been imputed to structure and to its modi- fications, natural and morbid ; the alterations of function, of sensibility, and of action have been so generally connected with lesions of organization, both by teachers and writers, as to mislead those who are seldom at the trouble of thinking for themselves or of attending to the suggestions of common sense in medical observation and reasoning. Organization, func- tion, and disease are so frequently viewed in connexion, and function is so generally consid- ered as resulting from structure, and disease from alterations of structure, that the principle which not only endows, and regulates, and con- trols, and ultimately arrests the functions, but also alters the whole organization, is left out of the question ; and the results of observation in respect to its various conditions and agen- cies—the circumstances which modify these conditions, and which change its manifesta- tions in the various organs, either from healthy to morbid states, or from the latter to the for- mer—are either insufficiently appreciated or entirely neglected. Too much is ascribed to the material and gross effects, while the con- ditions out of which they arise are kept out of view, in respect both of their primary opera- tion and of their continued influence. It is un- necessary to add anything to what is advanced on the modifications of inflammation by struc- ture in the various articles where the pathol- ogy of the different tissues and organs is fully discussed. 79. IV. Diagnosis.—Inflammation may exist in internal parts without being evinced, by the usual local and general symptoms; and the parts affected by it during life may present very few, or even no indications of it after death, while some affections closely resemble inflammation, and cer- tain appearances very nearly approach those pro- duced by it in the tissues. To each of these points the diagnosis of inflammations in general has especial reference. 80. A. Inflammation may be so latent, or so obscure, owing to the absence of the most im- portant symptoms, and to its seat, as to be rec- ognised with great difficulty. The more slight and chronic forms of inflammation are those most frequently latent or concealed; yet th© most acute states, especially of an asthenic form, and occurring in states of the system characterized by impaired sensibility, or in vis- cera whose organic sensibility is naturally low, are often latent or obscure. These concealed inflammations have been noticed by Hoffmann, Baglivi, Stoi.l, Weinholt, Mayer, Meckel, Reyland, and Hartmamn, and been frequently observed in certain epidemics. They are more common in some organs than in others, espe- cially in the course of adynamic and typhoid fevers, and in other complications. Although they may be expected to exist chiefly, if not al- together, in parenchymatous structures, where the organic sensibility is the most obscure, yet they are not infrequent in serous and sero- fibrous tissues, which are usually acutely sen- sible in the inflamed state. A morbid condi- tion of the blood, as well as a generally impair- ed state of sensibility, seems to diminish sensi- bility in inflamed organs ; for the consecutive or secondary inflammations, which proceed from pre-existing inflammation or disease, are com- monly latent or concealed.—a. Epidemic fevers are very frequently complicated with acute asthenic inflammations, which seldom betray themselves during life, owing both to the de- pressed state of organic sensibility and to the condition of the blood. The brain, the lungs, the liver, the kidneys, the digestive and the respiratory mucous surfaces are the most liable to be thus affected, without indicating, upon the strictest examination, the extent of mis- chief, even auscultation, percussion, and press- ure often failing in furnishing the usual evi- dence of it. Inflammations, however, of the respiratory organs would much more frequent- ly be concealed if these means of investigation were not resorted to. Indeed, in fever, in in- fluenza, and in various epidemics, pneumonia would almost always be concealed without these aids. Inflammation of the abdominal viscera, during these and other maladies, often, also, does not become manifest, unless upon the strictest examination of the stools, the urine, and the patient’s position in bed, and upon the closest observation of the effects of pressure, &c. 81. b. Inflammations of serous and sero- fibrous structures are not infrequently latent, especially when they commence gradually and proceed slowly, or when they appear under the same circumstances as have just been men- tioned. Pleuritis and pericarditis, in chronic forms, and as complications of febrile or epi- demic maladies, are often concealed ; and, al- though less frequently so when auscultation and percussion are employed, yet they often escape detection, especially when they give rise to little effusion, until disclosed by exam- ination after death. The same is observed, although much less frequently, with respect to peritonitis, which, however, often supervenes in more or less obscured states in the course of adynamic fevers.—c. Concealed or obscure inflammation of mucous surfaces, especially of the digestive, is remarkably common. Many of the disorders attributed to disturbed func- tion merely are actually slighter states of in- flammation. But much more severe, and even acute forms of the disease may exist in this tissue without the usual evidence of them having been furnished, and may run on to dis- organization, and even to death. This, how- ever, chiefly occurs in the course of continued fevers, and in the other circumstances just mentioned. 82. B. Various febrile diseases, and painful and spasmodic affections, so closely resemble in- flammations as to be distinguished from them with difficulty.—a. Several internal inflamma- tions are liable to be mistaken for the more sthenic forms of continued fever; and that is the more likely to occur when the latter become complicated, particularly at an early period of their course. But internal inflammations, es- pecially those of a sthenic character, present, among the earliest phenomena, some, at least, of the principal symptoms of inflammation, even before the chills or rigours take place which usually attend their development. The disease is strictly local from the commence- ment, and is not attended by the vital depres- sion and loss of muscular power, which not only accompany, but also precede idiopathic fever. In the former the fever is sympathetic of and contingent upon the local affection ; in the latter the inflammatory complication is a contingency or accident, arising either soon af- ter the commencement or in the course of the constitutional malady. 83. b. Painful affections of internal or con- cealed parts are liable to be mistaken for in- flammation. But violent pain is not always an attendant upon inflammatory action ; and, un- less in very acute cases of pleuritis and peri- tonitis, the pain of inflammation is seldom so severe as that which is dependant solely upon nervous disorder. It is only when the pain is attended by increased vascular action and heat of skin ; by symptomatic fever, or, at least, by some degree of vascular excitement; by heat or tension in the vicinity of the pained part; arid by a white, loaded, furred, or excited state of the tongue, and high-coloured urine, and when it is increased by pressure, that it be- comes an indication of inflammation. The pain of nervous disorder is intermittent or re- mittent ; it often suddenly ceases for an indef- inite time, and as suddenly reappears. It is not attended by a sense of burning, or of heat, or of throbbing, and it is generally eased by firm pressure ; whereas the pain of inflamma- tion, when severe, becomes gradually so, is continued, although often exacerbated at times, is frequently throbbing, and is always associa- ted with very marked disturbance of the func- tions of the pained part. 84. c. Spasmodic disorders are often referred to inflammatory action ; and about twenty-five years ago, when blood-letting was the alleged cure for everything, and for these disorders es- pecially, they were firmly believed to proceed from this source. However, like painful af- fections, they are more frequently purely ner- vous, or independent of inflammation. It is true that they may be complicated with one or other of its forms, and that either painful or spasmodic affections may proceed from conges- tion, or active determination of blood to the organs thus affected, or to parts in their vicin- ity ; but still these are not inflammation. Both classes of disorder most frequently proceed from some unnatural excitement or irritation at the origin, or in the course either of the INFLAMMATION—Diagnosis. nerves supplying the painful or convulsed part, or of those connected with them. Thus, irri- tation of the intestinal or uterine nerves will produce pain or spasm, or both, in remote parts, by their direct and reflex sympathy ; and the ir- ritation of calculi in the kidneys will occasion colic by the direct sympathy of the ganglial nerves, and pain or spasm of distant voluntary parts by the reflex sympathy of the cerebro-spi- nal nerves. (See Direct and Reflex Sympathy, in my edition of Richerand’s Elements of Physi- ology, edit. 1824 and 1829, p. 546.) 85. d. Determination of blood to particular or- gans may also be confounded with inflamma- tion ; and it may run on to the more sthenic forms of the disease, either in acute or in chronic states; but care should be taken to distinguish between them. I have, in the arti- cle Blood ($ 25), entered fully upon the con- sideration of local determination of blood, and upon the differences between this affection and inflammation; and have shown that while the first of these consists only of augmented circu- lation and functions of a part, and is unattend- ed by symptomatic fever, or any other altera- tion, the second is an actively morbid state of the organic nervous influence, and of the ves- sels of a part, accompanied by symptomatic fever, and tending generally to change of struc- ture, and often to disorganization. In the for- mer the functions are usually increased, or in- ordinately excited, the organic sensibility being either unaffected, or not easily excited; in the latter the functions are rarely increased, but always much deranged, or entirely suppressed, organic sensibility being early excited or dis- ordered, and generally sensibly disturbed. (See art. Blood, § 25-33.) 86. e. Congestion of blood in one or more or- gans has also been mistaken for inflammation, both during the life of the patient and in ex- aminations after death. In the article Con- gestion, I have defined it to be deficient vital tone or power, chiefly of the veins of an organ or part, occasioning accumulation of blood in them, and a languid or retarded circulation, the functions of the organ being thereby pro- portionately disordered. The pathological re- lations, terminations, appearances, and symp- toms of this form of disorder are there so fully described that it is unnecessary to notice, at this place, the distinctions between it and in- flammation, farther than that, in the former, the functions of a part are generally more or less impaired, without the organic sensibility being morbidly excited, and without symptomatic fe- ver being present ; in the latter there is not only disturbance of functions, but also exalted or disordered sensibility and vascular action, and more or less febrile commotion. The one is a morbid state of the capillaries and arter- ies, originating in the organic nervous influence of a part, with which state the system gener- ally sympathizes; the other is an engorgement of the veins, sometimes extending to the capil- laries, owing either to a mechanical obstruction to the return of blood through the former, or to deficient vital energy of the affected organ. The blood in congested capillaries and veins is of a purple or black hue, while that in the ca- pillaries of inflamed parts is much more red or florid. (See art. Congestion op Blood.) 87. C. There are certain appearances observed 447 448 INFLAMMATION—Constitutional and Predisposing Causes. after death, which are often difficult to be dis- tinguished from those consequent upon inflam- mation.—a. The congestion of blood from me- chanical obstacles to the circulation in the veins will not be mistaken for inflammation, if the exact state of the congested tissues, and if the course of the venous trunks be carefully ob- served. It is in mucous membranes especially that the diagnosis is at all difficult, and in them only when the redness presents a ramiform appearance. In congestion from this cause the veins are full, often tortuous, and rarely varicose, states not existing in inflammation ; and the obstruction is commonly organic dis- ease of the liver, or of the heart, or of the lungs, or the pressure of some tumour on large veins. Mechanical congestion sometimes, how- ever, gives rise to inflammation, or is associa- ted with it, and then the difficulty of diagnosis is much increased; but the state of the tissues, the capillaries of which are thus congested, and the presence of one or other of the usual con- sequences of inflammation will generally lead to a correct conclusion. Dr. Macartney men- tions, in his work on Inflammation, which ap- peared as this article was passing through the press, that the arteries of a congested part are smaller than natural, and that he verified the fact by experiments ; the corresponding arter- ies to the veins, which were congested by tying ffiem, being very much reduced in size. 88. b. Congestion from, position or gravitation is much more likely to be confounded with in- flammation than that produced by mechanical obstacles; but attention to the relative situa- tion of the congested part especially with ref- erence to a depending position and gravitation of the fluids, will generally aid the observer. When congestion of the capillaries is present, where gravitation could not aid in causing it, and when there is no manifest mechanical ob- struction of the veins, it must be ascribed to inflammatory action, although the usual con- sequences of such action are absent, for the inflammation may have been too recent to have given rise to them. 89. c. Redness from imbibition, or from the dyeing of the internal coats of vessels by the colouring matter of the blood, is sufficiently dis- cussed in the article on Diseases of Arteries (: ve the healthy pitch, or whether or not they ire also otherwise changed. I have stated them to be morbidly or unnaturally excited, thereby indicating that they are increased differently from what we observe in a healthy part from the application of a stimulus, as respects both the duration and the kind of action they occa- sion. 151. The duration of the healthy exalted ac- tion consequent upon simple excitement, men- tal or physical, is generally brief—the effects soon subsiding with the removal of the cause —because the nervous influence exerted on the capillaries is simply increased, without the mode or habitude of this influence being changed in kind. When, however, an irritant, stimulus, or other cause operates upon a part so as to change the mode of organic nervous influence endowing it and its capillaries, the consequent vascular excitement or action is not only of longer duration, but is also altered in kind : it becomes truly morbid; and it either subsides gradually before the conservative powers of this influence as exerted throughout the frame, or undergoes a succession of changes, until it terminates in one or other of the ways de- scribed, as usually observed in sthenic inflam- mations. 152. That the first change occasioned by the exciting cause takes place in the organic ner- vous influence of the part, is proved by the eaily effect produced by it upon the organic sensibil- ity, and on the functions more immediately de- pendant upon this influence. The uneasy sen- sation of inflammation, in its various states and modes, is to be ascribed (§ 8) to the mor- bid impression made on the organic or ganglial nervous tissue, and is to be viewed as the sensible expression of the consequent change in the condition of the influence exerted by this tissue in the affected part—as indicating a mor- bid state of this portion of the nervous system, producing and attended by deranged action of the capillaries in the affected organ, and often exciting or otherwise disturbing the sensibili- ty and functions of the cerebro-spinal nerves, with the terminations of which the former be- comes associated in many of the textures. The pain or uneasy sensation attending the changes in the organic nervous tissue, which affect the state of the capillary circulation, so as to give rise to inflammation, is, as shown above (§ 82), very distinct from the morbid sensibility often manifested by the cerebro-spi- nal ramifications, as in the different forms of neuralgia and of spasmodic affection ; and, al- though the latter is much more acute and vio- lent than the former, yet it never gives rise to much vascular disorder. Excitement of the cerebro-spinal nerves has but little immediate influence upon the capillary circulation, except- * The views which I now proceed to state were pub- lished by me first, as already noticed, in 1815 ; on several occasions during the years 1821 and 1822, in the Medical and Physical Journal, and in the London Medical Reposi- tory; and still more fully in my Appendix to M. Riche- rand's Elements of Physiology, published in 1824. They were the result of a close investigation of the subject; and if the reader will refer to the section on Inflammation, which I added to the last of the works just mentioned, and after- ward to that of Kaltenbrunner, published in 1826, he will find my doctrine and observations fully confirmed by his researches, as well as by those of M. Gendrin, also published in 1826. A very large reprint of my Appendix, containing the same section on Inflammation, without any alteration or addition, appeared in 1829. In 1835, and at still later periods, treatises and essays on Inflammation have been published by several writers,’in which the principal parts of my doctrine have been adopted, but without any reference to the, original propounder of them. Of this I thought it not worth while to take any notice at the time, as 1 was about having it in my power to do myself full jus- tice, and to an extent, in respect of circulation, infinitely beyond what could be reached by the works in question. It is very probable that, the opinions first brought forward by me have been subsequently suggested to these writers, with- out having ever perused any of my writings on the subject; yet one of the works only, and that one containing a full exposition of my doctrine, has been circulated to the exten- of several thousands. INFLAMMATION—Path ol o gy. 463 ing that of the countenance, as in the act of blushing ; and then this is only temporary. Whatever influence these nerves may possess over the circulation is only produced through the medium of the organic or ganglial nervous tissue distributed to the capillaries and struc- tures generally. This provision is important as respects the preservation of the healthy functions of parts; for if the vascular system were directly under the dominion of the cere- bro-spinal nervous system, all the functions of circulation, secretion, nutrition, &c., which are subjected to the organic nervous influence, would be liable to continual derangement from the various impulses of the will and the pas- sions. From this it will appear manifest that changes in the cerebro-spinal nerves of an or- gan, or part, can have but little effect in the production of inflammation, while alterations of the organic nervous influence or sensibility are almost, if not altogether, necessary to its existence. In cases of severe injury to the spinal chord causing paraplegia, the lower ex- tremities are not more liable to inflammation than in health. 153. h. The causes being of an exciting nature, the primary effect on the organic nervous influence and 071 the capillary circulation will partly or chiefly consist of excitement—the sthenic states of inflammation generally resulting.—Whenever the causes of inflammation, either directly or indi- rectly, are of an exciting kind, whenever ex- citement is even one only of the effects pro- duced by them, we must admit that the vital influence of the organic nervous tissue of the part upon which these causes act will be in- creased for a time by them; the excitement being, however, modified by their nature. The organic nervous tissue supplying the capillary vessels of the affected organ will especially manifest this effect in the altered action of these vessels. Whenever the organic nervous influence is locally increased, the vital actions of the associated capillary vessels are also aug- mented—the diameter of these vessels becom- ing enlarged, and a larger column of blood cir- culating in them with increased velocity. This is evinced during excitation of secreting sur- faces and of erectile parts, and by the enlarge- ment of the nerves and blood-vessels of the uterus after impregnation. That the principal part of the more direct effects produced by the application of stimulants to living structures consists of exaltation or excitement of the or- ganic nervous tissue, causing increased action of the vessels, is proved also by the phenome- na observed to follow such applications to or- gans or parts supplied either chiefly or only by organic or ganglial nerves. Now, if we admit, what cannot be disproved, that excitement of the organic nervous influence of a part increas- es the vascular activity and circulation of that part, it must necessarily follow that, whenever an increase in degree forms a part of the change induced in this influence by the causes of in- flammation, a proportionate augmentation of the size of the capillaries will take place—an active expansion, or turgescence, of the ex- treme vessels will result, and give rise to states of inflammation of a more or less sthenic char- acter, according to concomitant circumstances, either extrinsic or intrinsic, in respect of the person affected. But that the causes of sthenic inflammations do not merely excite the sus- ceptible nervous tissue, and, consequently, vas- cular action, but also otherwise change the former, and consecutively the latter, is proved by the duration of the resulting effects and by the succession of alterations, both local and general, as above described. 154. c. In sthenic inflammations, organic ner- vous influence and. vascular action are not only primarily increased, hut also otherwise changed.—• In the early stage of all inflammations there is every reason to suppose that the organic ner- vous influence of the capillaries and inflamed part is not merely changed in degree, but that it is also modified in kind ; and that the differ- ences existing, not only in the forms and va- rieties, but also in the stages of inflammation, depend upon the extent and combination of these changes—an excited, and, at the same time, a modified kind of influence, especially characterizing the sthenic forms of this dis- ease, the combination of impaired and altered influence with excited action constituting the more active states of the asthenic varieties. The irritant or other cause of inflammation seems to impress the organic or vital influence, or the ganglial nervous tissue of the part, or of the system more generally, in such a man- ner as to prevent this influence and the vascu- lar disorder produced by it from returning to the natural state, at least for a considerable time. Morbidly excited action is thus induced in the capillaries of a part, particularly in the sthenic forms of the disease, and is succeeded by other changes. When the exciting cause alters the organic nervous influence in other modes, the capillaries are co-ordinately affect- ed. If this influence is depressed as well as oth- erwise altered, locally or generally, either by the operation of the cause or by pre-existing dis- order, a state of action characterized by defi- cient power is the result. The specific forms which inflammation assumes when arising from certain causes, particularly from infection or inoculation, depends upon the mode or nature of the morbid impression made upon the or- ganic nervous tissue of the part, especially that distributed upon or interwoven with the capil- laries. The causes may act by their continued presence ; thus, irritating bodies, or the lesions of structure produced by chemical agents or by injury, may prove sources of irritation to the nerves and capillaries of a part; but more fre- quently the exciting causes change by the im- pression made at first by them, the degree, mode, or state of influence exerted by the or- ganic nervous tissue upon the capillaries and smaller vessels, and upon the fluid circulating in them; the resulting morbid action present- ing corresponding and peculiar characters in respect of kind, degree, and power or tone. This is more remarkable in the more specific forms of inflammation, either produced by cer- tain poisonous agents or attending some con- stitutional maladies. 155. In experiments upon living tissues, the effects produced by various stimulants and as- tringents have, in some respects, been misin- terpreted by the experimenters ; and the slight constriction of the capillaries that directly fol- lows application of such substances, and before the dilatation which subsequently occurs, has been viewed as the first part of the inflam- 464 INFLAMMATION—Pathology. matory act. But this effect depends upon the action of these substances, particularly of tur- pentine, alcohol, the salts, and many others, upon the vital contractility of the tissues and extreme vessels. The instant effect of these is more or less constriction of the capillaries ; but this very soon ceases, the natural state, or expansion beyond it, soon following. When the substance employed is of an irritating na- ture, without any astringent property, an en- largement of the capillaries is the next phenom- enon to follow the impression made by it upon the organic nervous tissues, this impression being frequently rendered instantly and acutely sensible. In observations or experiments made upon the living tissues, care should be taken to distinguish between the effects produced, 1st, upon the organic sensibility; 2d, upon the or- ganic contractility ; and, 3d, upon the physical properties of the tissues, upon their cohesion, elasticity, &c., or upon the properties which animal substances continue to manifest some time after death. The first of these ceases in- stantly with dissolution; the second remains for a short time afterward, but is soon exhaust- ed by strong stimuli; and the third continue much longer, but gradually disappear with the supervention of decomposition, yet admit of being more or less preserved and somewhat modified by various substances of an astringent and antiseptic nature. In the investigation of the nature of the changes in living structures, usually called inflammatory, the intimate rela- tion existing between these changes and the causes which induced them should not be overlooked. The mode of operation of the causes, especially with reference to the vital and physical properties just enumerated, and to the local and general circulation, ought to be strictly regarded; and the manner in which the results may be modified by constitutional predisposition should be taken into account. 156. d. The state of circulation in the early stages of sthenic inflammations.—The primary affection of the organic nervous tissue having been shown to be one of morbid excitement in the sthenic forms of inflammation, and the effects of this excitement to be turgescence, enlargement, or active expansion of the capillaries, it next re- mains to inquire as to the state of the circulation in the enlarged vessels. This topic has been much discussed, for observations of the current of blood in the capillaries are liable to error; and, besides, the flow of blood may be retarded at a single point, and greatly accelerated at others, particularly when inflammation is pro- duced by mechanical or chemical agents. The state of circulation also undergoes a succes- sion of changes, as will be hereafter shown, with the progress of the disease. It will not be denied that the organic or ganglial nervous tissue exerts a manifest influence, not only upon the capillary circulation, but also upon the blood itself; and that the secreting and other organic functions are under the dominion of this part of the nervous system. It conse- quently follows that excitement, depression, or other affections of this influence will produce co-ordinate changes, not only in the capillaries and related vessels of a part, but also in the state of circulation and in the blood in them. During excitement of the organic nervous func- tions of an organ, the vessels experience not only an expansion, but also an increase of tone, a vital turgescence. The capillaries, although increased in diameter, still retain the power of reacting sensibly upon the blood propelled into them, so as to preserve, if not to accelerate, the rapidity of the currents passing through them. The necessary result of these states is an increased flow of blood, and a rise of tem- perature, and these effects continue until the excitement is exhausted, varying, however, in feature as well as in continuance, and more especially in the associated phenomena and consequences, with the mode or kind of excite- ment directly resulting from its cause. 157. When the propelling power of the heart and the tonicity of the larger arteries give rise to an increased vis a tergo, and particularly when the expansion of the extreme vessels is such as to allow a portion of their contents to escape through the delicate or imperfect canals in which they terminate, or when an obstacle is opposed to the return of the blood through the veins, a portion of the red particles escapes with the serum into the inflamed tissue, gener- ally at minute or distinct points. This is ob- served especially when the tone of the capilla- ries in an inflamed part is exhausted, either by the nature of the exciting cause or by the pre- vious excessive excitement, before the in- creased action of the heart has subsided. 158. e. Of the development of new vessels in inflamed parts.—It is not only the vital turges- cence or expansion of the capillaries, so that those which could not admit the coloured glob- ules of the blood in the healthy state readily admit them in an inflamed part, but also the development of new vessels that is often ob- served. But this latter event takes place chiefly in serous membranes, and especially in albuminous exudations from the inflamed sur- face. It possibly may also occur in other parts, to a more limited extent, although it does not admit of so obvious a demonstration as in these. It can only occur in the various grades of sthenic inflammation, and it fully evinces that, although truly morbid in its nature, this form of the disease is characterized by vital activity, and by a deranged increase of the formative process in the affected part. In asthenic in- flammations, however much capillary canals may be enlarged so as to admit a greater col- umn of blood, no new vessels are developed, unless the asthenic be converted into the sthen- ic state. In the former state of disease, the expansion is the result of impaired vital tone and resistance, both of the capillaries and of the tissues affected ; and the organic nervous power of the part and the action of the capil- laries upon their contents are incapable of forming either coagulable lymph Or new ves- sels. In the latter state, nervous power and vascular action are capable of producing the one, and often, also, the other. 159. When sthenic inflammation affects se- rous membranes, the morbid exudation thereby formed on their surfaces is sufficiently consist- ent to admit of the extension or growth of new vessels from those which had become enlarged in the early stages of the inflammatory act, and to give them support until they acquire considerable development. But when the as- thenic disease implicates these membranes, the secretion from their surfaces is too watery or INFLAMMATION—Pathology. 465 serous to furnish consistent canals or channels in which the contents of the capillaries may be conveyed beyond those which are morbidly en- larged, without commingling with the rest of the effused matter. In cases where new ves- sels form, the exuded lymph or albumen into which they run is not only, to a certain extent, consistent, but also somewhat scanty, or, at least, not very abundant; but in cases where they cannot be formed, the fluid effused is gen- erally both serous and copious. 160. The production of new vessels in parts 3thenically inflamed, particularly in exudations of lymph, is observed chiefly in young persons, and especially in those who are in the course of development. Occasionally the new vessels are numerous and distinct, even before the lymph has become at all abundant or consist- ent. In some very beautiful injected prepara- tions by Mr. Kiernan, the eminent pathologist, that, he kindly showed me, this was most re- markably demonstrated ; as well as the fact, which has been controverted by some French pathologists, that the new vessels shoot out from the inflamed surface, if not from those enlarged in the early stage of the inflammatory act. When new vessels form in the fibrinous lymph exuded from serous membranes, they may often be injected, the continuity of these vessels with those of the affected part being thereby clearly shown. Yet the most vascular part of the newly organized false membrane may not be that nearest the seat of inflamma- tion, the new vessels forming several anasto- moses, and occasionally becoming enlarged in some places at a distance from the surface whence they were produced. 161. f. Consecutive changes in the sthenic forms.—The successive changes taking place mthe course of sthenic inflammations are con- formable with the laws of the animal economy. The excitement produced in the organic ner- vous tissue and capillaries of the part is ex- hausted with a rapidity and to an extent in proportion to its intensity relatively to the powers of the constitution and of the part af- fected ; and as the exhaustion proceeds, the tonicity of the extreme vessels and of the dis- eased tissue, as well as the vital cohesion of both, is weakened, the circulation through them retarded, and the colour of the blood deepened. The extent to which these changes take place, in connexion with the degree of general vascular action and of constitutional power, fully accounts for the lesions conse- quent upon sthenic inflammations. When phlegmasia arises from specific causes, the kind of morbid excitement primarily induced by them will, according to their nature, more or less modify these changes, and give rise to certain results in preference to others. We perceive this in the exanthemata and in vari- ous inflammatory diseases. The tissue affect- ed will also modify the continuance and mode, as well as the consequences of the morbid ex- citement. But there can be no doubt that the successive alterations in the inflamed struc- tures are merely consequences of the morbid impressions made by the exciting causes upon the organic nervous tissue, particularly in its connexion with the capillaries; the states of these and the connected vessels, of the circu- lation through them, of the blood, and of the diseased part, being the effects which may either disappear before the vital resistance of the frame, or terminate in any of the ways de- scribed above ($ 39, et seq.). 162. B. Of the Nature of the Asthenic States. —The remarks which I have just offered more especially refer to the nature of the more sthenic inflammations, and it is, therefore, necessary to consider the circumstances in which the asthenic states differ from these. It has been shown that these states proceed chiefly from constitutional predisposition, or from previous or associated disorder, or from the nature of the exciting cause. In either case, the organic nervous in- fluence, and, consequently, the tone or vital contractility of the tissues and capillaries in the seat of the disease, are quickly exhausted or readily depressed, and soon become otherwise morbidly affected—effusion, softening, disor- ganization, or gangrene, taking place with a ra- pidity in proportion to the primary vital depres- sion, or to consequent exhaustion, and to the nature of the impression made by the exciting cause. In cases of asthenic inflammation, ei- ther there has been originally or acquired great debility or deficiency of the organic nervous power, or the assimilating and excreting func- tions have been long disordered and imperfect- ly performed, or the exciting cause has been of a powerfully depressing or poisonous nature. Indeed, two, or even all of these circumstances, may be concerned, each more or less, in the production of some one or other of the morbid states of action comprised under the more ge- neric appellation, asthenic inflammation. Ow- ing to one or more of these circumstances, the vital contractility of the capillaries and tissues of the affected part is impaired ; vital cohesion is weakened, so as to occasion remarkable soft- ening and friability of the structures ; the tone of the extreme vessels is so far lessened as to admit the effusion and percolation through the more yielding tissues of the more serous por- tions of their contents, sometimes coloured by red particles ; the vital resistance of the capil- laries, owing to the loss of tone, is insufficient either to resist even the weakened impetus of the blood, or to react upon it so as to carry on the circulation through them and the venous capillaries ; and, ultimately, increased effusion, retardation or stagnation of the blood in the minute vessels, and all the consequences shown to result from the asthenic forms of inflamma- tion 70, et seq.), take place. Throughout the course of asthenic inflammations, the states of organic nervous influence, of vital action in the extreme vessels, and of the circulation in the affected part are incompatible with the produc- tion of coagulable lymph ; and hence the effu- sed fluid infiltrates the more soft surrounding tissues, and, owing to its morbid condition, caused by the states of vital action and of the blood, contaminates them, or promotes their disorganization. 163. The distention of the capillaries in as- thenic inflammations is referable to impaired or lost tone, rather than to an active vital ex- pansion or turgescence similar to that which characterizes the early stages of sthenic inflam- mations ; or, if the latter state exist at first, as it probably does for a very short time, in the less asthenic cases, it soon exhausts itself, and passes into atonic distention, with retarded 466 INFLAMMATION—Pathology. circulation. But there is every reason to infer that the current of the blood is impeded or re- tarded in the capillaries at an early stage, or even from the commencement of many cases of asthenic inflammation, particularly those caused by septic agents or animal poisons, and that the blood soon becomes stagnant in them, the various consequences already noticed ap- pearing according to the intensity and rapidity of the previous changes upon which this has been shown to depend. In proportion, gener- ally, as the circulation is retarded in the ex- treme vessels, the temperature of the inflamed part sinks, and the colour becomes deep or livid, until a purplish or brown hue is acquired. As soon as these changes take place, disor- ganization soon follows, and proceeds with a rapidity in proportion to the weakness of vital power and resistance. If the organic nervous energy be aroused or re-enforced by appropri- ate constitutional and local means, the mis- chief may be arrested, unless it have already proceeded beyond the powers of restoration, and it may be ultimately remedied, as in the ad- vanced stages of sthenic inflammations. When the asthenic forms are arrested at an advanced stage, they generally assume more or less of the characters of the sthenic condition, repa- ration taking place as in that form of the dis- ease. [“ It seems,” says Williams,* “ to be well established that an essential part of inflamma- tion is the production of numerous white glob- ules in the inflamed vessels, and that the ob- struction of these vessels is mainly due to the adhesive quality of these globules. The pro- duction of these globules must probably be con- sidered as an ultimate fact in the history of in- flammation and nutrition ; but it may be ob- served that sometimes it seems to be the direct effect of an irritant acting on the blood-vessels and their contents ; in other instances it seems rather to result from determination of blood into previously-congested capillaries. Any cir- cumstances causing continued determination of blood, where congestion is already present, will occasion the production of the white glob- ules, and, consequently, inflammatory obstruc- tion may ensue. The complete obstruction of some capillaries by coagulation takes place in all cases of severe inflammation of the frog’s web ; but there are slighter kinds of increased vascularity, in which there is no total obstruc- tion, but a continued enlargement of the capil- laries and veins, as well as of the arteries. This might be called simple determination of blood; but it differs from that of a transient character in the motion in the capillaries and veins being slower, and in the vast number of white globules seen moving slowly in them. Very probably this kind of process takes place in the lowest forms of inflammation, and an in- creased nutrition independent of inflammation. Something of the kind is generally seen in the capillary circulation of young frogs. “ Numerous experiments and considerations lead to the conclusion that the most essential character of inflammation consists in. an in- creased motion or determination of blood to the affected part, with a more or less obstruct- ed flow through the part, the force of the in- creased motion being partly expended in the arterial portion of the dilated capillaries, and partly diverted into the collateral channels so abundantly supplied by the anastomosis of ves- sels. The obstruction in the vessels of an in- flamed part we have found reason to ascribe, in part, to the increased mass in the smaller vessels and to the diminished elasticity of their coats, and in part to the unusual formation of white lymph globules, which adhere to the walls of the tubes and to each other. Of the exciting causes of inflammation, the direct ir- ritants seem to produce obstruction in both these modes; those which act indirectly, on the other hand, in the first instance produce congestion, to which determination of blood being subsequently added, the inflammatory process begins; hence the latter causes, al- though very common, are not so sure of ex- citing inflammation as direct irritants are. “ The effect of these changes, essential to inflammation, is to expend much of the circu- lating force conveyed by the arteries on their capillary terminations; and the enlargement and tortuosity of these capillaries, the produc- tion of globules which adhere to their sides, and their total obstruction by the same means, seem to be so many progressive expedients used by nature to direct the force of the circu- lation to that part of the vessels by which the process of reparation and nutrition is chiefly carried on.” Between the application of an exciting cause and the establishment of that morbid action which goes under the name of inflammation, a certain period, varying in duration, elapses, which has been called the stage of incubation Gradually the blood begins to flow towards tht part affected with increased velocity ; the cap- illaries and minute arteries at first contract, and exhibit a diminished caliber, from increas- ed tonicity of their coats ; but this slowly van- ishes, and the same vessels become distended with blood. This forms the stage of simple vascular excitement, or vital turgescence of some physiologists, which may speedily subside on the withdrawal of the exciting cause ; but if the cause persists, or is of a severe character, a stage of active congestion follows, which re- acts upon the general circulation, in conse- quence of which still larger quantities of blood are sent into the affected part, and the minute vessels become over-distended, and give way beneath their burden. The blood now begins to grow more viscid, the lymph globules to in- crease, becoming unusually adhesive to each other and to the walls of the vessel, thus lead- ing to obstruction. The circulation is, prob- ably, also retarded in consequence of an in- crease of vital attraction between the blood and the surrounding parenchyma. Exudation of serum and liquor sanguinis becomes more copious ; the fibrin of the blood is increased, not only in quantity, but in plasticity, or its tendency to become organized. The natural function of the part is at first exalted, then •prevented ; from the effusion of fibrin and co- agulable lymph the structure of the part be- comes changed, and, perhaps, to that extent as to be incompatible with future integrity of function. This state of things may also sub- side on the withdrawal of the cause, or it may advance to true inflammation, where the over- distention of the capillary vessels is fully es- * Principles of Medicine. Philadelphia, 1844. INFLAMMATION—Pathology. 467 tablished, and their contractile power annihila- ted or suspended. The blood either slowly circulates through the part or actually stag- nates ; coloured and colourless corpuscles dis- tend the minute vessels, for causes already assigned ; the altered liquor sanguinis is ex- uded in profusion ; the coats of the capillaries yield, and blood is extravasated. In conse- quence of extravascular degeneration of the fibrinous effusion, or from a secretive elabora- tion of it ere it has left the vessels, pus is formed and extravasated, and thus the tex- tures become broken down and disintegrated. Coextensive and concomitant with these chan- ges, normal function is deranged and vitality diminished. It is now conceded by physiolo- gists, that although there is a remora, or stag- nation of blood in an inflamed part, yet that the circulation is preternaturally active in the parts adjacent. The arteries beat with greater force ; more blood is sent to the spot, which, however, meets with obstruction, and thus causes an unusual beating and throbbing ; ab- sorption seems to be suspended during the in- flammatory process, but is speedily resumed as soon as abnormal action has ceased, by which the part is restored to its former condi- tion. MM. Becquerel and Rodier (Gazette Medi- cate de Paris, 1844) have recently, by an exten- sive series of experiments, confirmed the ob- servations of Andral, that the development of a phlegmasia increases the fibrinous con- stituent of the blood. They have, moreover, shown that the cholesterine as well as fibrin is increased, while the albumen is diminished. The increase of fibrin they found to correspond with that observed by Andral, it being in di- rect relation to the extent and intensity of the phlegmasia, to its influence on the general state of the organism, and particularly to the febrile disturbance to which it generally gives rise. They found its increase, also, coincident with the development of the phlegmasia, and ac- companying, but never preceding it, and much more observable in acute than chronic phleg- masia. Blood-letting they found to have lit- tle influence on the fibrin, which decreases with the disease rather than with the means employed to combat it. Its increase in the blood, they observe, is usually manifested by the formation of a buffy coat on the surface of the clot, which is, at the same time, more dense than in the normal state ; or, if the buffy coat is not formed, by the presence of more or less numerous whitish striae, especially exist- ing near the superior surface of the clot, and announcing, as well as the buffy coat, the ex- cess of fibrin in the circulating fluid. In ac- counting for the fact that, while the fibrin is increased in inflammation, the albumen is di- minished, they suppose that these substances are the same, or at least that fibrin is derived from albumen, and that the increase of fibrin is produced by the transformation of an equal quantity of albumen ; a change which may ea- sily occur, considering that they both have the same chemical composition. They found the quantity of cholesterine in inflammation nearly double that of the normal state ; and they sug- gest that it may be owing to a diminution of the biliary secretion from the rigorous diet en- joined, thus leading to an accumulation of this fluid in the blood. We have formerly remarked that the fibrin is also increased in chlorosis and in pregnancy. The opinion generally prevails among phys- iologists that fibrin has a spontaneous tendency to coagulate; that this spontaneous coagula- bility is a characteristic property of fibrin, by which it is distinguished from albumen and ca- sein ; and that the coagulation of the blood, and of various other animal fluids, depends on the spontaneous coagulation of the fibrin which they contain. Dr. Buchanan, however, of Glasgow, has recently advanced the opinion, which is sustained by a variety of facts and experiments, that fibrin has not the least ten- dency to deposite itself spontaneously in the form of a coagulum; that, like albumen and casein, fibrin only coagulates under the influ- ence of suitable reagents ; and that the blood and most other liquids of the body, which ap- pear to coagulate spontaneously, only do so in consequence of their containing at once fibrin and substances capable of reacting upon it, and so occasioning coagulation. Thus, Dr. B. shows that the clot in blood, cellular membrane, and other organic solids have the property, by a sort of catalytic action, of inducing the coagu- lation of fibrin in liquids containing it. Thus, if we mix a very small portion of liquid blood, just drawn from the vein, with six or eight parts of pure serum obtained from blood drawn the day before, we shall be able to separate a portion of fibrin in a perfectly soluble form, in a translucent mass, although the coagulation will be much retarded. This experiment shows very conclusively that the fibrin is actually dis- solved in the blood, and is not a constituent of the red particles. Dr. B. has also shown that a serous fluid, as that of hydrocele, may hold fibrin dissolved, and that this principle will not separate by spontaneous coagulation, requiring a catalytic action, similar to that of the clot in blood and analogous to the action of rennet, or casein, to induce it. These results show that spontaneous coagulability is no long- er a sure test for fibrin in organic liquids; and that the old division of blood into coagulable and uncoagulable lymph is founded in truth.— (See Land. Med. Gazette, Aug. 8, 1845, p. 20.)] 164. C. Of the Intermediate States of Vascular Action and Vital Power in Inflamed Parts.—As shown in the article Disease (§ 87, et seq.), the states of organic nervous influence and vascu- lar action do not always present specific grades or forms, which certain terms can precisely represent. The terms applied to morbid action are entirely relative ; and while we use the ap- pellations sthenic and asthenic, to convey an idea of the more extreme and opposite states of nervous power and of vascular action, we must not overlook that every intermediate form and grade may exist between them. To de- scribe states, so diversified as these are, is ob viously impossible. All that can be attempted is to notice certain circumstances generally ap- pertaining to them. The organic nervous pow- er, evinced by certain inflammations, may not materially vary in kind from the natural stand- ard or condition, and yet vascular action may be excessive and very acute, or much more moderate, and, consequently, more protracted or slight, and more or less chronic. The forms of inflammation, particularly as respects the 468 INFLAMMATION—Pathology. acute, chronic, and intermediate or sub-acute states, result chiefly from the grades of organic nervous excitement and vascular action ; while the more specific characters which they present depend principally upon the conditions of the organic nervous energy, as regards not only the amount of the excitement or depression, but especially the alterations or deflections in kind from the natural habitudes of this energy. While the activity of the inflammation depends chiefly upon the grade of vascular action in the inflamed part, in connexion with the degree of general vascular commotion, the specific char- acter of inflammation arises principally from the truly diseased impression made upon the or- ganic nervous tissue of the part, and from the change thereby effected in the influence of this tissue on the vascular system, such change be- ing in the kind, rather than in the degree of organic nervous influence. 165. The varieties of Erysipelas, the local inflammations attending the different exanthe- mata, and, indeed, the numerous specific forms of inflammatory action induced by these and other infections or animal poisons, are illustra- tions of alterations in the kind or mode, rather than in the degree of local and general organic nervous energy and vascular action. In these, and in all the asthenic states of inflammation, there is a much more remarkable alteration in kind from the natural standard than in the sthenic forms. The intermediate states between the most fully expressed sthenic and asthenic conditions, depend chiefly upon specific or other deviations in kind—upon the truly morbid changes now contended for, especially such as immedi- ately proceed from the nature of the exciting causes, or from contagion. The principal of these, owing to their specific form, are fully dis- cussed under appropriate heads. 166. D. Of the Existence of different States of Capillary Tone and Circulation in the same In- flamed Part and the Vicinity.—Much of the dis- cussion which has taken place as to the capil- lary circulation in inflamed parts has been ow- ing to the variations in this state during the course of the disease, and to the different vital conditions of the capillaries and of the small arteries in different parts, or in the several tissues comprised in the seat of inflammation. When compound or parenchymatous structures are inflamed, such differences or variations are the most remarkable, particularly if the disease has commenced at a single point. At this point, especially, the tone of the capillaries be- comes the soonest exhausted, and the current of the blood retarded ; and these states increase the vital turgescence of the surrounding ves- sels, and accelerate the circulation through them. When the substance of an organ is in- flamed, the fibrinous lymph exuded at the point first affected often retards, by its pressure, the circulation in the vessels at this point; and ow- ing to this obstruction, the surrounding vessels are the more readily developed, and more prone to become morbidly turgescent. The lymph effused also affects the vitality of the part, either occasioning more or less irritation to the organic nervous tissue, or perpetuating or mod- ifying the disorder of this tissue already exist- ing, that caused its effusion. Muller thinks that the lymph coagulates in the extreme capil- laries when the inflammation is seated in the substance of an organ ; but I believe that it is exuded in the areolae of the structure, thereby rendering the part more solid or dense; the change thus produced having been termed con- densation, solidification, hepatization, or spleni- fieation, according to the appearances assumed, and to the organ affected. It is only in the sthenic forms of inflammation that the effused fluid gives rise to these changes, as shown above. 167. If the intensity of the morbid action in the spot first affected be so great as to exhaust its organic nervous power, or its vitality, and to retard its circulation, or to stagnate the blood in the capillaries, not only do the sur- rounding vessels become more turgescent and developed, but the blood which has thus stag- nated, and the tissue itself, undergo very mate- rial changes, as described above (§ 156). Hence very opposite states of the circulation general- ly exist in different parts of the seat of inflam- mation, especially when the disease is advan- ced. In cases of injury, particularly of lacera- tion, pressure, or other changes, the capillary circulation is often directly obstructed; and either independently of lesion of the organic nervous tissue and sensibility, or aided by such lesion, diseased vascular turgescence is thereby developed around the seat of injury—the capil- laries thus obstructed, and the blood contained in them, soon undergoing changes productive of suppuration, or ulceration, or gangrene, while sthenic vascular action is either proceeding in the surrounding turgescent vessels, or passing into exhaustion or into the asthenic condition, progressively from the point of injury, or from the spot first affected, according as the consti- tutional powers may resist or may favour the extension of the mischief. 168. E. O f the State of the Venous Circulation in Inflamed Parts.—There is every reason to believe that the venous circulation is locally more than usually active in the sthenic and acute forms of inflammation ; but that it is more or less languid in the asthenic varieties. When the former, also, goes on to suppuration, and especially to ulceration, the circulation in the veins, more immediately proceeding from the part, is generally somewhat retarded, the re- tardation increasing these changes. Hence the importance of favouring the return of blood from the part by position when these conse- quences of inflammation have taken place. Whenever the venous circulation is obstructed, effusion and oedema increase rapidly in the part affected, and in its vicinity; and the consequent retardation or stagnation of the blood in the capillaries induces or accelerates disorganiza- tion. This is observed very frequently in ery- sipelas, and constantly when the inflammatory action extends to the veins, which not infre- quently occurs when the constitutional powers are depressed, or in the more asthenic forms of the disease. In such cases the local lesions are remarkably increased, not only by the stasis of blood in the capillaries, but also by the more copious morbid effusion caused by the obstruct- ed return of blood. 169. Of the Function of Absorption in the Seat of Inflammation.—In the early stages of sthenic inflammation especially, absorption seems to be less than usually active ; but, when the disease proceeds to ulceration, or even to suppuration, INFLAMMATION—Reparation of its Consequences. 469 and when it assumes asthenic forms, then the absorbent action is often increased, although there are numerous exceptions to this, ab- sorption sometimes being manifestly impaired. When the absorbents become inflamed, owing to the morbid nature of the cause, or of the matter formed in the primary seat of disease, then more or less of obstruction results, and the function is arrested, great tumefaction of the parts beyond the obstruction taking place, and increasing the local mischief by pressure and by the contaminating influence of the mor- bid secretion. In obstructed venous circulation the swelling increases rapidly, chiefly from aug- mented effusion ; in impeded absorption it ad- vances with nearly equal rapidity from the fluid being undiminished by removal. In either case the effused fluid undergoes material changes during its retention, and becomes more and more hurtful to the tissues containing it, and more irritating to the vessels which may ab- sorb it. 170. It was supposed by John Hunter and others, that ulceration depends upon increased activity of the absorbents of the part, when in- flammation has reached a certain period of its progress. But I believe that it is chiefly owing to the superficial softening or loss of the vital cohesion at that part of the inflamed tissue where the extreme vessels have lost their func- tions, and to the solution of the molecules of the tissues in the fluid effused from the diseas- ed surface (§ 48). Absorption is probably also concerned in the process, and in various de- grees, according to the seat of the inflamma- tion, and the states of organic nervous or con- stitutional power, and of vascular action. 171. G. Of the States of the Blood in the Cap- illaries of Inflamed Parts.—The blood circula- ting in inflamed parts presents very different appearances with the form and stage of the dis- ease. In the sthenic forms, and particularly in the early stages, before any of the more unfa- vourable consequences have supervened, the blood is florid, and partakes much of the char- acters of arterial blood ; but in the asthenic forms, and less remarkably in the advanced stages of the sthenic, it is more venous, or of a darker hue. It is sometimes quite purplish, or blackish, particularly when a tendency to sphacelation or gangrene occurs. Also, as it circulates in the capillaries, the globules seem, under the microscope, gradually to move more slowly, and to be attracted by the sides of the vessel, or to stagnate in the capillary canals. This change seems to commence in the smaller or capillary veins, and to extend, especially in the asthenic states of inflammation, in the di- rection of the minute arteries, the temperature sinking with the deepening of the hue, and with the loss of motion of the blood globules. In other respects the blood presents the appear- ances already described with reference to the different forms of inflammation. (See § 25, 66). 172. iii. Of Reparation of the Consequen- ces of Inflammation.—Reparation of the ef- fects of inflammation is accomplished only un- der the influence of life, although much assisted by art. It may be very briefly considered with reference, 1st, to the removal of those changes more immediately resulting from inflammation that are independent of loss of substance ; and, 2d, to the restoration of disorganized or of lost parts, where either has taken place. Whether morbid depositions are to be removed or losses of substance are to be supplied, restoration of the manifestations of life in the various organs to their healthy states is the chief intention to be fulfilled. Frequently nothing more than the subsidence of the morbid action in the affected part is necessary to the reparation of the injury done ; but often something more is requisite, and the aids of science are needed to assist in the work of restoration. 173. a. The softening, or impaired vital cohe- sion of the inflamed part, the fluids effused in the areolae of the tissue, and the coagulated lymph thrown out upon a serous surface, or poured into the porous structure of an organ, so as to solidify it, will generally be removed, when the morbid action which caused these changes has altogether subsided. With the return of the functions of the part the vital co- hesion will be restored, and the activity of ab- sorption will gradually remove the fluids effused in the substance or upon the surface of an or- gan. If the lymph have become partially or- ganized, or have formed false membranes on serous tissues, or have agglutinated the oppo- sing surfaces of shut cavities, the difficulty of removal will be increased and the time of ef- fecting it prolonged. But if the inflammatory action be entirely subdued the object will be ultimately attained, and with a rapidity and certainty in proportion to the restoration of the powers of life throughout the frame. Even when the coagulated albumen is organized into false membranes, or into cellular adhesions, their extent and their vascularity will gradual- ly diminish, and they will either entirely and slowly disappear, or become merely lax bands, or thin films, offering little or no impediment to the functions of the parts which they con- nect. Yet, where such adhesions form, a dis- position to returning inflammation will gener- ally exist, or the morbid action which produced them will continue in a much slighter and chronic state. It is chiefly to these circum- stances that most of the unfavourable results consequent upon adhesions are owing. The lymph effused in the areolae of a parenchyma- tous viscus, as in hepatization or splenification of the lungs in pneumonia, is commonly soon removed with the subsidence of the disease, and much more rapidly and certainly than the lymph poured out upon a serous surface. The albuminous exudations sometimes formed on mucous membranes very rarely or never be- comes organized, but are detached and thrown off as the diseased action subsides by an in- creased secretion of mucus from the follicles underneath. In the course, however, of their excretion from the canals which those mem- branes cover they often occasion remarkable disturbance, severe spasms, or even death by asphyxia, especially when they form on the re- spiratory surfaces, as in croup, laryngitis, &c. 174. b. When the organic nervous and vital powers continue but little impaired, serous and albuminous fluids effused during inflammation are generally removed upon the subsidence of diseased action, although the rapidity and com- pleteness of removal will depend much upon the nature, consistence, and extent of the effu- sion, and the states of constitutional energy. If the fluid is truly purulent, and especially if 470 INFLAMMATION—Treatment of Sthenic. it form an encysted or circumscribed abscess, restoration is then generally difficult, and only to be accomplished, particularly when the col- lection is deep-seated, either by absorption or by the extension of the abscess to an external or internal surface, as is fully shown in the art. Abscess (§ 30). When the fluid of an abscess is absorbed, nothing but a firm cicatrix, gener- ally linear, or irregular and circumscribed, is observed in its former seat. But when it finds its way to a surface and is evacuated, either the patient sinks under the local lesion and dis- charge and the constitutional disturbance, or the work of reparation proceeds under the in- fluence of the vital energies. In this latter case the discharge from the surface of the ab- scess becomes albuminous, the parietes con- tract, and the cavity diminishes. Instead of pus an albumino-puriform fluid is secreted, which gradually becomes more and more al- buminous and scanty. The fluid exuded upon the internal surface of the abscess at last pass- es into the state of coagu table lymph, under the restoring influence of the organic nervous energy ; it becomes vascular, and healthy gran- ulations thus form, and fill up the cavity which the contraction of its parietes is incapable of obliterating, and thus the injury and loss of substance are repaired. 175. In the reparation of ulcerated parts a similar process takes place. The softening and solution of the molecules of the tissues in the fluid discharged from the ulcerated part are first arrested by restoring organic nervous energy, by local or constitutional means, or by both. Thereby a more healthy secretion takes place, and suppuration is established, and is followed by granulation in the manner just described, the mischief being thus repaired. Ulceration is most prone to occur, and to proceed rapidly in parts exposed directly or indirectly to the air, or to the contact of irritating matters ; and in those which are most distant from the centre of the circulation, and in which the capillary circulation is naturally weak or slow. Hence it is of importance to the reparation of an ul- cerated part to protect it from those sources of irritation. When an ulcerated surface is extensive and the tone of its vessels much im- paired, the discharge is generally so copious as to detach from it all applications calculated to protect it from irritation, and is so injurious or contaminating as to increase the mischief if allowed to remain any time in contact with it. The first object in such cases is to restore the organic nervous energy and tonicity of the capillaries of the part, and thereby to diminish the quantity and to improve the quality of the discharge. The fluid subsequently exuded on the diseased surface will often of itself serve as a protection ; and applications which restore the tone of the extreme vessels and diminish or coagulate the discharge, while they farther protect the part, will then be of service, com- plete reparation taking place under the eschars, or scabs, sometimes thus formed. In this man- ner strong solutions of the nitrate of silver, or other stimulating and astringent substances, often act very beneficially on ulcerated surfa- ces, whether the discharge coagulate on them or not. But this subject will be more appro- priately considered hereafter. 176. c. In cases of divided or injured parts, when the blood or the fibrinous lymph exuded from the capillaries coagulates so as to pro- tect them entirely from the air, and without allowing coagula or any other substance to re- main that may occasion irritation, the healing process often proceeds without any evidence of phlegmasia taking place. When divided parts are brought in contact, after the haimor- rhage from them has ceased, the lymph exuded from the opposing surfaces will first slightly agglutinate, and afterward perfectly connect them, small capillary vessels penetrating and organizing the connecting medium, which will diminish more and more as it becomes firmly- organized. In this process, which has been called by surgeons “ union by the first intention,” inflammatory action can hardly be said to ex- ist. If it actually take place, very different phenomena present themselves. This process has, however, been described as a consequence of phlegmasia—probably owing to the circum- stance of inflammation actually taking place in some parts or other of the surfaces, the union of which is thus attempted, and which various causes prevent from uniting, and chiefly by ex- citing inflammation in them. It is very rare that divided surfaces entirely unite without this disease being excited in some portion or other ; for incongruous parts or tissues are often brought together that are incapable of uniting directly. These must necessarily become in- flamed, and give rise to the usual consequences of phlegmasia. Moreover, the fluids and blood effused from the divided structures, and the ligatures placed upon the larger vessels, are sources of irritation, seldom failing of produ- cing inflammatory action, although the more congruous tissues may have perfectly united. In all such cases union has taken place in the uninflamed parts only.—(See the Local Treat- ment of Inflammation.) 177. VIII. Treatment. —The treatment of inflammation must necessarily be guided by a variety of circumstances and considerations. The chief of these refer, 1st, to the disease it- self ; 2d, to the individual affected ; and, 3d, to the nature of the exciting causes.—a. The character, form, progress, and consequences of the inflammation existing at the time of treat- ment should be carefully weighed, as these severally require very different, or even oppo- site indications and means. — b. The age, strength, temperament, diathesis, habit of body, modes of living, and occupations of the patient, ought also to be taken into consideration, and the treatment modified accordingly.— c. The exciting causes, the states of constitutional predisposition, and the predominating influen- ces to which the patient is subjected, should be ascertained as fully as possible, and the means of cure selected with strict reference to them. As the form and character of the inflammation depend chiefly upon the circumstances here al- luded to, I shall discuss the treatment which observation has shown me to be most appro- priate and successful in each of the principal forms under which I have described this im- portant class of diseases. 178. i. Treatment of Sthenic Inflamma- tions.—A. Acute Phlegmasia.—a. At an early stage of all sthenic inflammations, the indica- tions of cure are, 1st, to lower general and lo- cal vascular action ; 2d, to equalize the circu INFLAMMATION—Treatment of Sthenic—Blood-lettino. 471 lation, and to derive from the seat of disease. Several of the means which are employed to fulfil the first also often accomplish the second indication. 179. (a) In order to lower general and local ac- tion, numerous agents are usually prescribed, according to the peculiarities of the case. ■These operate either upon the system in gen- eral, and indirectly upon the part affected, or immediately upon the latter, and consecutively upon the former, according to their natures and the manner of employing them.—a.' Of those which act in the first of these modes, blood-let- ting is one of the most important. It has been, however, very much abused ; and the cure of inflammations has too generally been attempted by it chiefly, or even alone. There are numer- ous circumstances which either very remarka- bly limit or entirely contra-indicate the employ- ment of blood-letting, in those morbid condi- tions in general which have been all denomi- nated inflammation, although differing greatly from each other; and even in this the least equivocal form of the disease, there are many considerations which should weigh with the practitioner in limiting the amount of the de- pletion on the one hand, or in inducing him to carry it far on the other. The extent to which it may be prescribed should be deter- mined by the age, strength, temperament, di- athesis, and habit of body of the patient; by the constitutional symptoms ; by the vital im- portance and structure of the part affected ; by the duration of the inflammation ; by the states of the pulse and of the blood first drawn ; by the effects produced by a former depletion ; and by the condition of the tongue, skin, and urine. 180. If the patient be young and robust, and well nourished—if the disease be very acute, or seated in a vital organ or serous surface— and if the constitutional affection be of a man- ifestly sthenic kind, the quantity of blood taken at first should be very considerable, and it ought to be taken in such a manner as to make a decided impression upon the circulating sys- tem as soon as possible—or in a large and full stream, so that the rapidity of the abstraction may assist the quantity in the effects produced upon the disease. As I have recommended in the article Blood ($ 64), the depletion should be effected while the patient is in a semi-erect or semi-recumbent posture, in order that the desired approach to syncope may be more cer- tainly produced, without, however, causing syn- cope, for the reasons fully explained in the ar- ticle just referred to. The first abstraction of blood ought to be instantly followed by the means about to be noticed ($ 196); but the cir- cumstances now stated as demanding a full or large depletion in the first instance, will require a repetition of it, generally to a less amount, but in strict reference to the local and consti- tutional symptoms, to the effects produced, to the time which has elapsed from the first blood- letting, and to the appearance of the blood then taken away. 181. The pulse, the blood, and the character of the pain in inflammations furnish many use- ful indications as to the institution, the repeti- tion, and the amount of depiction; but they may mislead most remarkably, if the numerous ex- ceptions they afford, and the circumstances in which these exceptions occur, be not taken into account. In inflammations of vital organs, and particularly of the stomach, of the intestines, or of the substance of the brain or liver, the very intensity of the disease may produce so severe an effect upon the constitution—so vio- lent a shock to the vital powers—as to deprive tbe pulse of firmness or tone, and to cause, not only an oppressed, but also a weak, small, slow, or an irregular state of pulse. In such cases the practitioner must not be deterred from blood-letting by this circumstance ; for, after a few ounces of blood are abstracted, the pulse will become more full, strong, and regu- lar. In all inflammations, especially of vital parts, depletions should be performed with a most attentive regard to the phenomena while the blood is flowing; and in cases similar to those alluded to, the effects ought to be most assiduously watched. If the pulse rise in strength, and especially if it become hard, as well as developed or full, the blood-letting may even at first be carried so far as to make an impression upon the circulation, and to reduce the pulse again in strength and fulness. When the pulse is open and throbbing, or jerking, as generally observed after copious haemorrhages, blood-letting will rarely be of benefit, although it has not been already resorted to, and it may be most injurious. Where a moderate blood- letting produces sinking or syncope, without affording relief, it will be injurious to pursue the practice farther, if, indeed, it has not al- ready been prejudicial. 182. A hard, tense, or strong pulse not only requires a very copious depletion at first, but generally also a repetition of it. If a pulse which was too frequent and too full is reduced in these respects—or if a hard, constricted, or small pulse is softer and freer—or if a pulse hitherto slow and oppressed has become more natural—it may be concluded that the bleeding has been of service, and that it may be safely repeated to a less amount if the symptoms re- quire it. If, on the contrary, the pulse has be- come weak, hurried, compressible, open, jerk- ing, irregular, or intermittent, without produ- cing relief, the bleeding has already proved in- jurious, and a repetition of it would be produc- tive of danger. It may be taken as a general rule, that when the pulse is above 110 and compressible, whatever may be the organ in- flamed, the system will not bear general blood- letting, even in the first instance. The local abstraction of blood, however, with caution, may prove of service. 183. The appearances of the blood first ab- stracted have generally influenced the physi- cian more or less in prescribing a repetition of depletion ; but they ought to be considered in strict connexion with the other symptoms. The appearances most deserving of notice are, the firmness or looseness of the crassamen- tum ; the proportion it bears to the quantity of the serum ; and the presence or absence of buffiness, and cupping of its surface. In the article Blood (§ 96, 97), and in a previous sec- tion (<) 25), I have fully discussed the appear- ances of the blood indicative of sthenic inflam- mations. These should receive attention in practice ; but I may here remark, that although a cupped and buffed state of the crassamentum is evidence of an excited state of circulation, and very frequently attends inflammation, yet 472 alone, or without the presence of other symp- toms indicating the propriety of blood-letting, it is no proof that this measure has been indi- cated, or that its repetition is requisite. When, however, the crassamentum is large, firm, or dense, and the buffy coat is considerable, thick, firm, and tenacious, the other signs of inflam- mation being present, depletion may be repeat- ed, and occasionally oftener than once. If the clot be loose, has a thin or an irregular edge, and especially if it be small relatively to the quantity of the serum, a repetition of depletion will be injurious. In all cases the appearance of the blood depends much upon the manner in which it is taken, especially upon the size of the orifice, the posture of the patient while the blood flows, and the shape and size of the ves- sel in which it is received. A buffy, cupped, and firm coagulum will form in a deep or nar- row vessel, particularly if the blood flow rapidly, while neither of these appearances will occur if it be received in a wide and shallow vessel. 184. The fain and other local symptoms ought also to guide the practitioner as to the extent to which depletion should be carried; but these should not be exclusively confided in, for the most violent pains, as shown above (§ 82), are generally independent of inflamma- tion, and are not abated by vascular depletions. Nor are all alterations of sensibility depending upon inflammations to be relieved by blood-let- ting ; for the most severe pains accompanying asthenic inflammations will very often not be even mitigated by it, although altered sensibly in the sthenic forms, now more especially un- der consideration, will generally be entirely re- moved by it, if it be actively and judiciously practised. As long as pain and tenderness on pressure continue, the pulse being firm, resist- ant, or constricted, and not very frequent, gen- eral blood-letting may be repeated, although some exceptions to this rule may present them- selves ; but in most of these local depletions may be employed. If the pain return after having disappeared, or if it become exaspera- ted, although blood-letting has been instituted, a repetition of the measure is necessary, unless the other symptoms obviously forbid it; for, in this latter case especially, the first depletion has only relieved the load which overwhelmed the sensibility of the organ, and a second, or even a third, is requisite to restore the circu- lation of the part to its healthy state. 185. The absence of fain ought to be no argu- ment against resorting to vascular depletion, if other symptoms indicate the propriety of it; for intense inflammation may exist in the pa- renchyma of an organ, particularly the brain, the liver, the lungs, or the kidneys, and even in mucous or serous membranes, without pain being complained of, or without sensibility be- ing farther disturbed than is indicated by a feel- ing of heat., or of oppression, or of weight. 186. The functions of the inflamed organ ought also to indicate the propriety of repeat- ing depletion. When they are restored, then the chief object is attained, and no farther loss of blood should be inflicted on the patient; but if they continue to be suspended or disordered, or if they are only partially restored or impro- ved, local depletions, at least, are required, es- pecially if due time have been allowed for the first bleeding to produce its effects. INFLAMMATION—Treatment of Sthenic—Blood-i.ettino. 187. The tongue furnishes important indica- tions as to the propriety of general or local blood-letting. When the papillae are distinct and erect, the tongue being white or loaded, and inclined to be dry, or its edges or point more or less red, vascular depletions are gen- erally necessary. When the fur on the tongue is erect and white, and the sides and point red, blood may be taken away, if no symptoms con- tra-indicate the practice. On the other hand, when the papillae or the fur is flat, and the tongue very moist or watery on its superior surface ; when it is broad, flabby, fissured, or lobulated; when its edges are indented by or retain the impression of the teeth ; when it is pale, especially at its point or edges ; when it is tremulous on being held out; and when it is covered by a thick, dark mucus or fur, bleed- ing is generally inadmissible. 188. When the cutaneous surface is hot and dry throughout, depletion will be of service ; but if it be cold, clammy, and shrunk, or if it be covered by a hot, clammy perspiration, blood- letting will be inappropriate, as the chief ob- jects intended to be accomplished by bleeding are to lower general action and to produce re- laxation, and these are already attained. If the urine is high-coloured, scanty, and does not deposite a sediment, blood-letting may be prac- tised, if other symptoms do not contra-indicate it; but if the urine be pale, limpid, and copious, it will generally be injurious. 189. Besides these guides to the institution and repetition of vascular depletion, there are various others, appertaining to the organ affect- ed, &c., which should guide the physician ; but these do not come under consideration in this place. The age, constitution, and diathesis of the patient, and the other states of predisposi- tion, as well as the exciting causes, however, require some notice. The very young (infants) and the aged should be depleted with caution. Persons of a nervous or lymphatic temperament cannot bear so large losses of blood as those who are sanguine, irritable, or sanguineo-mel- ancholic. In the gouty and scrofulous, in the previously diseased, in the ill-nourished, in the very obese, and in persons of a relaxed fibre, or leucophlegmatic or cachectic habit of body, such losses are generally injurious. 190. The nature of the exciting causes, and the influences, mental and physical, operating on the patient during treatment, should greatly in- fluence the amount of vascular depletion. In- flammations consequent upon active excite- ment, or attending vital reaction, are most benefited by this measure, while those caused by septic, poisonous, infectious, or contamina- ting agents are generally aggravated by it. All the depressing affections of mind, an air load- ed with malaria or paludal exhalations, the foul air of hospitals, and the confined atmosphere of large towns, particularly in crowded dwell- ings, in low cellars, in close lanes or alleys, and in manufactories, frequently not only pre- vent the good effects of bleeding from ensuing, but also render its institution or repetition in- jurious. 191. The prevailing epidemic constitution, or the general character presented by epidemic and other diseases, should always be kept in recollection, especially as respects the employ- ment of blood-letting. The inflammations which INFLAMMATION—Treatment of Sthenic—Dlood-letting. 473 occur in the puerperal states, erysipelas, and the inflammatory complications observed in the courses of exanthematous and continued fevers, vary remarkably in their particular characters, according to the prevailing constitution. At the period of change from one general consti- tution to another, it is very difficult at once to determine upon the admissibility of blood-let- ting, particularly as regards the diseases just named and others allied to them ; but close ob- servation of the morbid phenomena, and atten- tion to the circumstances and considerations now enumerated, will lead to a right determi- nation as to this practice. Generally speaking, also, it will be found that all inflammatory dis- eases attended by a free state of the secre- tions ; by copious fluid defluxions, particularly from the seat of disease ; by a moist or relaxed skin, or irregularity and weakness of pulse ; by physical and mental depression, and espe- cially by great despondency, unfavourable an- ticipations of the result, or indifference to ob- jects of former or natural endearment, will ei- ther not be relieved or will be aggravated by blood-letting. 192. (3. Local depletions are often sufficient, in many forms, states, or stages of inflamma- tion, to accomplish the ends in view. The cir- cumstances requiring local in preference to gen- eral blood-letting are chiefly the following : 1st. The slighter states of inflammatory action ; 2d. Forms of the disease approaching to or partaking of the asthenic condition ; 3d. A stage of inflammation too far advanced to ad- mit of or to be benefited by general depletion ; 4th. When venaesection has been carried so far as not to admit of its repetition, the disease being either unsubdued or only mitigated, and requiring to be aided by this means ; 5th. When it is desirable to derive from the seat of dis- ease, as well as to deplete moderately ; 6th. When it is wished to remove local congestion of the vessels, and to restore the sensibilities and functions of the affected part; and, 7th. When inflammations occur in debilitated, ner- vous, or delicate constitutions, and as compli- cations of febrile or other diseases. 193. The modes in which local depletion should be performed also require attention. When a considerable quantity of blood is to be abstracted, and it is desirable to effect a rapid derivation from the seat of disease, then cupping is to be preferred ; but when the quan- tity is to be small, and when the application of warm fomentations and poultices to the part subsequently is likely to be serviceable, then leeches are more appropriate. Where the mor- bid sensibility and situation of the parts pre- vent the having recourse to cupping, a large local depletion being requisite, then a great number of leeches should be applied. In such cases the fomentations and poultices used to promote the bleeding will act beneficially in soothing the altered sensibility, upon which much of the diseased action depends. When the part inflamed admits of the direct applica- tion of leeches, it is often doubtful whether they should be placed upon it or not; for in some constitutions the punctures of leeches are followed by much local and general irrita- tion, or even by erysipelatous inflammation ; and if a small number be employed, they only increase the local irritation and determination, without unloading the vessels of the diseased part. In these cases, depletion by more or less numerous or deep scarifications is some- times more beneficial than by leeches, espe- cially if the vessels are much engorged. It should also be recollected that bleeding by leeches occasions much greater depression, relatively to the quantity of blood abstracted, than by any other mode, especially in nervous and susceptible persons ; and that in some con- stitutions and situations the bleeding from their bites is not readily arrested. When the vital tone and cohesion of the tissues are much weakened, as in febrile and malignant diseases, a fatal loss of blood may take place from them, if the bites be not watched for a considerable time after they are removed. In some cases, cupping over the bites of leeches is very advan- tageous in abstracting both a greater and more determinate quantity of blood, in preventing a prolonged and weakening discharge from them, and in determining the circulation to the part to which they were applied. 194. In visceral or internal inflammation it has often been recommended to apply leeches over the seat of disease ; but, unless some ad- vantage be expected from the subsequent fo- mentation, no additional benefit will result from the selection of this situation; and, if an inti- mate vascular connexion exist between the part inflamed and that to which leeches are applied, the blood may be injuriously deter- mined thereby to the former place. When the phlegmasia is entirely visceral, the application of leeches to that part of the external surface which is over the seat of disease probably ef- fects as complete a derivation from it as when applied to any other situation ; while the sub- sequent fomentation tends to equalize the gen- eral circulation, and to determine to the sur- face of the body. 195. In conclusion, the propriety or impro- priety of repeating blood-letting in inflamma- tion, as well as of adopting it in the first in- stance, cannot be inferred from one symptom or consideration alone. The constitution, hab- it of body, and previous state of the patient, the condition of the various functions, the in- crease or decrease of the pain, and other mor- bid phenomena in the affected part, and the other circumstances stated above, should chief- ly influence our decision upon these important points of medical practice. 196. y. Calomel and opium, as so ably rec- ommended by Dr. Hamilton, should be pre- scribed in a full dose immediately after the first blood-letting, whenever the inflammation pre- sents an active or sthenic form. In acute phlegmasia of a vital or important organ, from ten to twenty grains of calomel, and from two to three of opium, and one grain of ipecacuan- ha, may be given at once. This combination will generally succeed in keeping down the general morbid action to that grade to which it had been brought by the depletion, and in preventing reaction from following thereupon. It will also relax the cutaneous surface, deter- mine to the skin, and thereby equalize the cir- culation. In some cases, smaller doses, espe- cially of the calomel, may be given, and re- peated every fourth, fifth, sixth, or eighth hour, according to the urgency of the case, until a decided effect is produced upon the disease. 474 INFLAMMATION—Treatment of Sthenic. In all sthenic inflammations the specific effect of mercury upon the tongue and gums is not readily produced ; but as soon as it begins to appear, the mercurial medicine should be re- linquished, or the dose of it reduced. It is chiefly in cachectic persons, and in the asthen- ic forms of inflammation, particularly when vascular action is languid or low, or when there is but little excitement, that mercurials, especially in large quantities, are injurious. When sthenic phlegmasia is seated in serous membranes, or extends to them, the decided use of mercury, in the combination just pre- scribed, or in others hereafter to be noticed, is most requisite, in order not only to aid in the resolution of the morbid action, but also to prevent effusion, or the exudation of coagula- ble lymph, and the several ill consequences shown to depend upon effusion in its various states. 197. When inflammation implicates serous, fibrous, or even parenchymatous parts, prep- arations of antimony, especially James’s pow- der or tartar emetic, may be combined with the calomel and opium, particularly for phleg- masia of the serous membranes of the chest and of the brain, and for pneumonia, &e.; but when mucous surfaces are inflamed, especially the intestinal mucous surface, ipecacuanha is preferable, and it may be given in large doses, as two, three, or four, or six grains, in the form of pill, with a full dose of opium. In many ca- ses, also, camphor will be beneficially conjoined with calomel and opium ; but when it is to fol- low a large depletion, or when sthenic inflam- matory action is not fully subdued, it should be prescribed in small doses, so as to act as a re- frigerating diaphoretic. It is chiefly in asthen- ic inflammations that full or large doses of camphor are required. 198. The repetition of calomel and opium, with or without either of the other medicines just mentioned, as to frequency, or the inter- vals between the doses, as well as the quanti- ties of both, should entirely depend upon the intensity, the seat, and the other circumstan- ces of the disease. The largest doses already mentioned should not be frequently repeated, unless in the most urgent cases. In some in- stances it may even be sufficient to give them only after each depletion, or to prescribe also, in the intervals, smaller quantities, as may be required. In the less severe states of inflam- mation it will be preferable to prescribe much smaller doses, as from two to five or six grains of calomel, and a quarter or half a grain of opium every four, six, eight, or twelve hours, according to the peculiarities of the case, in combination with either of the other medi- cines already noticed. After depletion has been decidedly employed, these doses will gen- erally be sufficient, even in the more severe cases, and will often give complete relief, with- out affecting the mouth, their good effects being manifested chiefly on the general and local states of action, on the skin, and on other ex- creting organs. 199. d. Purgatives.—Unless it be desired to produce a very speedy effect upon the system by calomel, or other mercurials given in the above combination, an occasional or even fre- quent recourse to purgative enemata will gen- erally be necessary, although purgatives taken by the mouth may not then be requisite. Pur- gatives, however, are among the most impor- tant remedies used in the treatment of inflam- mations, their good effects depending upon sev- eral circumstances: 1. They evacuate morbid secretions and faecal accumulations, which in- jure the organic functions, and depress or oth- erwise derange the powers of life, and which thereby favour the extension of the local affec- tion, and increase the constitutional disturb- ance. 2. They diminish vascular fulness, by increasing the intestinal exhalations and the secretions of collatitious organs, and thereby lower febrile action. 3. They determine the blood to the digestive mucous surface, and de- rive it from remote parts. Owing to this last circumstance, they should be given with due caution when the digestive tube, or even when the viscera associated with it are inflamed. They are more serviceable in some inflamma- tions than in others ; thus they are more effi- cacious in congestions and inflammations of the head than in similar affections of the ab- dominal and thoracic viscera. The selection of, and modes of administering purgatives, also, are matters of great importance, but are so intimately dependant upon the nature of in- dividual cases that no general rules can be stated as to these topics. The refrigerant pur- gatives are usually the most appropriate, as the sulphate of magnesia, and other neutral salts, either alone or with the infusion of sen- na ; the bitartrate of potash with jalap; the spirits of turpentine with castor oil; calomel with the compound extract of colocynth, or with jalap, &c. One of the best modes of ad- ministering these medicines is to. give them at first, or a few hours after a full dose of calomel or blue pill, in briskly cathartic doses, so as to clear out the bowels, and afterward to keep up a more gentle action by milder and cooling do- ses, or by suitable enemata, or by both. The operation, as well as the antiphlogistic effects of these, and of other purgatives that may be employed, will be promoted by adding to them the potassio-tartrate of antimony, or ipecacu- anha. 200. e. Mercurials.—Although calomel is one of the best purgatives that can be given in this class of diseases, yet it, as well as other prep- arations of mercury, is often required for its alterative effects chiefly, not only after blood- letting has been practised, and as above ad- vised (§ 196-8), but also where depletion should not be adopted. In some cases it is necessary to use every means, and even several simultane- ously, in order to arrest the usual course of the disease, particularly in inflammations of serous membranes, and of the larynx, trachea, iris, &c. ; and one of these means is the rapid pro- duction of the specific effects of mercury. These effects being produced, not only is the resolution of the local morbid action thereby favoured, but also effusion is diminished, and the disposition to form coagulable lymph is en- tirely prevented. Hence mercurials, employed with the view of affecting the system, are most useful for inflammations of parts which give rise to albuminous exudations, and are either of little service, or even prejudicial, when pre- scribed for inflammations of cellular or paren- chymatous structures, especially if these as- sume a diffusive, or spreading, or irritative INFLAMMATION—Treatment of Sthenic. 475 form. In such cases, other means, hereafter to be noticed, will be found more beneficial; but in acute sthenic inflammations, neither mercury nor any other means should interfere with blood-letting. It may assist in subduing and in removing several of the effects of these diseases, but it should never wholly supersede vascular depletion in some form or other. In chronic inflammations, however, where altera- tions of structure have commenced, and where they are but little influenced by depletion, mer- cury is one of the most efficient means that can be prescribed for the prevention of farther effusion, or other change, and for promoting the absorption of whatever deposition may have already taken place. 201. (. Spirit of turpentine is hardly known as an antiphlogistic remedy ; and yet, from an experience during nearly thirty years of its ef- fects, both in sthenic and asthenic inflamma- tions, I believe that none is more deserving of confidence if appropriately and prudently pre- scribed. As I have long ago shown (Lond. Med. and Phys. Journ. for July and August, 1820), the operation of this medicine depends upon the dose, the frequency of the repetition, and the combinations of it with other reme- dies. Hence it may be made available in ev- ery form of inflammation. In the sthenic form it is remarkably serviceable after depletions have been duly practised, and it may be used both internally and externally—in draughts, or in enemata—in liniments, embrocations, or fo- mentations. In all inflammations tending to copious effusion, or to fibrinous exudation, after blood-letting has been resorted to, and more especially when it becomes doubtful whether general depletion should be prescribed, or re- peated, or not, this substance, in hands expe- rienced in its operation, is a most valuable remedy. In these cases it should be given in quantity sufficient to act upon the bowels and kidneys—either one drachm twice or thrice daily, or from three to six drachms once a day, alone, or with castor oil. It may also be ad- ministered once or twice a day in enemata in larger quantities. Where it is desired to pro- duce as rapid an impression as possible upon the malady, not only should the one mode of exhibition be made subsidiary to the other, but both should be aided by the external use of this substance, in the form of a warm embro- cation, fomentation, or epithem. In such ca- ses I have generally directed several folds of flannel, large in proportion to the extent and severity of the disease, to be wrung as dry as possible out of very hot water, to be instantly freely sprinkled with spirit of turpentine, and applied immediately over the affected organ; to be closely covered, when thus applied, by wash leather, or a dry cloth, to prevent evap- oration ; to be kept thus applied as long as possible, or as the patient may endure it, and to be renewed as circumstances may require. In less severe cases, or at the commencement of inflammation, I have found a single applica- tion of this fomentation instantly arrest the disease, without depletion or any other means beyond a purgative medicine having been em- ployed. In chronic inflammations, the lini- ments containing this substance, prescribed in the Appendix (F. 296-311), may be used either as such or as embrocations, or they may be applied over the affected organ, on the surface of warm flannel, in the way just described. 202. The spirit of turpentine, thus employed internally or externally, or both, need not pre- vent a recourse to calomel or other mercu- rials, but may be used, particularly in the more urgent cases, in conjunction with them, the former aiding the operation of the latter. Al- though one of the most efficacious means of arresting inflammation and its consequences, there is no remedy that requires more dis- crimination and experience of its action and effects than this. Much of the disappointment sometimes felt as to its operation has been en- tirely owing to the inappropriate use of it, and to injudicious modes of prescribing it. The practitioner who is well acquainted with its effects, in the various doses and modes of using it, will find it most effective in lowering general action when inordinately excited; in controlling local disease ; in arresting the ef- fusion of morbid fluids consequent thereon, and in determining the momentum of the circula- tion to the intestinal canal, to the urinary or- gans, or to the cutaneous surface, according as either effect may be desired, and thereby in deriving from the seat of disease. 203. rj. Refrigerants and Diaphoretics.—Of these, the former are generally used in aid of more active measures, with the view of redu- cing the increased temperature, which aggra- vates or perpetuates the local morbid action; and the latter are prescribed with the intention of restoring or increasing the cutaneous func- tions, of thereby equalizing the circulation, and of removing a portion of the serous and excre- mentitious elements in the blood. In many cases, substances acting both as refrigerants and as diaphoretics are most appropriate, or those which exert the former action more read- ily produce the latter effect. Indeed, whenev- er vascular action is sthenically excited, the skin being hot and dry, it is necessary to lower the general action, and to give such substances as act in this manner, as the most certain means of procuring perspiration. In the major- ity of cases, after vascular depletion and other evacuations have been duly employed, the cool- ing diaphoretics are thus indicated; and, al- though more active means may be still requi- site, particularly those already described, yet these will generally be found useful when taken in the intervals, or as occasions may offer. The diaphoretics which will be found most ben- eficial are, the solution of the acetate of am- monia, camphor, spirit of nitric aether, and a solution, or the wine of the potassio-tartrate of antimony, which may be variously combined, according to the peculiarities of the case. 204. Warm, vapour, and medicated baths are among the most energetic diaphoretics; but much judgment is required in prescribing them ; for their effects will entirely depend upon the form, state, seat, and stage of the in- flammation against which they may be employ- ed. In acute sthenic inflammations, they should not be resorted to until vascular depletion has been duly employed and alvine evacuations freely procured. When, however, the stomach or bowels are inflamed, they may precede the use of means for the evacuation of the latter. In chronic inflammations of the internal visce- ra, or of the joints, fibrous tissues, 6cc., vapour 476 INFLAMMATION—Treatment of Sthenic. baths, various fumigating baths, and particular- ly those with sulphur or camphor, warm baths, especially those containing the decoctions of emollient herbs, or weak alkaline solutions ; aqueous vapour with the fumes of camphor, or this latter conveyed around the patient, may severally be brought most advantageously in aid of other appropriate means. 205. Diuretics are sometimes required in the treatment of inflammations, not merely on account of any derivation from the seat of dis- ease thereby procured, but with the view of re- ducing whatever serous plethora may exist; and of removing from the circulation, by in- creasing the action of the kidneys, those ulti- mate products of assimilation wliich are liable to accumulate in the blood to an injurious amount during the febrile state, and thereby to heighten the local affection. With this inten- tion, several of the more refrigerant diuretics may be advantageously employed, especially the spirits of nitric aether, the bitartrate of pot- ash, and the neutral salts in small doses. They may be taken either in the patient’s usual drink, or conjoined with the other medicines required by the particular circumstances of the case. 206. t. Narcotics are occasionally beneficial, especially when inflammation is attended by great pain and irritability, and in the sthenic forms after vascular depletions and alvine evac- uations have been duly practised. Opium and the salts of morphia are the narcotics most fre- quently prescribed, although hyoscyamus, bella- donna, &c., may likewise be employed in some circumstances. Opium was much recommend- ed for inflammation by medical writers during the seventeenth and eighteenth centuries, and frequently in combination with other medicines; but its use, or. rather, its abuse,was also great- ly condemned. There are few medicines which require greater discrimination than this, and particularly when given in this class of dis- eases ; for the propriety of having recourse to it will entirely depend upon the seat, stage, and form of the inflammation, upon the constitu- tional symptoms, upon the means previously employed, and upon the dose and combination in which it is prescribed. Dr. Armstrong ad- vised large doses of opium after blood-letting, in a paper published in 1824 in the “ Transac- tions of the Associated Apothecaries,” under the belief that the advantages derived from the combination of calomel and opium, recommend- ed by Dr. Hamilton, were entirely to be ascri- bed to the latter substance alone. In this, however, he was altogether mistaken ; for this single remedy is not nearly so beneficial as in combination with calomel and the other medi- cines mentioned above (<) 196-8). Nor, indeed, did the practice present any originality; for it had been employed by numerous writers and practitioners long before he advocated it, even before the periods which I have already assign- ed.* Besides other instances in which I had prescribed it with great benefit previously to this time, I attended a case of phrenitis in 1820, with Mr. Carroll, of Walworth, in which three grains of opium were given at one dose, after blood-letting had been carried sufficient- ly far. In slighter cases, after vascular deple- tion and the operation of a cathartic, a large dose of laudanum, or of solid opium, has mani- festly aided greatly in tranquillizing the nervous system, in reducing vascular action, and in pro- curing refreshing sleep, the patient awaking with a soft or moist skin, and with freedom from pain. Dr. Stokes has recently adduced evidence in favour of this practice, and shown that it is peculiarly beneficial in cases of recent inflammation of serous and mucous membranes, where blood-letting and other antiphlogistic remedies are inadmissible, and where the sys- tem is greatly depressed. In most instances, however, opium, or the salts of morphia will be more advantageously combined with calomel, as above advised (§ 196-198), or with ipecacu- anha, or with camphor, or with James’s pow- der, or the other preparations of antimony. Where pain is so excessive as to constitute the most prominent symptom, it is a most im- portant remedy. When great exhaustion follows blood-letting, owing to its having been carried too far, or improperly resorted to, opium and camphor conjoined are most valuable medi- cines ; and in the asthenic forms of inflamma tion, especially, should never be overlooked, particularly in conjunction with other means. The salts of morphia in similar combinations will be found equally beneficial. 207. The other narcotics, as hyoscyamus, co- mum, stramonium, belladonna, &c., are less use- ful in inflammations, and not so generally ap- propriate as opium ; and yet instances often occur, in which a large dose of some one of these, according to the features of the case, may be preferred ; and, after blood-letting and alvine evacuations have been duly practised, and in the combinations already mentioned (§ 196-8), will be found frequently of service. The chief recommendations in favour of these are, the circumstances of their not interrupting or suppressing the functions of secretion and excretion, and of their relaxing spasm of cir- cular fibres and canals, as well as allaying irri- tation. It should, however, be admitted that, when opium is prescribed in large doses, it does not interrupt secretion or constipate the bow- els so remarkably as when given in smaller quantities ; and that these effects are then fre- quently even not observed. 208. k. Sedatives.—Of these, colchicum is the most active ; and, in certain kinds of inflamma- tion especially, as the rheumatic and gouty, the most serviceable, when prudently prescribed. In the sthenic forms, also, of phlegmasia, it may often be advantageously brought in aid of other means. When it is desired to promote the se- creting functions of the kidneys, and thereby to eliminate from the blood urea and its combi- nations, or other materials which would in- crease the local and general affection, if allow * [The treatment of inflammatory affections by large doses of opium, as recommended by Armstrong, was prac- tised somewhat extensively in this country long anterior to its introduction into England. The late Dr. Post, of New- York, was partial to the use of this remedy in many of the phlegmasise, especially when attended with severe pain, and gave it in large doses, combined with mercurials, as far nack as the year 1800. During the epidemic pneumonia, which prevailed in almost every section of the United States, in 1812-13-14, opium was given, by many practition- ers, in large quantities, combined with calomel or tart, ant., and often with good effects. It has also been used in a similar way in the treatment of acute rheumatism, gastritis, and inflammatory affections of the intestinal canal, espe- cially dysentery, &c., from almost the first settlement of this country, so that the claim of originality, which has been set up by some late practitioners in England, can kr no means be sustained.] INFLAMMATION—Treatment of Sthenic 477 ed to accumulate in the blood, then colchicum may be made a valuable remedy. Also, when inflammations are attended by a torpid or ob- structed state of the liver, this medicine, con- joined with deobstruent purgatives, will be of essential service. In cases attended by very acute pain, or by the effusion of fluids from the inflamed part, it will also be of service, partic- ularly when judiciously combined with other means ; but its action should be carefully watch- ed, as in some constitutions it produces most depressing and even injurious effects. It is best conjoined with camphor, the alkaline car- bonates, magnesia, the neutral salts, and other purgatives; and is most serviceable after de- pletion and alvine evacuations. 209. Digitalis has been more generally em- ployed than colchicum in inflammatory com- plaints, although it is a less efficient and even a more uncertain remedy than it. As long as vascular action is acute or sthenic, digitalis, even in large doses, exerts but little influence upon the circulation; while its cumulative ef- fects will sometimes appear as soon as the symptomatic fever abates. It is most service- able as an adjunct to other means, whose op- eration is more decided and certain, especially where effusion has commenced, or is about to commence, from the diseased part; when in- flammation attacks debilitated, cachectic, or delicate persons, who cannot bear general or free blood-letting ; and when it assumes slight, chronic, or subacute forms. 210. The preparations of antimony, particular- ly the potassio-tartrate, given in large and fre- quent doses, produce a sedative, or, according to Rasori and his followers, a contra-stimulant effect. After causing vomiting, they act upon the bowels and skin, and reduce the pulse in strength, fulness, and sometimes in frequency. For inflammations of the thoracic viscera, and of the brain and its membranes, a decided and judicious use of these medicines, after due vas- cular depletion, is generally of great service ; but they should never supersede this latter, al- though they may prevent the having recourse to very large or repeated blood-lettings. In oth- er circumstances, as well as in those just in- stanced, these preparations are very beneficial, particularly when conjoined with opiates or other narcotics ; they lower general and local vascular action, relax the cutaneous surface, favour perspiration, and equalize the circula- tion. 211. The potassio-tartrate of antimony is sel- dom prescribed as an emetic in sthenic inflam- mations, unless in those affecting the respira- tory organs and passages. In order to procure its depressing effects, a quarter or a third of a grain is usually given every two or three hours. The first two or three doses may cause vomit- ing, but nausea and a lax state of the skin and bowels will subsequently be the chief effects. Chronic inflammations are often subdued by this medicine, and the most successful results frequently follow it in delicate constitutions, when blood-letting does not promise any deci- ded advantage. It should not, however, be carelessly employed, as I have seen it produc- tive of the most injurious effects when pushed far in debilitated persons, and in young chil- dren. In smaller doses, as from the one fifth to the one tenth of a grain at the same inter- vals, it produces a salutary diaphoresis To effect this, however, it is seldom givtm alone, but is usually conjoined with camphor mixture, solution of the acetate of ammonia, the spirits of nitric aether, and sometimes with a small quantity of sulphate of magnesia or of the ni- trate of potash. 212. The employment of large doses of tar- tar emetic in inflammations originated in Italy ; and although it was at first discouraged by Brit- ish practitioners, yet the experience of the ablest physicians in this country and on the Continent has now fully decided in favour of the practice. Since 1819, I have generally re- sorted to it in the manner just mentioned, es- pecially in the treatment of inflammations of the respiratory organs, and generally with great benefit. There are few cases which, if prompt- ly treated by bleeding, and subsequently by this medicine, will not be very materially relieved ; and in those which have been neglected, or in which the proper time of bleeding has gone by, this substance, with mercury, or with the so- lution of the acetate of ammonia, or with opium, if it irritate the digestive canal, or with other appropriate means, will frequently prove of great service. 213. The empirical powder, introduced by Dr. James, is the next to tartar emetic, as an effi- cacious preparation of antimony in the treat- ment of inflammations. The pulvis antimonii compositus in the Pharmacopoeia, which was in- tended as a substitute for it, cannot be depend- ed upon. The different effects of these medi- cines have been attributed by Dr. Thomson to the fact of the antimony in the former being a protoxid, which is soluble ; in the latter a per- oxid, which is insoluble. Mr. Phillips seems to confirm this in his translation of the Phar- macopoeia. In numerous cases of inflammation, and in many circumstances, James’s powder should be preferred to any other antimonial. In children, particularly those which are very young, and for inflammations of the pulmonary organs, as well as of the brain and its mem- branes, in this class of patients, it is generally the best preparation of antimony, and the best sedative, that can be prescribed. 214. Cold is one of the most powerful seda- tives, and one which is not always judiciously employed. There are few agents which are more efficient in constricting the vessels of the part than it; also, by altogether removing the principal stimulus to, as well as the chief consequence of vascular excitement, namely, increased temperature, it prevents the conse- quent exhaustion of the tone and vital cohe- sion of the capillaries and inflamed tissues. Yet, in medical practice, its appropriate use is comparatively limited, for it cannot be brought to act upon the majority of internal inflamma- tions in such a manner as to ensure its good effects, or without interfering with other means upon which still greater dependance may be placed. It is also applicable only to the sthenic and acute forms of inflammation, for it is gen- erally injurious in the asthenic and specific va- rieties, particularly the diffusive, erysipelatous, gouty, and rheumatic. In all cases of visceral inflammation where the application of cold tends to constrict the external surface, and to determine the circulation to internal parts, cold can rarely be advantageously prescribed; for 478 INFLAMMATION—Treatment of Sthenic. even when employed internally, or in enemata, it can seldom be prevented from superinducing reaction, or be so applied as to keep down vas- cular action for a continued or prolonged pe- riod. It is, however, different with inflamma- tions of the brain or of its membranes, for the comparatively superficial and isolated situation of the diseased parts, their distance from the centre of the circulation, the minute division of the vessels in these organs, and the complete manner in which cold applications may be made to surround the whole seat of disease— in the form of the cold affusion, the ice-cap, evaporating lotions, &c.—combine to render cold more beneficial in these inflammations than in any others affecting internal organs. 215. It has likewise been recommended to employ cold in the treatment of other visceral inflammations, as in pneumonia, enteritis, peri- tonitis, &c. Breathing very cold air has been tried in the first of these by practitioners of the United States of America, and cold applied to the abdomen in the others by Dr. Sutton and by several German physicians, but with very doubtful advantages. Indeed, the results of such practice may be tolerably accurately inferred a priori* 216. Among other sedatives, mention may be made of the tepid bath, and the tepid affusion, or douche; these, by abstracting heat, exert a depressing effect, and slightly constrict the sur- face. When the heat of skin is very consid- erable, the pulse being rapid and somewhat hard or resistant, the tepid bath is to be pre- ferred to the warm bath, as it not only cools the surface, but also generally favours diaph- oresis with more certainty than this latter. In- deed, in acute sthenic inflammations, the warm bath should not be used of a higher tempera- ture than 96°, unless in cases presenting pecu- liar features. The tepid bath, or affusion, is frequently more appropriate in the early and acute stages of inflammation than the cold on the one hand, or warm, vapour, or medica- ted baths on the other, as it gradually reduces the temperature without favouring the occur- rence of reaction. Warm, vapour, and medi- cated baths are most serviceable at advanced periods of inflammation, after evacuations have been freely procured, or when the disease be- comes chronic or complicated. 217. The abstraction of all causes of irritation, as well as of the exciting causes of the disease, is obviously requisite in the treatment of in- flammation. The excitement of the senses, es- pecially of the organs of sight and hearing, and of the mental faculties, should be carefully guarded against. Muscular action, and stimu- lation of the stomach by heating food and bev- erages, ought also to be prevented, the anti- phlogistic regimen being strictly enforced in all its parts. 218. A. Derivatives and counter-irritants.— These should never be employed until the gen- eral vascular excitement is subdued by blood- letting and other evacuations, and until a pow- erful impression has been made upon the local affection. These ends being attained, the mode of derivation or counter-irritation should next be considered. This should depend upon the seat, form, and duration of the inflammation, and the consequences to which it may already have given rise. In acute cases, and at early stages of the disease, the hot turpentine cpithem, or application, already described (<) 201), is the most efficacious, the safest, and the most im- mediate in its effects. It should always be ap- plied over the inflamed organ, or as near it as possible. It is applicable to all forms of in- flammation, in whatever organ they may be seated. It tends, more than any other deriva- tive, to determine the circulation to the cuta- neous surface, and to prevent the more dan- gerous consequences of the disease. 219. Sinapisms are extremely serviceable, and produce their effects rapidly, but they are less efficacious than the turpentine epithem. The application of the strong solution of ammo- nia, with tincture of camphor and spirit of rosemary, as advised by Dr. Granville, is also of use, and especially in weak, irritable, or ner- vous persons, and when inflammatory irritation is attended by much pain. It produces a very rap- id effect, and either a superficial and slight, or a more severe and caustic action, according to the duration of the application. The liniment employed as a counter-irritant by the notorious empiric, St. John Long, was recently analyzed by Dr. Macreight, who found it to consist of oil of turpentine and acetic acid, held in sus- pension by yolk of egg. Having prepared a liniment consisting of one ounce and a half of oil of turpentine, of one ounce of strong acetic acid, three ounces of water, and the yolk of one egg, the last, three being rubbed together, and the first being afterward added, Dr. Macreight found it, in its sensible properties and effects, to be identical with the empirical medicine. That a liniment consisting of these ingredients should prove of essential service in many cases, can- not be doubted. For upward of twenty years, and for several years before this fashionable empiric appeared, I had frequent recourse to a liniment, consisting of equal parts of the com- pound camphor liniment and the compound tur- pentine liniment, with a little eajeput oil as a counter-irritant, varying it, however, according to the peculiarities of the case, and as pre- scribed in various parts of this work, and in the Appendix (see F. 296-311). When this liniment, or any of the others just referred to, is applied on the surface of warm flannel, or of * [The Aconite (Aconitum napellus) has been latterly employed as an antiphlogistic agent, especially by the ho- meopathic school; but the statements of its virtues as a remedy for inflammation are entirely vitiated by the small- ness of the doses, by which the beneficial effects are said to have been produced. Writers have gravely asserted, that they have witnessed the most striking benefit to result from administering a few drops of the thirtieth, and even the two thousandth dilution, and claim that it may be substituted with perfect safety for blood-letting, antimony, and the oth- er antiphlogistic agents. No physician who values the life of his patient will place the slightest confidence in these assertions, however confidently made, but in all serious cases of acute inflammation will resort to those well-known and established antiphlogistic remedies which, if suitably timed, will rarely disappoint his expectations. The late researches, however, of Dr. Fleming, of Edinburgh, would seem to prove that aconite possesses powerful antiphlogistic virtues, and is calculated to be of great value in all cases where there is inordinate activity of the circulation ; that it is, moreover, calmative, anodyne, and antispasmodie. Dr. F. shows that, when given in an over-dose, it is a directly sedative poison, producing death in three forms: 1st, by a powerfully sedative impression on the nervous.system ; 2d, by suspension of the respiratory function; and, 3d, by syn- cope. Dr. F. also maintains, that it acts solely by direct transmission with the blood, to the part affected. The good effects of aconite as a local remedy in different forms of neu- ralgia have long been known ; its powers as a general anti- phlogistic agent remain to be confirmed by farther experi- ments.] INFLAMMATION—Treatment of Sthenic. 479 a ciotn wrung out of hot water, over the sit- uation of internal or deep-seated inflamma- tions, it produces an almost immediate effect. But friction during ten or fifteen minutes with the cold liniment will give rise to erubescence, sometimes to exudation, and more or less de- cided relief. In acute cases, the former mode of application may be adopted ; but in chronic or sub-acute inflammation, particularly when alteration of structure has taken place, repeat- ed frictions with this liniment, short of infla- ming the skin, are often to be preferred. When the irritation produced by it gives rise to vesi- cation or abrasion of the cuticle, the parts soon heal; but it is frequently of service to continue this effect for some time by the re- peated or prolonged use of the application. 220. Blisters may be employed as counter-ir- ritants in three modes: 1st, as rubefacients ; 2d, as simple and slight irritants ; and, 3d, to procure a puriform secretion from the part. In acute inflammations they ought not to be pre- scribed until blood-letting has been carried as far as circumstances will permit; and in early periods of the disease they should not be ap- plied longer than seven or eight hours, and a warm bread and water poultice should be placed over the part to promote the vesication, and to prevent the irritation sometimes consequent on them. It will occasionally be advisable to place tissue paper between the blister and the surface. On children, blisters ought not to be applied longer than from three to six hours, and warm poultices should generally replace them, and be renewed frequently. For sub- acute and chronic inflammations, or for the advanced stages of the acute, blisters may be prescribed for a longer period, and sometimes with the intention of procuring a sero-puriform discharge from the blistered surface. 221. Warm pediluvia, the hip bath, and the semicupium are often useful modes of deriva- tion when the head or the thoracic viscera are affected, or when it is desirable to excite the uterine discharge. Their effect will generally be promoted by the addition of mustard and of common salt to the water. But in acute in- flammations the temperature should not be too high, or such as may heighten the general vascular action ; they also ought not to be re- sorted to until depletion and alvine evacua- tions have been duly practised. Besides these, there are other substances sometimes used to produce counter-irritation and derivation, as croton oil, the powder or tincture of capsicum, bruised garlic, and scraped horseradish. They quickly produce a rubefacient action, when ap- plied on the skin, but are not so efficient in the severer cases of acute inflammation as those previously noticed; they are all, how- ever, often of service, particularly in the slight- er forms of the dieases that are attended by acute pain. Besides these, cupping with scari- fication, and dry cupping, are serviceable modes of derivation in the sthenic forms of phleg- masia. 222. The foregoing modes of counter-irrita- tion are most serviceable in recent, acute, or sub-acute inflammations. Those which are about to be noticed act chiefly as suppurants, and are most suited to the chronic states, or to the more advanced stages, or rather to certain of the consequences of the acute and sub-acute forms of inflammation. They consist chiefly of ointments or plasters containing the potassio- tartrate of antimony, or cantharides, or savine ; the decorticated bark of the mezereon root, moist- ened in water or vinegar, and applied to a small portion of the cutaneous surface ; croton oil, either alone or suspended in twice the quan- tity of camphor or soap liniment or olive oil; issues and setons of various forms and kinds ; moxas, and the actual and potential cauteries. The exact circumstances requiring either of these means in preference to others are so nu- merous—the choice of them depending so en- tirely upon the seat, peculiarities, and stages of the disease, upon the constitution and diath- esis of the patient, and upon the other reme- dies employed—that no general rules can be stated for the guidance of the inexperienced in this respect; the powers of observation, expe- rience, and views of the practitioner must be his chief guide in the adoption of these as well as of many other means of cure. 223. It has been very justly remarked by my early friend and former colleague, Dr. Dungli- son, in his very judicious observations upon the use of revellents in the phlegmasiae (see his excellent work, entitled General Therapeu- tics, or Principles of Medical Practice, &c., 8vo. Philad., 1836, p. 363), that when we are desi- rous of maintaining a succession of revulsions, or a constant revulsion, we employ either re- peated blisters, or keep the blistered surface discharging by applying some of the other means just mentioned. Tartarized antimonial ointment is well adapted for chronic inflamma- tions, as of the lungs, because, while the pus- tules, induced in any one part of the exterior of the thorax, or elsewhere, are going through the stages of increment and maturation, a fresh crop may be elicited on some other part of the chest, and thus a succession of irrita- tions can b.e developed which is more beneficial than one that is more permanent. 224. It is of importance to determine the extent of surface to be affected by a revulsive application. This is not always so easy a mat- ter as may be supposed; for, if the vital con- ditions be affected by it in a very limited ex- tent of surface, the morbid action, intended to be remedied, may be entirely uninfluenced by it; and, on the other hand, if a very large sur- face be irritated, constitutional disturbance will be thereby excited ; or that depending upon the primary disorder, as well as the dis- order itself, will be aggravated or perpetuated. As to the time during which the counter-irri- tation should be maintained, but little can be stated, for it must depend almost entirely upon the circumstances of the case. On this topic, Dr. Dunglison remarks, that it is chiefly when the diseased action has been prolonged for a considerable period, and in affections of a neu- ralgic kind, that sudden and violent revulsions are productive of the most marked advantage. In the different phlegmasiae, revulsions which implicate a greater extent of surface, and are more prolonged in their action, are decidedly preferable. In the former cases, moxas and the cauteries may be employed ; in the latter, rubefacients and vesicants. 225. The permanence o-r remittence of the counter-irritation deserves consideration in every case for which this meaas is prescribed 480 INFLAMMATION—Treatment of Sthenic. In most of the phlegmasiae, remittent revul- sion is more serviceable than a prolonged or permanent revulsion. Dr. Dunglison justly observes, that when an artificial irritation, ac- companied or unaccompanied with increased secretion from the part, has been established for some time, it ceases, in a great measure, to be a morbid condition, and cannot be ar- rested without an inconvenience or risk to some organ predisposed to disease; but if a succession of irritations be produced, the sys- tem never becomes habituated to them, and the repetition of the irritation, after a short period, is as beneficial as at first. A succession of vesicants, therefore, is to be preferred to a more permanent application, setons and issues losing much of their beneficial influence in the latter periods of their employment. 266, Broussais and many of his followers have contended that revulsive irritations should be stronger than the morbid action they are in- tended to replace, otherwise they tend to in- crease the latter; but although it is manifestly necessary to reduce the inflammation as much as possible by depletions, before counter-irri- tants are prescribed, yet great good will result from the judicious use of them. There are, also, several that may be very safely employed early in some of the phlegmasiae, and even be- fore depletions have been practised, as the tur- pentine epithem, liniments, &c. (§ 201, 219). I therefore agree with Dr. Dunglison in believ- ing that good will be derived from revulsions in appropriate cases, even should they fall short of the precise degree necessary for completely putting an end to the disease for which they were prescribed. 227. The situation to which revulsants or counter-irritants should be applied, relatively to the seat of inflammation, is deserving of atten- tion, especially as a contrariety of opinion ex- ists on the subject. And yet the very terms here used ought to guide the practitioner to the application of them to parts which are not sup- plied with branches of the same nerves and blood-vessels as proceed to the seat of disease. Much, however, should depend upon the nature of the adopted revulsant; for the turpentine epithem or embrocation will never be injurious, but generally beneficial, however close it may be applied to the inflamed organ. But it is dif- ferent with blisters and other counter-irritants. I cannot agree with Dr. Thomson’s and Dr. Chapman’s recommendation to place these “as near as possible to the affected part.'” I have often seen mischief result from the early appli- cation of a blister to the scalp in meningitis and encephalitis, and to the throat in laryngitis and tracheitis. When, however, the inflammation is of an asthenic or adynamic kind, or when the sthenic form has given rise to effusion, blisters, as well as several other counter-irritants, may generally be applied close to the diseased or- gan. Yet, even in these circumstances, excep- tions to the rule are not few. The choice of situation must, therefore, depend upon the seat and character of the phlegmasia and other pe- culiarities of the case ; precise directions re- specting it can be given only when discussing the treatment of particular inflammations. In all cases the choice should be guided, as M. Begin remarks, by sound physiological princi- ples ; for they only can render this mode of practice more certain than it has hitherto been and prevent the inconveniences which often follow it. 228. It has been already stated that blood- letting, both general and local, may be so insti- tuted, in several of the phlegmasiae, as to de- rive from the seat of disease. The older wri- ters paid much attention to this method of de- pleting. Bleeding from the saphena vein, the feet and legs being immersed in warm water, was often prescribed for phlegmasiae of the vis- cera, and particularly when consequent upon suppressed evacuations ; and bleeding from the vicinity of the anus by leeches is generally adopted by foreign physicians for inflammations of the liver, stomach, &c. Indeed, to derive the impetus of the circulation from the seat of the phlegmasia by vascular depletion, by ca- thartics or other evacuations, and by counter- irritants or other revellents, both internal and external, must always be a principal indication of cure in this class of diseases. 229. iu. Of applications to the inflamed part it- self, there are some that require a particular notice. They may be all comprised and con- sidered under the following modes of operation: 1st. Those which reduce the temperature, and thereby remove one cause of morbid irritation and of vascular expansion. 2d. Those which soothe the morbid sensibility or diminish pain, either by their influence upon the affected nerves, or by diminishing the tension, rigidity, or pressure of parts. 3d. Those which con- stringe the expanded capillaries, restore their lost tone, and prevent the stagnation of the blood or promote the circulation in them ; and, 4th. Those which protect the part from exter- nal irritants, &c. It is obvious that many lo- cal applications produce benefit by acting in more than one of these modes ; but still they may be referred to one or other of these espe- cially. Moreover, many internal means of cure act upon the part affected, particularly in vis- ceral phlegmasia, in one or other of these ways. As topical means are applicable chiefly to exter- nal inflammations, which are generally viewed as belonging to the province of the surgeon, my remarks respecting them will be as brief as the importance of the subject will permit; yet it must not be overlooked, that most external inflammations, particularly when spontaneous, are merely symptomatic of constitutional dis- order—are only the external manifestations of visceral or general disturbance, or of hereditary vice ; that they all react upon the frame through the medium of the organic nervous and vascu lar systems ; and, consequently, that, while lo- cal remedies form only a part of the treatment required, the rest being employed with refer- ence to the internal and constitutional affec- tions, the entire treatment, even in the exter- nal phlegmasiae, is more strictly medical than surgical, if, indeed, the distinction should be at all entertained. 230. (a) Of those applications which directly re- duce the temperature some notice has already been taken ($ 214). They have generally the effect, not only of removing a principal cause of excitement and irritation, but also of con- stricting the morbidly expanded vessels. Cold applications are, however, often injurious, and consequently inappropriate or hazardous, when- ever the external inflammation is merely the INFLAMMATION—Treatment of Sthenic. 481 outward expression of internal or constitutional disorder, as in gout and erysipelas; they are less so, however, in sthenic than in asthenic or spe- cific inflammations; for in the sthenic phleg- masiae the vital energies are capable of resist- ing their sedative influence, and the suppression of the local affection rarely endangers internal viscera. But in the other kinds of inflamma- tion the repulsion of the external affection oft- en caused by these applications is frequently followed by serious internal disease. In such cases, the source of mischief is in the frame, and in some important or vital organ ; and when the effects are prevented from appearing externally, they often break out in some inter- nal viscus. 231. Of the numerous cold applications, there are few which are preferable to the solution of the di-acetate of lead, inasmuch as it combines astringent with cooling and sedative proper- ties. But this, as well as the common cooling or evaporating lotions, and cold or tepid water- dressings, should be suited to the intensity of the inflammations, and be used unremittingly until the local affection is subdued ; for if em- ployed only at intervals, or if at all intermitted, reaction will take place in the inflamed part, and the disease will be thereby aggravated, or, at least, perpetuated. We observe this in the treatment of scalds by cold applications, when used in this latter mode. When the inflamma- tion is of a specific or asthenic kind, and when it is attended by great tumefaction and excess- ive pain, or when cold applications do not give relief to the pain in a short time, they ought either not to be employed at all, or not to be continued, but give place to very different means. Also, when they produce general chil- liness, they ought not to be persisted in. 232. (b) Applications which soothe the morbid sensibility are, perhaps, more generally appropri- ate, and are certainly less dangerous in the symptomatic or specific phlegmasiae just allu- ded to, than those which are cold. They all more or less diminish the tension of rigid and unyielding tissues, lessen pressure on sensitive parts, and have an emollient and soothing ef- fect. Moist warmth, employed in various ways, but especially in the form of steam, simple and medicated, and of fomentations, poultices, and warm baths, also either simple or medicated, &c., is the principal agent by which the physi- cian or surgeon produces these effects. Steam, or warm aqueous vapour, has lately come into notice in the treatment of inflammations ; and we are indebted to Dr. Macartney and Dr. Wilson for a knowledge of its virtues in re- spect of Its topical external use; for as re- gards its internal employment by inhalation in affections of the respiratory organs, it has been long prescribed. (See Asthma, and Bronchi— Inflammations of.) In the form of the vapour bath it has also been generally used, particu- larly in circumstances already noticed (§ 204). By very simple, yet suitable appliances, steam, either of water alone, or of water containing various narcotic or emollient herbs or extracts, or camphor, or acetous or terebinthinate substances, may be brought in contact with, or entirely sur- round the seat of inflammation. It may like- wise be inhaled into the lungs for the affections referred to, either in its simple or medicated states. When employed externally, and par- ticularly to a limited extent of surface, it should be continued for a very considerable time, and at a somewhat higher temperature than when inhaled. The substances, also, whose fumes are conveyed in the vapour or steam, may be used in much greater quantity when applied thus externally and locally than when prescri- bed internally. Fomentations and ■poultices con- taining emollient, narcotic, or other medicines, are also efficacious, not merely by the moist warmth they afford, but, in great measure, by the impression made upon the nervous tissue by the particular medicinal substances they contain. The same remarks apply to medica- ted warm baths. 233. It is principally for inflammations at- tended by excessive pain, by much constitu- tional irritability, by a very frequent and irrita- ble pulse, and depressed vital powers, that the warm and soothing applications now mentioned are required. Hence they are generally appro- priate in the specific and asthenic inflamma- tions, and in them especially afford very great relief, particularly when brought in aid of judi- cious internal treatment and suitable regimen, and employed early in the disease. 234. (r) Applications which constringe the expanded capillaries, restore their lost tone, and prevent the stagnation of the blood, or pro- mote the circulation in them, are suitable to certain states of the advanced stages, and to some of the consequences of sthenic inflam- mation. They are also appropriate to most of the specific and asthenic phlegmasiae from their commencement. When the former proceeds to ulceration, and especially if this assume a spreading or phagedenic form, the more ener- getic astringents, as the various turpentines and balsams; certain metallic salts, particularly solu- tions of the sulphates of zinc, of copper, iron, &c., of the nitrate of silver, and of the acetates of lead, zinc, &c. ; the dilute mineral acids; solutions of the chlorinated soda, of the chloride of lime, and of the chlorate of potash ; various vegetable astringents and tonics ; crcasote, cam- phor, the vegetable acids, &c., are severally ben- eficial in such circumstances, when suitably prescribed, and combined with other appropri- ate means—in some instances, with narcotics, and in others with mucilaginous or albuminous substances—occasionally in aqueous vehicles, and sometimes in unguents, cerates, &c. It is chiefly, however, when the states or conse- quences of inflammation just noticed are exter- nal, or near the surface, or within reach, that applications containing any of these are found useful; yet even when seated in internal sur- faces, as in the intestinal and respiratory, they are occasionally beneficial, employed either in the form of draught, pill, and enema, or by means of the inhalation of aqueous vapour par- tially charged with the fumes of some of them. Although it is chiefly for the advanced stages or consequences of asthenic inflammation that astringent substances are required, yet the ear- ly and acute stages are also sometimes bene- fited by them, however stimulating or irritating they may seem to be. Thus, in scalds, and in certain states of burns, the application of a cloth wetted with spirits of turpentine will gen- erally not merely afford relief, but hasten reso- lution of the inflammatory action. In such ca- ses it mav be truly said, with Shakspeare, that. INFLAMMATION—Treatment of Asthenic, 482 “ One fire burns out another’s burning.” 235. (tl) Substances which protect the infla- med surface from the irritating influence of the air, and of the exhalations floating in it, are extremely beneficial in all cases in which the part is abraded or its continuity injured. They are, however, less useful when they prevent the morbid secretion of the inflamed part from being discharged. In most cases, therefore, they should be so employed as to prevent any accumulation of this secretion from taking place, whereby the surrounding tissues might be contaminated. Most of these substances are advantageously made the vehicles of astrin- gent or detergent medicines, thereby diminish- ing the discharge by constringing the extreme vessels, as well as excluding a chief cause of irritation, and of the consequent morbid secre- tion. The principal advantage derived from plasters, cerates, ointments, &c., is owing to the exclusion of the air by them from the abrad- ed or divided surface. In many cases of inju- ry, the fibrinous lymph exuded from the ex- treme vessels, by coagulating over them, pro- tects them from irritation ; and were this nat- ural protection more frequently allowed to re- main, and confided in, inflammation would less frequently supervene on these cases than it otherwise does. The albuminous exudations formed on superficial ulcerations and inflam- mations of exposed surfaces protect them in a similar manner, and dispose them more readily to heal; and if the inflammatory action should at any time be exasperated, so as to give rise to an increase of the morbid secretion or to the production df pus underneath the protection thus formed, the mischief will often soon sub- side and the secretion become absorbed, the parts healing under the scabs, or dried lymph or albumen covering them. Superficial sores, when protected by the while of egg, often heal underneath; and dressings with this substance, by entirely excluding the air, are often more serviceable in preventing inflammation after incised wounds and in promoting union than any other. Strong solutions of the nitrate of silver,* or of sulphate of copper, or sulphate of zinc, or other astringents, applied to ulcerating surfaces, not only excite the organic nervous tissue, and constringe and give tone to the ex- hausted extreme vessels, but they likewise co- agulate the albuminous portion of the secretion, and thereby protect the part against the irrita- ting influence of the air. They also change the morbid secretion, causing it to assume a more healthy character. Substances which either simply protect a raw inflamed surface, or act in the more complex manner just mentioned, are especially serviceable in cases exposed to the influence of impure air, whether the impu- rity proceeds from terrestrial exhalations 01 from animal emanations, as in the wards of a hospital, or in close, low, or crowded habita- tions. 236. ii. Treatment of Asthenic Inflamma- tion.—When phlegmasia presents the asthenic form, the treatment should be very different from that recommended above. The states of organic nervous power and of vascular action differ from those attending the sthenic condi- tions ; and as the differences are great, so should the indications of cure, and the means employed to accomplish them, be different. As all the modifications of asthenia depend chiefly upon two classes of circumstances—upon de- pressed conditions of the constitution, and weakened functions of the viscera concerned in assimilation and excretion, and upon the sed- ative, poisonous, or septic nature of the exci- ting causes—so all the indications of cure ought to be determined, and the remedies selected with strict reference to these circumstances. If the local phlegmasia is associated with, or consequent upon general asthenia or debility, vital power must be augmented by suitable means, otherwise the local disease will more readily terminate unfavourably, especially it it exist in much intensity. If, in addition to general or constitutional adynamia or asthe- nia, there be impaired excretion, and conse- quently accumulation of effete elements in the blood, or deterioration of it, not only must vital energy be supported or roused, but also the ex- creting or eliminating functions must be exci- ted, and means employed which may correct 01 change the morbid tendency or conditions of the blood ; for if these ends are not attained, the structural lesions which the inflammation rapidly induces, instead of being arrested, or terminating in spontaneous resolution, would be rapidly accelerated, and themselves become the source of farther local disorganization, and of constitutional contamination. 237. Asthenic inflammations, whether de- pending upon original, acquired, or accidental states of the frame, and of the vital organs, or proceeding from specific causes, require a treat- ment directed more strictly to the conditions of vital power and function—to the constitu- tional affection and the existing visceral disor- der—than to the local disease ; and they, more- over, require this kind of treatment much more than the forms of phlegmasia already consider- ed. In the latter, the constitution and the vital organs have generally been either unimpaired or not materially affected, before the local dis- ease originated and drew them within the circle of its sympathies; in the former, either the constitution, or some important viscus, or both, have been seriously deranged before the in- flammation appeared; this latter being either the consequence of, or an accidental contin- gency upon such derangement, and depend- ing upon it in its subsidence as well as in its appearance. Even when the asthenic forms of inflammation more especially proceed from specific or septic causes, still very much of their local characters and of their constitutional ef- fects depend upon pre-existing states of vital energy and of the assimilating and excreting functions. To these, in their antecedent as * [The nitrate, of silver deserves particular mention as a local antiphlogistic application, especially in the erysipela- tous forms of inflammation, and the* different species of cy- nanche. Applied in substance, or saturated solution, to the sound skin bordering the inflamed part in erysipelas it speedily checks the extension of the disease, and in the ’in- flammatory affection of the throat which complicates scar- let fever, there is no local remedy which exerts an effect so speedy and decidedly beneficial as this. In chronic la- ryngitis and bronchitis, unconnected with tubercular dis- ease of the lungs, an application of a solution of the nitrate to the larynx (40 or 50 grains to the ounce), after the manner recommended by Trousseau and Belloc, will often effect an alleviation, if not an entire removal of the disease.—(S eeNew-York Journal of Med. and the Collateral Sciences, vol.v., 1844.) There is scarcely any form of local inflammation in which this article will not prove a useful topical remedy.] INFLAMMATION—Treatment of Asthenic. 483 well as in their existing conditions, the atten- tion of both physician and surgeon ought to be mainly directed ; and neither the one nor the other will discharge his duties if he does not connect the forms and changes of the local af- fection with the constitutional disorder and the visceral derangements, and treat each of them with strict reference to the rest. 238. Although indications of cure should not be followed in succession, nor acted upon indi- vidually, and without regard to their joint oper- ation—although attempts at accomplishing one intention, without endeavouring to attain oth- ers at the same time, should not be made in as- thenic any more than in sthenic inflammations —yet it will be necessary to have just ideas as to the principal objects to be attained, in or- der to arrive at a successful issue, and as to the importance and applicability of them sev- erally in the treatment of each particular case. These objects or intentions should be entirely based upon the characters assumed by the con- stitutional commotion, by the visceral disorder, and by the inflammation—the seat and cause of the phlegmasia, and the circumstances im- mediately connected with the patient, being also taken into account. Upon these, the ac- tivity with which each indication of cure should be pursued, and the importance assigned to one or more of them, should chiefly depend. Influ- enced by these considerations, and by the phe- nomena and progress of asthenic phlegmasise, the physician, in their treatment, will pro- pose to himself: 1st. To promote organic ner- vous power, and thereby to enable the constitu- tion to resist the progress of the local disease ; 2dly. To preserve or to restore the healthy state of the circulating fluids, and the crasis of the blood, by promoting the excreting or depura- ting functions, and by other appropriate means ; and, 3dly. To assuage the urgent symptoms re- ferrible either to the local malady, or to the constitutional affection. The means which most efficiently fulfil the first of these intentions will generally also promote the attainment of the second and third ; and whatever has the effect of accomplishing the second will also most materially advance the other indications. 239. A. The constitution will generally be en- abled to resist the local progress of the malady, by whatever increases the tone or energy of the organic nervous system, through the medium either of the digestive canal, or of the respira- tory organs—by means of appropriate tonics and stimulants, and by a dry, pure, and tem- perate air, duly renewed. All asthenic inflam- mations have a tendency to spread or to extend themselves with a greater or less rapidity, and to terminate unfavourably; the changes that successively arise tending to gradual disorgan- ization, or to more immediate sphacelation. Unless under the influence of agents which rally the constitutional powers, they seldom or never show a disposition to spontaneous resolution, as often observed in sthenic phlegmasia. The only exceptions to this rule are met with in those asthenic inflammations which constitute a part of specific constitutional maladies ; and these are mere symptoms, or parts only, of these maladies, and are generally co-ordinate with, and dependent upon them in their rise, progress, and decline. This tendency to spread, and to give rise to a succession of unfavourable changes, constitutional as well as local, re- quires agents possessing powers of sufficient activity to meet the intensity of the disease. As this tendency depends upon depressed or- ganic nervous energy and deficient vascular tone, as shown above (§ 58); and. as the per- manent fluidity of the effused fluids, and their infiltration and contamination of the surround- ing tissues, depend upon these pathological states, it is obviously requisite to employ such means as attentive observation and enlighten- ed experience have proved to be most efficient in removing them. All parts which are the seat of asthenic inflammation rapidly lose their vital cohesion or tone ; and this loss is partici- pated in, not only by the extreme vessels giving rise to a copious morbid effusion, but also by the tissues affected. The chief pathological con- ditions, from which all the consecutive changes have been shown to proceed (§ 162, et seq.), manifestly require an energetic recourse to those means which will enable the constitution to resist the progress of the local mischief. Where cellular or adipose tissues are implica- ted, the extension of disease, and even of dis- organization will be rapid, if organic nervous energy be not promoted, and if vascular action in the seat of inflammation be not changed by suitable remedies. In such cases, the consti- tution must be enabled, as John Hunter ably contended, to form coagulable lymph, either in or around the inflamed part; or, in other words, to change the fluid and often septic matter ef- fused in the areolae of the tissues, that extends the mischief by infiltrating and contaminating them, into coagulable lymph or albumen, where- by these areolae may be rendered impervious to the more fluid part of the effused matter, and the progress of the local malady may be more readily limited. <. 240. The principle of treatment in asthenic inflammations being established, the means by which it may be most successfully carried out in practice will be readily found ; although the application of these means, appropriately to the varying phases of individual cases, requires great discrimination and care. In the truly as- thenic forms of phlegmasia, the principle con- tended for must be acted upon with decision, and without wavering or temporizing. In the treatment of them, doubt or hesitation is fraught with danger; and proceeding, as either gener- ally does, from ignorance of the true source and relations of the local malady, there will be ev- ery reason to fear that ifiuch of both positive and negative wrong will be farther perpetrated. The ignorant are usually presuming, and the half-informed self-sufficient. In other profes- sions and avocations the evils produced by both are comparatively trivial; but in the practice of medicine their consequences are of fearful and immeasurable importance to humanity. I have seen numerous cases of asthenic inflam- mation die in succession, without the occur- rence of a single instance of success to lull the suspicion that true principles of practice had not been adopted ; and yet the same principles were blindly pursued in each successive case. In a country where the most trivial invasion of the rights of property is visited by the most condign punishment, human life may be sacri- ficed to an extent that more than rivals both the pestilence and the sword, by ignorant pre- 484 INFLAMMATION—Treatment of Asthenic. tenders to medical knowledge—by the totally un- educated as well as by the half instructed—and not merely with perfect immunity from punish- ment, but actually with the protection of the government, that protection being virtually the most complete for those whose ignorance is the greatest! This sacrifice of human life, be it farther recollected, is constant and unceasing —not occasional only, or at long intervals, as that caused by epidemics, pestilences, and wars. It was said, upward of two hundred years ago, by a celebrated archaeologist (Sir H. Spelman), “ that while everything else had risen in nominal value in England, the life of man had become continually cheaper.” What would he have said had he lived in the present day l 241. The means by which the indication or practical principle above contended for is to be fulfilled must necessarily vary with the circum- stances of the case ; but the decoction of cincho- na, or the infusions of cascarilla and of gentian, &c., with the alkaline carbonates (F. 381, 385, 387, 388, 445, 869), are generally beneficial, es- pecially when aided by warm aromatic tinc- tures or spirits. When the pulse is very quick, soft, and weak, and when the patient is physi- cally and morally depressed, the chlorate of pot- ash, serpentaria, or other stimulants, may be added to the above (F. 415-417, 437-439). In these cases, camphor in full doses, the prepara- tions of ammonia, and capsicum, or other spices and aromatics (F. 845, 852), may likewise be prescribed. In all asthenic inflammations, the excretions, and the fluid effused in the diseased tissues, are more or less acid—a state which is most readily corrected by the alkaline car- bonates, conjoined with tonics and aperients. In many cases, however, the preparations of chlorine, particularly the hydrochloric acid, the hydrochloric (Ether, and chlorinated soda, prescri- bed with tonic vegetable infusions or decoctions, and with camphor, aromatics, &c., are equally beneficial with the foregoing (F. 847, 848). 242. B. But, in order to promote the powers of life, and thereby to enable the vessels of the diseased part to form coagulable lymph, where- by the progress of mischief may be arrested, it is necessary, not only to excite the organic ner- vous system, but also to depurate and to correct the circulating fluids by appropriate medicines. This intention will be fulfilled chiefly by pro- moting the excreting functions by mild purga- tives, conjoined with tonics and aromatics, as the compound infusions of gentian and senna with the alkaline salts (F. 266), the compound decoc- tion of aloes with warm aromatic tinctures or spirits, or the infusions of rhubarb and cinchona (F. 55, 387, 433), or other similar remedies (F. 53, 215, 216, 872). In the intervals between the exhibition of these, tonics and stimulants should be selected, and given in doses and com- binations suitably to the seat and urgency of the disease. If the purgatives just mentioned act insufficiently, a dose of oil of turpentine and castor oil (about half an ounce of each) may be taken on the surface of milk, or of any aromat- ic water (F. 216), and enemata containing the same oils (F. 135, 151), administered according to circumstances. If the biliary secretion be suppressed or interrupted, calomel or Plummer’s pill may be given at bedtime with camphor, and & draught containing the oils, or either of the above purgatives, may be taken in the morning. The combination of the mild alkaline salts, or of the chlorate and carbonate of soda (F. 439), with the foregoing tonic or other medicines, will generally correct the circulating fluids, di- minish the contaminating influence of the mat- ter effused in the seat of disease, and farther promote the fulfilment of the present indication. 243. C. From the commencement of the treatment it is often requisite to mitigate the more urgent, local, and constitutional symptoms.— a. The remarkable pain and tumefaction of the inflamed part are best relieved by anodyne fo- mentations, by warm bread and water poulti- ces, or by the local application of simple or medicated steam. In the more complete forms of asthenic inflammation, no advantage will accrue from the application of leeches to the inflamed part; although a recourse to incisions of the integuments, as recommended by Mr. A. Copland Hutchison and others, will often be of service when cellular and adipose parts are the seat of disease, and the tension is very great. I have seen also the application of a cloth moistened with oil of turpentine have a very remarkable effect both in mitigating the pain and in lessening the tension and tumefac- tion. It should be applied warm, and covered with wash-leather or oil-skin to prevent evapo- ration and cold. In several cases, where the swelling has been most extensive—the whole limb to the trunk having been affected—I have seen it subside very quickly after a decided re- course to the internal and external treatment here recommended. In most of these cases, the tone of the vessels has been rapidly resto- red, congestion ofthem removed, and the effused fluid absorbed, without coagulable lymph hav- ing been formed, or suppuration having super- vened, excepting in some instances at the point of injury, or where the disease originated. When this treatment is early resorted to, not only is the progress of the disease arrested, but also much of its more immediate effects is re- moved without the lesser evil, the formation of fibrinous lymph, for which John Hunter con- tended, having taken place. 244. h. At advanced stages of asthenic phleg- masia, more frequently, and even at early pe- riods occasionally, excessive pain and general irritability call for a prudent yet decided re- course to narcotics. In these cases a lowering treatment will neither mitigate the pain nor di- minish the other symptoms, but, on the con- trary, increase them all, and render still more rapid the already quick and irritable pulse. Here opium, or the acetate or hydrochlorate of morphia, or hyoscyamus in large doses, must be resorted to. But these ought always to be con- joined with camphor and some of the aromatics or spices. When delirium appears in the course of asthenic inflammation, depressing remedies are generally injurious ; but the narcotics just named, and combined as now advised, will be of the greatest benefit, particularly in conjunc- tion with the restorative treatment above rec- ommended, and after the excretions have been duly evacuated by appropriate means. (See art. Delirium.) 245. c. When asthenic inflammations are at- tended by general vital depression without reac- tion (§ 62), the most energetic stimulants, ton- ics, and restoratives are necessary ; and if de- INFLAMMATION—Treatment of Intermediate Forms of. 485 inum supervene, camphor, ammonia, and opi- um, with warm aromatics, should be freely ex- hibited. 246. d. When organic nervous or vital pow- er is depressed, although much general vascular excitement exists ('§ 63), the pulse being rapid and weak, similar means to the above are re- quisite, but in less energetic doses. Camphor, with the narcotics already advised, and aromat- ic spices, mild stomachic purgatives, occasion- ally aided by a draught and an enema contain- ing turpentine and castor oils, are also most efficient remedies. 247. c. In cases characterized by depressed vital power, acute nervous sensibilty, and cerebral disorder (§ 64), the means just recommended are urgently called for ; but the narcotics and camphor should be prescribed at an early pe- riod of the disease, and in large doses. The effusion of tepid or warm water on the head, according to the temperature of the part, may be employed. Medicated vapour or warm baths may also be tried, and medicated steam ( A. Schmitt, in M6m. de l’Aead.de Vienne, vol. ii.—A. Pauli' in Magaz. de Rust, vol. viii., p. 434. — V. G. Wedemeyer, Lntersuchungen iiber des Kreislauf des Blutes, 1828.-—7. Syme, in Edinb. Med. and Surg. Journ., vol. xxx., p. 316.— 7. Scott, Surgical Observations on the Treatment of Chronic Inflammation. Lond., 8vo, 1828.— Cruvcilhier, Anatom. Patholog., vol. i., p. 200.—Andral, Prdcis d’Anat. Pathol., 1829, tom. i., p. 12 ; et in Journ. Hebdom., tom. ii., p. 145. — Murat, in Nouv. Biblioth. Med., tom. iv., p. 5 ; et tom. v., p.^253.—Rust, Magazin, &c., tom. xi., p. 460; tom. xiv., p. 487 ; torn, xvii., p. 161 ; et tom. xxvii., p. 1.—7. F. Lob- stein, Traitd d’Anat. Path., $ 334, 8vo, et fol., 1829.—Du- puyiren, in Diet, de M6d. et de Chirurg Prat., t. i., 1829, art. Abces. — Caffort, Mdmoire sur la Nature de l’Inflam., Svo, 1829.—M. Sommi, Etudes sur l’lnflam. Bruxelles, 8vo, 1830.— ff. Chaujford, Traith des Inflam. Internes., 8vo, 1831.—M. Serrb, Traitd de la Reunion Immed., &c., 8vo, 1830; et in Encyclograph. des Sc. Mdd., Juillet, 1837, L., p. 97.—Otto, Compend. of Pathol. Anat., transl. by 7. F. South, 1831, I) 19. — Crawfood and Tweedie, in Cyc. of Pract. Med., vol. ii., p. 700. Lond., 1832. — 7. Jlf. Good, Study of Medicine, by S. Cooper, vol. ii., p. 283.—G. Roger- son, A Treatise on Iuflam., vol. i. Lond., 8vo, 1832.—7 L Prevost, in Mem. de la Soc. de Phys. de Gdneve, tom. vi., p. 142.—Roche, in Diet, de Mdd. et de Chirurg. Prat., tom. x.,p. 443. Par., 1833.—D. Badham, Reflections on the Na- ture of Inflammation and its alleged Consequences, 8vo, 1834. —7. M. Gully, in Lond. Med. and Surg. Journ., vol. vii., p. 551. — VV. Lawrence, in Med. Gaz., vol. v., p. 97. 7. VV. Earle, in Ibid., vol. xvi., p. 12, 70, 105.—Burke, in Ibid.j vol. xix., p. 228.—Bonnet, in Ibid , vol. xxi., p. 440.—Fro- riep, in Brit, and For. Med. Rev., vol. i., p. 569. — L. J. Sanson. De la Reunion Immed. des Plaies, &c., Svo, 1834. — Jlf. P. Alison, Physiology, &c., 2d edit., 1833; in 4th Rep. of Brit. Ass., p. 674; and in Edinb. Med. and Surg. Journ., vol. xiv., p. 98.—G. Rasori, Teoria della Flogosi, 2 vols., 8vo. Milano, 1837.—Mueller, in Brit. Annals of Med., 1837, p. 673.—G. T. Morgan, An Outline of Inflammation and its Effects. Edinb., 8vo, 1837.—R. Bright and T. Ad- dison, Elements of the Practice of Medicine, part ii., p. 129. Lond., 1837.— R. Carswell and T. Hodgkin, in Med. Chir. Rev., vol. xxix., p. 440.—R. Carswell, Illustrations of the Elementary Forms of Disease, fasc. viii., and xii. Lond., fol., 1838. — 7. Macartney, A Treatise on Inflammation. Lend., 4to, 1838.—(See, also, the Bibliography nnd Ref- erences to the articles Abscess and Gangrene.) [An. Bibliog. and Refer.—Benj. Travers, The Phys- iology of Inflammation, and the Healing Process. London, 1843, 8vo.— Wharton Jones, Report on the present Slate of Knowledge of the Nature of Inflammation, in Forbes's Brit, and For. Med. Review, vol. xvii., p. 567, 1844.—7. H. Ben- nett, On Inflammation as a Process of Abnormal Nutrition. Edinburgh, 1844, 8vo.—Fried. Gerber, Handbuch der Allge- meinen Anatomie des Menschen und der Haussaugethiere. Bern, Thur, und Leipzeig, 1840, 8vo ; translated as “Ele- ments of the General and Minute Anatomy of Man nnd the Mammaliato which are added Notes and an Appendix, by George Gulliver. London, 1842, 8vo.—J. Vogel, Ent- ztindung und ihre Aqsg&uge, in Handworterbuch fur Phys- iologie mit Ruchsicht auf Physiologische Pathologie, von R. Wagner. Braunschweig, 1842, p. 311. — J. Lisfranc, Clinique Chirurgicale de l’Hopitalde laPitid. Paris, 1841, 8vo. — John Jones, Surgical Works of, edited by Mease. Phil., 1795,8vo.—J. M. Chelius, A System of Surgery, trans- lated from the German by J. F. South, Am. ed., by Geo. IF. Norris., Phil., 1845, 4 Nos. — Nathan Smith, Surgical Me- moirs, edited by N. R. Smith. Baltimore, 1831, 8vo.—los. Parish, Practical Observations on Hernia and ’Diseases of the Urinary Organs. Phil., 1836, 8vo.—N. R. Smith, Sur- gical Anatomy of the Arteries, 2d ed. Baltimore, 1835, 4tn. — Wm. Anderson, System of Surgical Anatomy. New-York, 1822, 4to.— Wm. Ferguson, A System of Practical Surgery. London, 1842.—Joseph Pancoast, A Treatise on Operative Surgery, &c. Phil., 1844.—Robert Liston, Lectures iu Lend. Lancet, 1844-5; and Elements of Surgery, Am. ed., by S. D. Gross, M.D. Phil., 1842.—J. Syng Dorsey, Ele- ments of Surgery. Phil., 1813, 8vo, 2 vols., 2d ed., 1818.— Wm. Gibson, The Institutes and Practice of Surgery. Phil., 1824-5, 2 vols., 8vo, 7th edit.—Samuel Cooper, Dictionary of Practical Surgery, 8th ed. Lond., 8vo. Reprinted in New-York in 1843, edited, with a Supplementary Index, by D.M. Reese, M.D.—A. Velpeau, Nouveaux Elemens, &c., translated by P. S. Townsend and V. Mott, vol. i. and ii. New-York, 1845-6.—C. Rokitansky, A Treatise on Patho- logical Anatomy, part i., translated by J. C. Peters, 8vo. New-York, 1844.—J. C. Warren, Surgical Observations on Tumours, &c., 8vo. Boston, 1837.—C. J. B. Williams, Prin- ciples of Medicine, comprising Genera! Pathology and The- rapeutics, &c., with Notes, by Jlf. Clymer, M.D., 1 vol., 8vo. Phil., 1844.—E. Whitlaw, A Treatise on the Causes and Effects of Inflammation, pfjv, the mind), which he de- fines to be an exaltation of the feelings and sentiments to a state of sadness, and which he considers to exist at the commencement of al- most all cases, and, with lesion of the sensi- bility, to constitute the fundamental character of insanity, appearing as one of the more im- portant features of the malady. It frequently, however, assumes a monomaniacal, or, as he more correctly terms it, monopathic form (from povog, single, and midoc, disorder). 54. ii. Mania, or Hyperphrenie (from virep, above, and pyv), which he views as a state of cerebral reaction, in which the whole or some of the active manifestations of the intellect, or traits of the character, or propensities, &e., are remarkably exaggerated and disordered. This species of insanity presents two states: that of erethism, or tranquil mania; and that of orgasm, or furious mania. It may be par- tial—monopathic, or monomaniacal; or more or less general, as respects the extent to which the instinctive, intellectual, and moral powers are implicated. It may thus appear in the shape of ambitious, religious, lascivious, cov- etous mania, &c., assuming either a tranquil or a more or less furious character. The dif- ferent forms of this species may be associated, with melancholia, constituting melancholic mania. 55. iii. Madness, or Paraphrenie (from rcapa, along with, and typyv), which he defines to be cerebral reaction characterized by fantastic aberration. This species presents numerous varieties and modifications as to the extent and association of mental disorder ; but it is fre- quently partial or monopathic, and it may be either of a harmless or destructive nature. It is often associated with melancholia, or with ma nia, or with both. 56. iv. Extasis, or Hyperplexie (from vnsp, above, and nXijfic, astonishment), which he views as sub-convulsive reaction of the cerebral power, characterized by immobility and rigidi- ty. This state, although often monopathic, is also frequently complicated with melancholia, or with mania, or with madness, or with any two, or even all of these. 57. v. Convulsions, or Hyperspasmie (from vnep, and anaapoc, violent contraction). This species M. Guislain defines to be reaction, with mus- cular and mental agitation. He comprises un- der it tremour, convulsive syncope, chorea, hys- teria, and epilepsy, disorders previously not sim- ilarly classed, although either of them often complicates one or more of the mental disorders already enumerated, and even all of them in rare instances. 58. vi. Delirium, or Ideosynchysie (from idea, idea, and avyxomq, confusion), which he states to be reaction and aberration of the ideas, wandering of the intellects, illusions, halluci- nations. This may be monopathic, as when the patient is possessed by a single idea or illu- sion ; or it may be associated with one or more, or even with all of the mental affections just noticed. 59. vii. Incoherence, or R&vasserie, or Anaco- luthie (from uvaitoXovdia, incoherence). This state M. Guislain considers as different from delirium, inasmuch as in the latter the ideas run upon some illusion or hallucination, where- as in this state they arise vaguely, and with- out any connexion with each other, or with any particular subject or object: nothing is ex- pressed clearly or consecutively. In delirium 512 INSANITY—Classifications of. the idea, although false, presents some con- nexion, or even the colours proper to it. Inco- herence may be monopathic or associated: most frequently the latter ; and the association may be with either of the preceding affections, or with several of them. 60. viii. Dementia, or Noasthenie (from voof, intelligence, and dadevla, debility). This state is viewed by M. Guislain as one of mental prostration and incapacity, in which the men- tal powers are palsied. This species is made to comprise those forms of insanity which con- sist of various grades of imbecility, original or acquired—congenital idiotcy and senile fatuity. Like the preceding species, it is either mono- pathic or associated; more frequently the latter, in which state it is usually the consequence of chronic or greatly prolonged forms of the dis- orders already enumerated. 61. I have thus fully adduced M. Guislain’s arrangement of mental disorders, because it presents not merely a classification, but also an instructive analysis of them, especially when attentively considered in his own copious ex- position. For practical purposes, and for the inexperienced practitioner, it will be found de- ficient in simplicity; but, coming as it does from one of the most experienced and ablest writers on mental alienation, it deserves our careful attention and our respect. 62. M. Foville, in attempting a physiologi- cal arrangement of mental disorders, observes, that three orders of phenomena, sensations, in- tellectual combinations, and movements, suc- ceed one another in the actions of the nervous system; and that three orders of symptoms, exactly corresponding, show themselves singly or combined in mental diseases. In founding upon the existence of the symptoms of a single one of these orders, and upon the successive appearance of those of the other two orders, he hopes to have laid, not only a physiological, but also an anatomical basis of classification for the principal divisions of mental alienation, in- asmuch as he thinks it may be admitted, at least with the consent of many modern writers, that sensibility, movement, and intelligence have each their distinct organic seat, although dependant upon the same system. 63. As disorder of the intellects is the most constant, the particular instances in which it is alone present constitutes M. Foville’s first di- vision, which comprehends mania, monomania, demency, and idiotcy, without complication with false perceptions, or with any disorder of the muscular system. In the second division, he arranges all cases characterized by the coinci- dence of disorder of sensation and perception with derangement of the intellects ; and, in the third division, he comprises those which mani- fest that disorder of the muscular system, usu- ally denominated general paralysis, or the palsy of the insane. In this third class he also com- prehends the epileptic insane, as well as idiots, whose limbs are wasted and paralytic. 64. Dr. Prichard has distinguished insanity into, 1st. Moral; and, 2d. Intellectual: the latter he has divided into (a) Monomania, or partial insanity ; (b) Mania, or raving madness ; and (c) Incoherence, or dementia. Idiotcy, or mental de- ficiency, he has considered as entirely apart from, or unconnected with, any form of mental alienation. 65. Dr. Mayo, in his Pathology of the Human Mind, divides primary mental disease into, 1st. Perversion, or insanity; and, 2d. Deficiency of the mental manifestations. He subdivides Per- version of mind into, 1st. Moral incoherency; and, 2d. Intellectual incoherency : and Deficien- cy into, 1st. Brutality, or absence of the moral faculty; and, 2d. Imbecility, or intellectual de- ficiency. 66. I shall not notice at greater length the divisions of the various forms in which mental disorder presents itself that have been at- tempted by modern writers. Enough has been advanced to show the difficulty of the attempt, and to prove even (what many would en- deavour to conceal) that one form of mental disorder gradually and insensibly passes into that more nearly allied to it, not only in dis- tinct cases, but often also in the same individ- ual ; that, for instance, partial may rapidly pass into general insanity; that melancholia may quickly pass into mania, or mania rapidly lapse into melancholia, or that both may very fre- quently alternate ; and that the more simple states of intellectual disorder may be soon as- sociated with disorder of the sensations and perceptions, or be still farther complicated with lesion of the movements, in the form either of general palsy, or of epilepsy, or even of both. Nevertheless, although even the most different forms of insanity more closely approximate than is generally imagined, still it becomes ne- cessary to preserve and to recognise such dis- tinctions between them as really exist, inas- much as they furnish most important indica- tions for moral as well as for medical treatment. In the division, therefore, which I shall attempt, I shall endeavour, at the same time, to point out close relations as well as obvious distinc- tions ; and to follow the progress of mental dis- order from its more simple, partial, and com- mon forms, up to its more general and com- plicated states. Conformably with this inten- tion, I shall take a brief view, 1st, of the Par- tial Forms of Insanity—(a) as evinced chiefly in the moral manifestations of mind, and (b) as affecting principally the understanding or judg- ment ; 2d, of the General Forms of Insanity— (a) in the state of mania, or raving madness ; (b) in the states of incoherence and imbecility, or dementia; (c) in the state of fatuity, or anni- hilation of the powers of mind ; 3d, of Compli- cated Insanity, the insanity being associated (a) with paralysis, (b) with epilepsy, (c) with apoplexy, &c. Connate and Puerile Insanity— congenital privation of mind, or Idiotcy, and Pue- rile Imbecility; Puerperal Insanity—insanity during uterogestation, after parturition, and du- ring lactation; and Suicidal Insanity—or sui- cide in relation to insanity, will be considered in separate chapters of this article.* * The following classification of the manifestations and affections of mind, with reference to their influence in caus- ing mental and corporeal disorder, was published some years ago by the author. It may be found of use in consid- ering the different forms of mental disorder, especially in relation to their arrangement, to their causation, and to their moral management. This classification of the affec- tions of mind is based upon the relations of the human spe- cies to the rest of the animal creation, especially in respect of those manifestations which are exhibited by the higher animals. The Instinctive Desires and Feelings form the First Class, as being the most generally extended ; and the Intellectual States and the Moral Emotions constitute the Second and Third Classes, as belonging especially to man, and as furnishing him with a numerous class of INSANITY—Partial—Moral. 513 67. III. Of the special Forms of Insanity.— In the above general description, I have con- fined myself to the more obvious and fully de- veloped states of mental disorder. It is neces- sary, however, that I should consider, in a more minute, yet succinct manner, the specific forms in which aberrations of mind present themselves in practice, and more particularly those slight, moral, and partial states of disor- der to which I have as yet very imperfectly adverted. 68. i. Partial Insanity—the simpler forms and slighter grades of mental disorder.—Most au- thors have erred in viewing the more partial or slighter forms of insanity, as consisting of de- rangement of one, or of a few, merely, of the intellectual or moral manifestations; or of a false perception, or delusion, by which the mind is constantly haunted, while the other faculties are unimpaired. I have already hinted (<$ 3) at the inaccuracy of this view, and stated that, although a single faculty or manifestation may be prominently disordered, or a single train of ideas be almost exclusively entertained, the other mental faculties are never in a healthy state, or very rarely retain their former ener- gy. Conformably with this, the term partial insanity is not so applicable to the states of disorder about to be considered, as one which would imply a slighter grade, or a simpler form, of alienation. But as the former has been al- ready employed by recent authors, and as it may be conveniently used as implying slight- ness of grade, as well as an uncertain limita- tion as to extent, I shall retain it, and employ it synonymously with these expressions. 69. A. Moral Insanity—the Monomanie sans Delire, or M. instinctive, of M. Esquirol.—This state of mental disorder may be defined to be a perversion of the natural feelings, affections, in- ideas, which raise him above all other animals, which en- noble him in his social and moral relations, and which en- able him to derive advantages from the past to rationally enjoy the present, and to form the liveliest hopes, and even the firmest anticipations, of the future. CLASS I. Instinctive Desires and Feelings.—Strong and immediate incentives to action in the lower ani- mals, but controlled by reason in man. Order 1. Instinctive Feelings, tending to preserve the Individual. a. The sensations derived through the medium of the external senses contribute to the preservation of the in- dividual, by showing him what is injurious, and by en- abling him to supply himself with what his internal sensations or appetites indicate to be necessary to his existence.—b. The appetite for food and drink.— c. The desire of preserving the animal warmth.—d. The de- sire of repose.—e. The desire of place.—/. The desire of pleasure and the dread of pain.—g. The desire of continued existence. Order 2. Instinctive Desires tending to perpetuate the Species. a. Parental and filial affection.—b. The desires of sex.—c. Desire of society and social feelings, giving rise to mutual support. The sensations and desires are most powerful incentives of volition. The appeasing of the desires is necessary, not only to health, but even to existence. The inordinate gratification of them is most injurious to physical and men- tal health—is among the most fruitful sources of disorder of both mind and body. CLASS II. Intellectual Powers, or States of Mind. Order 1. Powers of Consciousness, or the simple Intel- lectual States of Mind. — Injurious to health, chiefly from their injudicious or excessive exercise. a. Perception.—b. Attention—effects of protracted, to a single object, or train of investigation.—c. Concep- tion—accurate or inaccurate views—their effects.—d. Memory. This last power is more or less concerned in a large proportion of the states of mind affecting the health. Order 2. Powers of Intellection, or the more active In- tellectual States of Mind.—The excessive exercise or misdirection of these is more or less injurious to mental and bodily health. a. Simple suggestion or association of ideas.—b. Habit. —c. Imagination—its activity as influenced by the mor- al emotions of mind, sometimes beneficial, but oftener injurious to health. — d. Judgment, or reasoning.— e. Abstraction. Order 3. Ideas of Reflection, springing from the Exer- cise of the two former Orders of Powers.—Rational in- centives to action. a. Mental identity.—b. Time.—c. Power.—d. Causa- tion and truth.—e. Right and wrong.—f. Existence of a Deity.—g. Immortality of the soul. All these are seldom injurious to health, but are often beneficial in controlling the emotions and desires, in governing and directing the instinctive feelings, and in enabling the mind and body to resist the influence of injurious im- pressions and agents. CLASS III. Moral Affections of Mind, in which some of our Instinctive Feelings, as well as of our Intellectual Powers, are frequently more or less engaged. Order 1. The Instinctive, or simple Moral Emotions of Mind, often sudden and violent incentives to action. When strongly excited or much indulged, they are among the most influential causes of both mental and corporeal disease. a. Anger, indignation, resentment, revenge—their ef- fects upon health.—b. Sympathy—its effects.—c. Beau- ty, or deformity.—d. Love and hate, jealousy, domestic misery.—e. Pride, vanity, and humility — the liability of the former to lead to insanity.—/. Gladness, regret, sadness, and grief. Grief from lost objects of affection —its effects —counteracted by progeny. Grief from moral degradation the least supportable — why 1 Ef- fects of sudden shocks of grief on sensitive minds. Dis- appointments of the affections. Grief from loss of for- tune, &c. Influence of repeated disappointment and losses—of harassing difficulties.—g. Hope and fear — their effects on health. Confidence. Various antici- pations— their effects. Anxiety; that of professions, particularly of medicine. Anticipated happiness—ef- fects of the sudden arrest of, on sensitive minds, &c. Terror, fright, &c. — often productive of nervous dis- eases, and sometimes of mental disorder.—h. Gratitude. —i. Wonder. Desire of Novelty. Mental languor.— k, Sublimity and ludicrousuess.—l. Love of approba- tion. — m. Desire of power and its related affections Desire of knowledge. Fame. Avarice. Order 2. Rational Emotions of Mind, arising out of moral and religious Obligations, often strong incentives to action. a. Rectitude, virtue, merit, and demerit, with all the duties we owe ourselves, as moral and responsible agents, and as tending to promote our intellectual and moral excellence and happiness.—b. Our various duties as members of society.—c. Our religious obligations as immortal beings. Remorse, or the consciousness of having neglected one or more of the above duties and obligations—sometimes productive of disorders of mind and body. i. The influence of mental culture — intellectual and moral—when duly directed in early life, upon the tern perament and constitution — upon mental and bodily health—in developing and in strengthening both the mind and body. ii. Temperament and constitution remarkably modify the operation of the affections of mind upon health. Illus- trations. iii. The influence of mental and bodily occupations—1st Upon mind ; 2d. Upon the body. iv. Ill effects of want of occupation—Ennui—Hysteria— Hypochondriasis — Melancholy — Insanity — Suicide Effects of solitary confinement. v. Bad consequences of improper occupations and amuse- ments, especially in females in early life. Mental dis sipation — its effects, particularly in impairing, 1st. Mental vigour ; 2d. Bodily health. vi. Consequences of habitual amusements, sensual indul- gences, and pleasurable excitements, on the nervous system. These generate feelings calling for their re- peated gratification, and for increased excitement, until nervous energy and vital power are exhausted, and un- til moral and physical ruin ensues. vii. Good effects of a well-regulated and cheerful mind on health—of agreeable pursuits, particularly those exer- cising both the mind and the body. The influence of confidence — of moderation—of contentment—and of agreeable and useful occupations, in securing both the health and happiness of their possessors. 514 clinations, temper, habits, moral dispositions or impulses, without any illusion or hallucination, the intellectual faculties being more or less weakened or impaired. This state has been noticed by Heinroth and Guislain, and more fully by Dr. Mayo, M. Esquirol, and Dr. Prichard, in their recent works. Its earlier or slighter grades, however, have not generally been viewed as amounting to insanity; and, indeed, unless ei- ther the disordered manifestations, which I have just enumerated as constituting it, be re- markably prominent, or the intellectual facul- ties be much weakened or impaired, it cannot really be considered as amounting to mental derangement. Dr. Mayo has noticed, in his Essay on the Relation of the Theory of Morals to Insanity, a certain variety of it as belonging to insanity, and given it the name of Brutality ; but in a more recent work he remarks, that farther consideration has satisfied him that to class it as such is loose and unphilosophical. He considers this as a distinct form of mental disease, especially in its fully-developed or strongly-marked form, and to be altogether dis- tinct from the moral symptoms of insanity that occur at an early period of the disease, and that often afford, at that time, the only clew to its existence. By Brutality—by the moral dispo- sition to which this term may be applied—he implies a destitution of principle ; by Insanity, a perversion of tendencies and want of self- control. In the latter case, the patient cannot hear the voice of conscience ; in the former, he has no conscience to hear. 70. The moral disorder, termed brutality by Dr. Mayo, is, however, only one of the modifi- cations of moral insanity, comprised in the more extended definition which I have attempt- ed to assign to this species of mental derange- ment, agreeably with the observations of Hein- roth, Geislain, and Prichard, and is one ari- sing chiefly from the unrestrained indulgence of the passions and appetites To it, however, I shall more fully advert, in the sequel. In re- spect of moral insanity, in its more extended signification, it is justly remarked by Dr. Prich- ard, that there are many persons living at large who are affected, more or less, with this mod- ification of mental disorder, and yet are repu- ted to be merely of a singular or wayward char- acter. An attentive observer will often recog- nise something remarkable in their manners and habits leading to doubts of their entire san- ity ; and circumstances often appear which strengthen the suspicion. An hereditary ten- dency to madness may have existed in the fam- ily, or various members of it have been subject to diseases of the brain. The individual him- self may have been the subject of an acute at- tack of insanity, or of inflammation of the brain, in a former period of his life; and from that time, or after having sustained some reverse of fortune, or the loss of a beloved relative, his temper and dispositions have undergone a change. This alterat ion of character may like- wise have followed some dangerous illness or severe shock of constitution, especially fever, phrenitis, paralysis, apoplexy, or epilepsy. In some, the alteration in the temper, in the pas- sions, the habits, or the disposition, may have been gradual or imperceptible ; in others, sud- den, or almost immediate upon its determining cause. In either case, it seems to have con- INSANITY—Moral. sisted chiefly of an exaltation of peculiarities or dispositions, more or less natural or habit- ual to the individual. In this state a person may continue for years, following the bent of his perverse inclinations ; always engaging in new pursuits, and soon relinquishing them, without any sufficient object or inducement ex- cepting caprice. At length the total perversion of his affections and dislike, or even enmity to his dearest friends, excites alarm. 71. a. When the head of a family is affected with this ambiguous modification of insanity, it often becomes necessary, to prevent ruin from absurd extravagance or wild projects and spec- ulations, to make some attempt at taking the management of his affairs out of his own hands ; but for this the laws are inadequate, and the endeavour is often unsuccessful. Persons la- bouring under this disorder are capable of rea- soning upon, any subject within the sphere of their knowledge, and often display great inge- nuity in giving reasons for their conduct, or in justifying their moral feelings. In these cases, as well as in others belonging to other modifi- cations of this species of insanity, the feelings and passions are more or less excited, while the controlling faculties of reason and judg- ment—of attention and comparison—are equal- ly weakened, errors in action and conduct re- sulting therefrom. 72. Moral insanity is not, however, limited to a preternatural excitement of the passions and temper, but comprises many other disor- dered states of the mind. Indeed, its varieties are almost as numerous as the modifications of disposition and temper. The most frequent forms are characterized, either by the kind of excitement just noticed, or by melancholy de- jection. Either of these forms of moral disor- der may continue more or less permanently ; but they sometimes alternate or supersede each other, an opposite state of temper or feeling arising without any obvious cause. The prev- alent character of the affection is occasionally derived from the natural disposition of the in- dividual ; but it is often remarkably different— lively persons becoming dejected; and the melancholy or taciturn, lively, loquacious, or sanguine. 73. b. When sorrow or gloom is natural to an individual, and is not excessive, it does not amount to disorder; but, when it is remarka- ble and constant, without any real cause, it be- comes a moral disease, although entirely de- void of any illusion or hallucination. Dr. Prich- ard remarks, that this tendency to morbid sor- row and melancholy, as it does not destroy the understanding, is often subject to control when it first arises, and probably receives a peculiar character from the previous mental state of the individual, from his education, and his religious or irreligious character. Persons of well-reg- ulated minds, when thus affected, express grief and distress at their conscious inaptitude to the active duties of life ; and often feel a horror of being driven to commit suicide, or some dread- ful crime to which they feel various obscure impulses or tendencies. This idea haunts them, and renders them fearful of being a mo- ment alone. It, however, generally subsides, and a healthy state of mind returns. Persons of an opposite character frequently relapse ini > a state of tadium vita, or of morose disgust; INSANITY—Moral. 515 loathe their very existence, and at length at- tempt to end it. A state of gloom and melan- choly may, however, give way to a state of morbid excitement. 74. c. When the moral disorder is one of un- natural excitement, the person affected is full of projects and enterprises, or is active and bois- terous beyond the limit that belongs to a nat- urally lively disposition. This state of disor- der may occur in persons whose temperament is the reverse of either the sanguine or lively ; and it then becomes the more striking. It usually displays itself in a want of self-govern- ment, in continual excitement, an unusual ex- pression of strong feelings, in thoughtless and extravagant conduct. A modest female be- comes violent and abrupt in her manners, loqua- cious, impetuous, talks loudly and abusively of her friends or relations before entire stran- gers ; or uses indecent expressions, and betrays, without reserve, unbecoming feelings and trains of thought. Persons thus affected often become drunkards ; and a debauch is followed by ra- ving madness, requiring restraint or confine- ment, which, with abstinence, removes for a time the maniacal excitement; but as soon as restraint is withdrawn, they resort to their for- mer excesses, although well aware of the con- sequences. This form of the disease I have met with in two instances in professional men. 75. d. In examples of a different description, as Dr. Peichard remarks, the mental excite- ment constituting the disorder is connected with religious feelings, especially when the pe- riod of excitement has been preceded by one of melancholy, during which the person affect- ed has laboured under depression and gloom, mixed with apprehensions as to his religious or future state. Formerly possessed by a domi- nant sense of condemnation and abandonment, when all hope and comfort have vanished, and nothing has mitigated the gloom and sorrow of the present, or allayed the dark and fearful an- ticipations of the future, his feelings become suddenly changed, and he experiences a lively joy in his contemplations, amounting often to rapture and ecstasy. Such a change is hailed by the devout as a happy transition from reli- gious destitution to divine acceptance and grace. But the train of excitement is too high, the ex- pressions of happiness too ecstatic to be long mistaken ; pride and haughtiness, a violent or boisterous deportment, and selfishness, are soon betrayed, with want of natural affection, variability of spirits, and irregularity of mental habits and of conduct. In these cases, there is no false sensation or perception impressed upon the understanding; no illusion or belief of a particular sentence of condemnation, or mes- sage of acceptance, specifically revealed. If this existed, the case would be one in which the moral disorder is only the consequence of a false perception or delusion, and consequently one which belongs to another species of men- tal disease. 76. e. Particular cases are marked, as noticed by Pinel, Esquirol, Holland, and Prichard, by the prevalence of certain passions and mental habits, displayed under modifications of which the human mind, in a sane state, seems hardly to be susceptible. Among these is an unusual prevalence of angry and malicious feelings, arising without provocation or ordinary excite- ment, constituting what Pinel designates “ Ma- nic sans Delire.” There are many instances, observes Dr. Prichard, in which the whole dis- eased manifestation has consisted in a liability to violent fits of anger without cause, and lead- ing to danger, or actual commission of serious injury to surrounding persons. The character- istic feature of this malady is extreme irasci- bility, depending on a physical morbid cause. There are other instances in which malignity has a deeper dye. The individual is continual- ly indulging enmity and plotting mischief, and even murder, against some object of his malice. When this is connected with the false belief of some personal injury actually sustained, the case does not fall under the head of moral in- sanity. It involves hallucination or erroneous conviction of the understanding ; but when the morbid phenomena include merely the expres- sions of intense malevolence without provoca- tion, actual or supposed, the case is strictly one of moral insanity. 77. /. In some instances, the impulses and propensities to which the patient is subject, or which he has indulged, are so exalted or disor- dered as to constitute the sole manifestations of insanity, as ably insisted upon by Reil, Hoff- bauer, and Prichard. A sudden impulse to commit an atrocious act may arise in the mind of a person otherwise apparently sane, and in possession of his intellectual faculties, and be resisted by reason and self-control, on each of many occasions of its successive occurrence. At last the patient either may doubt his own powers of control, solicit the interference of his friends, and submit himself to restraint; or he may, at last, be unable to resist the im- pulse. In other cases, crimes have been per- petrated without any fixed object or motive, and the punishment of the law has overtaken the victim of disease. Insane persons may dis- play their states of mental disorder by a pro- pensity to commit every species of mischief, al- though devoid of any feeling of malevolence. A propensity to theft is frequently a feature, and often the characteristic one, of moral insanity. In some, it may be nothing more than eccen- tricity of character, as Dr. Prichard supposes, but it is more commonly associated with other manifestations of mental disorder, when actual- ly amounting to moral insanity, and it is to be viewed in connexion with the individual’s po- sition in society, with his previous habits and character, and with the existence or non-exist- ence of mental derangement in any member of his family. 78. g. Moral Insanity—the Manie raisonnante of Pinel—the Monomanie raisonnante of Esqui- rol—is often manifested, especially, by the singular, absurd, and exceptionable nature of the actions, intentions, and propositions of those affected by it. Persons thus disordered are turbulent, unsociable, and engaged con- stantly in affairs which are blameable, ridicu- lous, and contrary to their former habits, to their real interests, and to the interests of their families. Their moral character is altogether perverted, and they become dangerous chiefly to themselves and to those depending upon them, owing rather to the consequences, than to the nature of the actions which they com- mit. Although engaged or entering upon what compromises their interests and character, or 516 INSANITY—Moral—Erotomania. abandoning the objects of their affection, or quitting their families or affairs, they argue strongly in support of their conduct. While there is a change or total perversion of the habits and affections, there is also sufficient power of intellect to attempt a justification of the sentiments and actions they have espoused. 79. h. Moral insanity has been viewed by M. Esquirol as presenting either an acute or a chronic course ; and he believes that it may be divided into three stages : in the first, the char- acter and habits are changed; in the second, the affections are perverted ; and, in the third, maniacal excitement, or violence of the tem- per or passions, with degradation of the facul- ties, more or less rapidly ensue. It may as- sume a remittent or intermittent course ; and after recovery from it, relapses are very fre- quent. If uncontrolled, it often passes into, or bcomes complicated with one or other, or even with more than one, of the other forms of in- sanity about to be distinguished, and even also with palsy. 80. i. The variety of insanity termed Senile Insanity by Dr. Borrows, as occurring in old age, often assumes the form of moral insanity, but more frequently that of general imbecility. In the former case, it consists in a morbid ex- citement of the passions, and a remarkable per- version of the temper and propensities—in a change in the whole moral character, without any hallucination or false perception, the exist- ence of which would constitute it a different species of mental disorder. 81. A variety of instances, as Dr. Prichard observes, is mentioned by writers, in which the unusual intensity of particular passions or emo- tions has been thought to constitute mental disease, and compound epithets have been ap- plied to these states of the mind and its affec- tions. Nostalgia and erotomania have been con- sidered as disorders of sentiment; satyriasis and mjmphomania, of the physical feelings. The excessive intensity of any passion is dis- order in a moral sense. It may depend, phys- ically, upon certain states of the constitution ; but this does not so clearly constitute madness as the irregular and perverted manifestation of desires and aversions. This form of insan- ity has undoubtedly been the source of moral phenomena of an anomalous and unusual kind, and of certain perversions of natural inclina- tion, which excite the greatest disgust and ab- horrence. Besides these, however, there are others, to which I may also more particularly advert, and which are noticed by M. Esquirol as constituting forms of monomania, under the designation of Monomanie d'lvresse, of M. incen- diaire, and of M. homicide. There may be doubts of the propriety of considering these, or even erotomania, as forms of insanity. But it is difficult, in respect of the mental manifesta- tions, as well as of the bodily functions, to draw the line of demarcation between health and disorder; and there can be no doubt that the excessive excitement of any particular pas- sion, sentiment, or emotion, or the undue pre- dominance of it for an unusually long period, or the uncontrollable impulse or desire to appease or to gratify any appetite, amounts to moral disorder, which becomes the more manifest and indisputable, as it is the more freely indulged. As long as reason restrains the appetites, pas- sions, and emotions within the conventional limits prescribed in society; and is competent to the decided exercise of this sway, moral dis- order cannot be said to exist; but when it loses this salutary influence, and in proportion as it is incompetent to exert such influence, either from the violence of passion, or the weakness of the understanding, the mental disorder is the more evident. 82. a. Erotomania—Monomanie irotique of Es- quirol—is characterized hy an excessive love of some object, real or imaginary.—It is a mental affection in which amorous ideas are as fixed and dominant, as religious ideas are in reli- gious monomania or melancholia. Erotomania is very different from satyriasis and nympho- mania In the latter, the mischief is in the re- productive organs; in the former, it is in the mind. The one is a physical, the other a mor- al disorder. Erotomania is the result of an ex- cited imagination, unrestrained by the powers of the understanding ; satyriasis and nympho- mania proceed from the local irritation of the sexual organs, reacting upon the brain, and ex- citing the passions beyond the restraints of rea- son. In the former, there is neither indecency nor the want of chastity ; in the latter, there is unrestrained expressions of sexual desire and excitement. The one is commonly caused by ungratified or disappointed affection excited in a virtuous mind ; the other, by inordinate irri- tation or indulgence of the sexual passion. 83. In erotomania, the eyes are bright, the manner and expressions tender and passionate, and the actions free, without passing the lim- its of decency. Self and selfish interests are all forgotten in the devotion paid, often in se- cret, to the objects of the mind’s adoration. A state of ecstasy often occurs in the contempla- tion of the perfections which the imagination attaches to the subject of its admiration. The bodily functions languish during this state of moral disorder : the countenance becomes pale and depressed ; the features shrunk ; the body emaciated ; the temper inquiet and irritable; and the mind agitated and despairing. The ideas continually revert to the loved and de- sired object; and opposition, or endeavours to turn them in a different direction, only render them more concentrated and determined in their devotion. At last, parents and fortune are abandoned, social ties broken asunder, and the most painful difficulties are encountered in order to obtain the object of admiration. 84. In some cases, the attempts made by the patient to conceal and to overcome this affec- tion occasion a state of irritative fever, with sadness, depression, loss of appetite, emacia- tion, &c., which has not inappropriately been termed by Lorky Erotic Fever, and which, af- ter continuing an indeterminate period, may even terminate fatally. When a young person becomes sad, absent in mind, pale and emacia- ted, sighs frequently, sheds tears without any obvious reason, is incapable of mental or bodi- ly exertion, scarcely speaks to any one, loses appetite, &c., it is sufficiently evident that the mind is inordinately possessed by some desired object. If a strong effort be not made to dis- possess it of the predominant sentiment, or if the object of desire be not obtained, the sym- toms become still more distressing. The cor- poreal functions languish, the eyes sink, the INSANITY—Moral—Homicidal. 517 pulse becomes weak and irregular, and the nights disturbed and sleepless. At last a form of slow hectic is produced ; and the weaker or- gans, especially the lungs and heart, are the seat of slowly-produced disease; the whole frame is blighted, and the patient sinks from the injurious influence of the mental affection on the vital organs. 85. This form of moral disorder may increase, and affect the intellects in a much more serious manner, until general insanity or mania is de- veloped ; and, with the progress of time, it may at last terminate in dementia or incoherent in- sanity. In each of these, the primary charac- ter of the disorder, or the original moral affec- tion, will still continue to be manifested by the frequent suggestion of the same train of ideas, or recurrence to the object of devotion. 86. /3. The irresistible propensity to intoxication —Monomanie d'lvresse of M. Esquirol—may be viewed as actually constituting a variety of moral insanity, and, indeed, has been thus con- sidered by the able and experienced writer just named. There can be no doubt of early ad- vances of partial as well as of general insanity being sometimes indicated by an irresistible impulse to indulge in intoxicating liquors. And this impulse may be connected with a physical or corporeal feeling, rendering it still more ir- resistible, especially to persons of weak char- acter. In many cases, indeed, the insanity is not so much caused by the intoxication, to which it is so frequently imputed, as the im- pulse to indulge it is a symptom of the incip- ient mental disorder. This is especially the case when a person, previously temperate, sud- denly addicts himself to the use of intoxica- ting liquors, and particularly of ardent spirits. Sometimes, at the commencement of insanity, the state of the stomach, and even of the whole vital organs, is such as to be attended by an irresistible craving for stimulating fluids—by a kind of pica. This craving and the mental im- pulse accompanying it are generally suddenly developed ; and occasionally, after having been appeased and gratified, they do not again re- turn until after some time. Moreover, at this period of the mental disorder, the moral pow- ers are weakened, and the mind altogether en- feebled and incapable of sufficiently resisting the morbid impulse, which is usually also at- tended by ennui, irritability, painful sense of sinking at the epigastrium, and restlessness. The desire to appease this instinctive craving is, at last, imperative. When gratified, the pa- tient becomes violent, maniacal, and danger- ous to himself and to those around him. He continues to swallow the intoxicating fluids as long as he can procure them, or as long as he has the power of doing so, until the paroxysm terminates. As the patient becomes sober, the maniacal turbulence often subsides, but it fre- quently continues for some time afterward, often for many days, with signs of more or less vascular excitement of the brain and its mem- branes ; and, in many cases, when he can re- vert to the means of intoxication as he becomes partially sober, the insane violence is very con- siderably prolonged. At last the paroxysm ter- minates, and the craving for exciting liquors is no longer felt. Instances have even occurred of these liquors being afterward loathed, until another paroxysm took place. M. Esquirol met with a case of mania consequent upon toxication, which was followed by a distaste 01 all fermented and distilled liquors for ten years afterward. Some persons, unable to withstand the impulse to intoxication occasioning fits ol insanity, have solicited the restraint of friends ; and others have committed suicide when they found themselves unable to resist the morbid impulse. 87. This state of moral disorder, while it gives rise to fits of maniacal excitement, often also occasions more permanent mania, and even dementia. The maniacal paroxysms, when thus excited in females, are frequently associ- ated with hysterical symptoms ; and when ma- nia or dementia is consequent upon it, palsy is not an infrequent complication. 88. y. Incendiarism is sometimes an act of par- tial insanity—Monomanie incendiaire of Esquirol —Pyromanie of Marc. {Ann. d’Hygiene, t. x. Paris, 1838).—It is, however, more generally one only of the modes in which an evil or mis- chievous propensity manifests itself, when ex- cited by envy, jealousy, or revenge, in the minds of persons unrestrained by reason and by the laws. Yet instances are recorded by Henke, Esquirol, Marc, and others, of persons being impelled to the commission of this act by an irresistible impulse, which their will was in- capable of overcoming. Most of these cases have occurred in girls and young women, who were either pregnant, or disordered in the ute- rine functions. Several of them presented signs of increased determination of blood to the brain ; and some manifested other signs of insanity, either with or without illusions or false perceptions. M. Esquirol concludes, from the history of cases of this kind, observed in France and Germany, 1st. That mental aliena- tion, whatever may be the character of the de- lirium, determines some insane persons to com- mit incendiarism; and, 2dly. That there is a variety of monomania without delirium (with- out hallucination) characterized by an instinct- ive impression—an uncontrollable impulse—to commit this crime. 89. 6. Homicidal Insanity—Monomanie homi- cide, Esquirol—Fureur maniaque, Fodere— Manie sans Ddire, Pinel.—Murder, or attempts to murder, are made by insane persons, 1st. When impelled by an involuntary impulse, or instinctive desire, which they are unable to re- sist ; 2dly. When actuated by motives on which they are capable of reasoning, and while con- scious of the evil they have committed ; 3dly. When influenced by illusions, hallucinations, or false perceptions ; 4thly. When excited by pas- sion or opposition; 5thly. When they believe that they are opposing an enemy, against whom they should defend themselves; and, 6thly. When the intelligence is so prostrate as to be incapable of distinguishing right and wrong, and when they act from imitation. It is respecting the first and second of these—the former es- pecially—that I now proceed to offer a few re- marks. 90. Persons who appear to enjoy reason, but whose active moral powers—whose affective functions of mind, in the language of French pathologists—are disordered, must, conforma- bly with what I have advanced, be viewed as insane. These persons perceive, compare, rea- son, and judge correctly of matters, but they 518 INSANITY—Moral—Homicidal. are influenced by the least cause, or even with- out any object, to acts of violence. They are irresistibly or instinctively impelled, with a full consciousness of their state, to commit the crime they most hate. They deplore their sit- uation, and give warning to guard against their fury, or to deprive them of the power of com- mitting the dreaded act. 91. But the question has been long since and often proposed, Is there really a form of insan- ity in which a person may enjoy reason unim- paired, and yet commit the greatest of crimes 1 M. Esquirol formerly answered this in the neg- ative ; and stated, that of the partially insane, who appear to enjoy their reason, and to de- plore the determinations by which they are so strongly impelled, all admit that they have felt something internally or mentally at this time, of which they could give no clear account.; that their brains were embarrassed ; that they experienced more or less difficulty—often an inexpressible difficulty—in the exercise of their judgment; and that this was preceded by phys- ical symptoms which they perfectly recollected. One felt a burning heat or a pulsation in the head ; another, a lacerating, or a sharp, or acute sensation rising from the abdomen to the inte- rior of the cranium; a third, a momentary illu- sion or hallucination ; or a fourth was betrayed by an erroneous process of reasoning. One person suddenly becomes red in the face, im- agines he hears a voice addressing him, and acts according to the injunction he believes imposed on him, or to the call addressed to him. A husband is persuaded that his wife is unfaithful to him; and, although every circum- stance is considered by him, and found to mil- itate against the truth of the persuasion, yet, in a moment when the jealous feeling gains the ascendency, an act of murder is committed. The mother of a family believes that her situa- tion is distressing, and that her children will be reduced to mendicity. In a fit of despair she forms the resolution of destroying them, in or- der to preserve them from a calamity which she considers greater than death; but in the mo- ment of her attempting it, maternal tenderness, speaking louder than despair, exclaims, “Pro- tect my children from me !” 92. All these instances may be referred to a momentary delusion or hallucination, under the influence of which crimes or insane actions may be committed, after which a lucid period occurs. But there are other instances which cannot be thus explained, and which do not al- together warrant the conclusion at which M. Esquirol arrived in his earlier work ; and of this he is aware in his more recent production, for he there admits that, although partially in- sane persons are often betrayed by their delir- ium or their hallucinations into the commission of homicide, yet there are others who commit the crime from an instinctive or irresistible im- pulse. In the former class of insane homicides, the understanding is disordered, under the in- fluence of false perception, or of a delusion momentarily entertained, and the insane per- son acts under an error of judgment; but, in the latter class, reasoning and judgment are al- together suspended, and the insane impulse im- pels and directs the will, without any effort of the understanding or of the moral powers to prevent the act. An individual thus affected acts uninfluenced by delirium, or delusion, or emotion, or passion, and almost without con- sciousness, impelled by an instantaneous, blind impulse, independent of the will, and before which reason and judgment are for a moment entirely prostrate. This constitutes the parox- ysm of monomania without delirium of the French writers. Of this affection I have met with three instances. In two of these, howev- er, there was more or less disorde- of the di- gestive organs ; and in the third, a female, the catamenia were disordered ; but there was no other indication besides this of mental aliena- tion. This subject is most important, and is, moreover, very intimately related to suicide, in- asmuch as the morbid impulse to destroy one’s self is similarly manifested, as will be shown in the sequel, and much more frequently than the impulse to destroy another. Yet has it been nearly overlooked by most writers, and especially by those of this country, notwith- standing the growing increase of both crimes, and the evidence furnished, by a careful inqui- ry into their remote causes, of a progressive increase of them being likely to result. Hom- icidal monomania most frequently occurs in persons of a sombre, melancholic, or capricious disposition; but it is also met with in those who are remarkable for the amiability of their tempers and manners. The state of the atmo- sphere, disorder of the digestive and excreting organs, excitement of the nervous system, a vicious education, the reading improper books, and accounts of crimes, suicides, &c., unsound and exalted religious sentiments, the influence of imitation, chagrin and disappointment, want, &c., are chiefly concerned in developing this moral distemper. A very few instances from among many will illustrate this state. 93. The mother of four children was sudden ly seized with the desire of killing them, and flew from her house as the only way of pre venting the commission of the act. A maid, on each occasion of her dressing the infant committed to her care, was seized with an un controllable desire to murder it. A man ex perienced repeated impulses to murder hia wife, to whom he was warmly attached, and was prevented on one occasion from attempting it by an accidental occurrence. He applied to the author for advice, and to be placed under restraint. He was at that time apparently well, and capable of pursuing his usual avoca- tions. A person, after reading the horrible de- tails of a murder, which was circumstantially narrated by the daily and weekly caterers to the most depraved passions of the multitude, was suddenly seized with an impulse to kill his wife. It has been observed in France, in Germany, and in England, that the publicity given to the particulars connected with a mur- der has been followed, within a few days, by several attempts to commit this crime. 94. Although various moral causes combine, in some cases, to predispose the mind to be in- fluenced by the insane impulse to perpetrate this and other crimes, yet it will be found, in most, if not in all instances, that the person thus morally affected is also physically disor- dered, if the examination be made with suffi- cient care, and with the requisite knowledge ol the several manifestations of gradual and in- sidious disease of the brain and of the abdom- INSANITY—Partial Disorder of the Understanding. 519 inal organs. A most attentive examination of the various functions of the brain and of the senses connected with it—of the temperature and circulation of the head—of the functions of those viscera which most readily sympa- thize with the brain, and which so powerfully influence both its actions and its circulation, and even of the appearances of the tongue, and of the several excretions, will generally dis- close more or less disorder in one or more of these quarters, and prove, that although there may not be very obvious disease, there is lurk- ing mischief, either primarily or consecutively, but always most seriously affecting the brain. In the slighter and more incipient states of mor- bid action in this organ, the general and local sensibility and the circulation often betray lit- tle or no disturbance, and, indeed, the whole amount of physical disorder may be so small as to escape the detection of all, excepting the closest observer, who, from experience, will look for it and detect it more readily in the sympathies and in the symptomatic affections of remote parts than in disorders of more close- ly related organs. It is reasonable to infer, that when capillary action in the brain is slight- ly but very generally disordered, and especial- ly when this disorder commences gradually, and almost imperceptibly, and proceeds slowly and insidiously, those manifestations of mind which are of the highest order in the scale of mental development will be the earliest and most seriously deranged ; and that, as the physical disorder proceeds or extends, the oth- er orders of mental operation—the intellectual and the instinctive (see Classification at 66) —will become successively implicated, until the various phases of moral and intellectual in- sanity are passed through, and instinctive in- sanity or fatuity is ultimately reached.* 95. B. Partial Disorder of the Under- standing—Amenomama of Rush—Monomania of Esquirol—is characterized by false percep- tions, illusions, or erroneous convictions referring to one or a few subjects merely, or involving chief- ly a single train of ideas, and so impressing the mind as to partially disorder the judgment. Par- tial insanity of the understanding may exist, 1st. In a more or less simple form ; or, 2dly. As- sociated, or complicated with moral insanity. In- deed, most of the instances in which crimes are committed in the insane state present this latter form. Even the more simple states of monomania of the understanding may be said to be insanity with reference to a small num- ber of subjects, rather than to one subject only, since the number of persons who are insane upon a single subject merely is comparatively few. Most of the cases usually denominated monomaniacal are those which present some predominant idea or hallucination, amid other indications of mental weakness or disorder, as I have already contended ( 167, et seq.), especially to the different forms of paralysis, to epilepsy and convulsions, to apoplexy, and to coma, either of which may terminate life.* 211. c. The development of serious diseases of vital organs seated in either the thoracic or the ab- dominal cavity, and even of the system generally, seems to be favoured by insanity; and it is tc these diseases that a fatal termination is often owing. Many consider the occurrence of these diseases accidental, but they are so frequently observed among the insane, relatively to other classes of persons, that something more than chance is concerned in their production. As I believe that insanity—and particularly certain forms of it—is more or less connected with general debility of the organic nervous system, expressed more especially in the brain, so I consider that the functions, and subsequently the structure, of other important organs will suffer during the continuance of it, particularly if any predisposition to disorder in these organs have already existed. And, accordingly, we find that those viscera most obnoxious to disease, especially in weakened states of vital energy, are the most frequently attacked.— a. Most writers and observing practitioners have re- marked the great number of instances in which the death of insane persons was owing to tu- bercular consumption and inflammations of the pleura. In these cases, the pulmonary disease, has generally proceeded in an insidious or latent form, until shortly before the fatal event has taken place. In many, insanity may be view- ed as inducing a disposition to disease of the lungs, and as favouring the operation of its ex- citing causes, which may be more than usually influential and frequent in their operation du- ring mental disorder. Dr. Greding found that 40 out of 100 maniacs, and 20 out of 25 melan- cholics, laboured under phthisis; and that 74 of 100 maniacs, and 20 out of 24 melancholics, were found to have more or less effusion either in one or both cavities of the thorax. This may be an extreme frequency of these compli- cations, or be owing to local or peculiar causes; but there can be no doubt of their frequency. Insane persons affected by these diseases of the lungs lose their strength, suffer slow or hec- tic fever, become emaciated, and nt last have cough and shortness of breathing, with diar- rhoea. In this state, the insane symptoms rather increase than abate, and generally continue un- til death. In some cases the pulmonary disor- der precedes the mental disorder, or accompa- nies it. Tins is especially the case with mel- ancholia, as remarked by M. Esquirol, and with hypochondriacal monomania. In these, the im- pairment of vital power affects both the lungs and the functions of the brain, and sometimes both nearly simultaneously. * [“ The distinguishing- features of the paralysis peculiar to the insane are, 1st. Defective action of the muscles of locomotion. This, at. first, is generally very slight, amount- ing to nothing more than an instability of gait, or tottering, or, at most, a sudden yielding of the knees beneath the weight of the body, the patient partly falling, but again re- covering himself and pursuing his progress. It afterward increases, and sometimes entirely destroys the ability to stand. “2d. Defective action of the organs of speech. Words are uttered indistinctly, and, at times, so confusedly as not to be understood. It not unfrequently occurs that, in at- tempting to speak a particular word, the patient finds it im- possible to pronounce any portion of it. “3d. Exalted ideas of station, riches, and power. Per- sons affected with the disease generally imagine themselves either as one of the sovereigns of the earth, or as having command of inexhaustible stores of wealth. “ 4th. It is generally, if not always, incurable. “5th. The pathological lesions are, thickening and opa- city of the meninges, with serous effusions between and be- neath them; their adhesion, by cord-like attachments, to the brain; and a degeneration and discoloration of the cin- eritious substance of the latter. “Death comes either very suddenly from cerebral con- gestion or epileptiform convulsions, or lingers long, until, from a generally depraved condition of the secretions, gan- grenous eschars, and sloughing of the flesh from the bones, and sometimes absolute loss of muscular action in nearly all parts of the system, the poor unfortunate patient ap- pears but little more than a motionless mass of corruption. “It is a remarkable fact, that while this affection is so prevalent in France as to have induced Esqijirol to assert that ‘one half of the insane die paralytic,’ it is almost un- known in this country. Dr. Bell, of the M‘Lean Asylum, mentions ‘ twelve or fifteen well-marked cases’ which have been under his care. “ The writer has had seven cases under treatment, nei- ther of which (a fact which is also stated by Dr. Bei.i. in regard to those just mentioned) was cured.”—(Earle, in New-York Jour. Med., Nov., 1845, p. 378.)] INSANITY—Fatal Termination of. 545 212. (3. Diseases of the heart and great vessels are also often concerned in hastening a fatal issue of insanity. M. Foville states that five out of six bodies display, upon examination af- ter death, some organic disease of the heart and great vessels, particularly hypertrophy of the heart. This is most probably owing, in part, as he supposes, to the violent jfforts and agi- tation of insane patients. 213. y. Although diseases of the digestive or- gans frequently exist previously to the appear- ance of insanity, and are often more or less concerned in causing it, yet they often do not become objects of attention until after it has fully declared itself, when, from their nature or severity, they obtrude themselves upon the no- tice. Whether the disorder consist of gastro- intestinal irritation or not at the commence- ment, it frequently passes into it, and at last terminates in ulceration, originating chiefly in the mucous follicles, or in abrasion of portions of the mucous membrane. At the beginning of the mental disorder, and particularly of mel- ancholia and mania, constipation is both obsti- nate and of long continuance, the most drastic or active medicines being required to act upon the bowels. But it generally at last gives way, and is followed by, or alternates with, diarrhoea, which sometimes passes into dysentery, and which rapidly exhausts the strength of the pa- tient without abating the mental disorder. 214. A The cachexia already noticed frequent- ly associates itself with other maladies, in caus- ing a fatal termination of insanity, particularly with disease of the alimentary canal, and en- largement, obstruction, torpor, and congestion of the liver, and even also of the spleen. In many cases, this state of cachexia is evinced by a sallow, lurid, dirty, and scaly state of the skin, and by papular eruptions or discoloured patches. It sometimes proceeds to more ob- vious disease of the fluids and soft solids ; fu- runculi and carbuncles break out in different parts of the body, and sometimes slough exten- sively ; the gums become spongy and sore, and bleed upon the slightest irritation; livid blotches occasionally appear on the lower extremities, and complete scurvy at last supervenes. In other cases, emaciation, occasionally amount- ing to marasmus, a cold and clammy state of the general surface, diarrhoea, and colicky pains in the abdomen, take place, either with or with- out the more obvious indications of scurvy, and the patient sinks from the gradual decay of vi- tal power, and the effects of this decay upon the digestive, the assimilative, and nutritive functions. These cases are most frequently met with in dementia and chronic mania, the mental faculties indicating a failure of the vital manifestations of the brain altogether similar to that of the other important organs of the body. 215. d. There are other maladies of more acci- dental occurrence, which often terminate the life of the lunatic.—These, as well as the most of those just noticed, may be masked by the mental dis- ease, or entirely concealed by it, until they reach a serious or even dangerous form, or they may not be detected until disclosed by a post-mortem examination. The complaints of the patient even are often overlooked and taken for delu- sions. This is especially the case in hypo- chondriacal monomania and melancholia. But the truly observing physician will frequently recognise, in the delusions of the insane, bod- ily disease of a serious nature. Several of the delusions already noticed have been shown to depend upon contingent organic lesion of a vi- tal or important organ. Sufficient proofs of the truth of this have been adduced above (§ 21); and I need not farther allude to this topic than to press the importance of this connexion, and the necessity for carefully ascertaining what connexion may exist between the illusion en- tertained and visceral lesion. Many of the dis- eases which may be viewed as accidental only as respects their occurrence in lunatics, may, in some degree, be owing to the physical state of these individuals, inasmuch as they are more frequently attacked by these diseases, and suf- fer more severely from them than any other class of persons. Fevers and chronic inflam- mations are often met with among them, the former generally assuming a typhoid character, with predominant cerebral affection, and fre- quently terminating fatally ; the latter often giving rise to effusion, and causing death in consequence. 216. e. The diagnosis of visceral diseases in lu- natics is remarkably difficult, owing either to the unfounded complaints made by them under the influence of fancied and erroneous sensa- tions, or to the extent to which the mental dis- order masks the physical disturbance. Many lunatics labour under severe diseases without evincing them by any expression, because ei- ther these diseases do not occasion much suf- fering, or the disturbed state of their minds pre- vents the morbid sensation from being perceiv- ed. In this latter respect, the diseases of lu- natics are more obscure than those of infants, because the latter express their ailments by their cries and attitudes. M. Georget justly remarks, that where we observe a lunatic, who had previously been agitated and furious, be- come morose and taciturn, and, at the same time, lose his appetite, seek repose, and display a suffering and dejected expression, we ought to examine him carefully, for he is attacked with acute disease. The development of symp- toms will soon point out the seat and nature of the malady. But chronic affections are so slow in their approach, and so latent in respect of their symptoms, that they often reach a very advanced stage before their existence is sus- pected, unless a careful examination had been made before, as well as after their commence- ment. This is especially the case in regard of diseases of the lungs, heart, pleura, and of the organs of digestion. From this, it is manifest that insane persons should be carefully watch- ed and examined, and that the states of the lungs and heart should be investigated from time to time by percussion and auscultation. 217. /. The rates of mortality among lunatics have received much attention from M. Esqui- rol and Mr. Farr ; the former of whom states, that the highest rate, for the two sexes, is be- tween the ages of 40 and 50-: that of women is greatest between 50 and 60; that of men be- twen 40 and 50. A greater number of men than women die insane; and this is partly ow- ing to the greater frequency of the more dan- gerous complications in the former than in the latter. M. Esquirol concludes, from a com- parison of different hospitals, the deaths to be, 546 in mania, 1 in 25 ; in monomania, 1 in 16; in melancholia, 1 in 12; and in dementia, 1 in 3. He farther states, that a greater number of deaths take place in December, January, and February than in any other three months. Mr. Fakr states, that the mortality furnished by Bethlem, St. Luke’s, and the asylums at Staf- ford, York, Lincoln, Gloucester, and Hanwell, amounted to 10 40 out of 100 treated ; that the annual mortality among lunatics was 9 per cent.; and that the mean ages of those admit- ted at Bethlem varied from 36 to 39. That no precise idea can be formed, however, from these data, of the mortality of the insane, is evident, from the fact that two of the principal of these institutions do not admit any but recent cases, and that they do not allow these cases to re- main longer than one year. Enough, notwith- standing, is adduced to prove that insanity re- markably shortens the mean duration of life. [At the Massachusetts State Hospital, from 1833 to 1841, inclusive, the mean average age of 99 patients who died was 46-4 years, that of men being 47-2, and that of women 45-6 years. At the Pennsylvania Hospital (Blockley), of 176 patients, in 1841, 48 were more than 50 years old. At the Boston City Asylum, in 1840, of 208, 32 were more than 50, and 2 more than 70 ; and at the Worcester, Massachusetts, Asy- lum, during the first 9 years, of 1359 patients, 268 were more than 50. At the Maine Hospital, 1840 to 1841, of 135 admissions, 6 died, or 4 44 per cent. At the Massachusetts Hospital (Wor- cester), 1833 to 1841, 9 years, of 1359,109 died, or 7 50 per cent, of admissions. At the Ver- mont Hospital, at Brattleborough, 1837 to 1841, 5 years, of 396 admissions, 21 died, or 5 32 per cent. At the Virginia Hospital, at Staunton, 1836 to 1841, 5£ years, of 131, 21 died, or 16 00 per cent. (12, in 1840, by dysentery). At the Ohio Asylum, Columbus, 1839 to 1843, 3 years, of 343 admissions, 36 died, or 10 49 per cent. At the Kentucky Hospital, at Lexington, 1824 to 1840, 16£ years, of 841, 337 died, or 40 65 per cent. (43 of Asiatic cholera). At the M'Clean Asylum, Charlestown, Massachusetts, 1818 to 1834, 16 years, of 1122 admissions, 96 died, or 8- per cent. South Boston, 1839 to 1841, 1$ years, of 153 admitted, 9 died, or 5 88 per cent. Hartford Retreat, Connecticut, 1824 to 1841, 17 years, of 1068 admitted, 69 died, or 6 45 per cent. Pennsylvania Hospital, Philadelphia, 1752 to 1841, 89 years, of 4366 admitted, 610 died, or 13 97 per cent, of admissions (man)' of delirium tremens). Ditto (Blockley), 1841, 1 year, of 176 admitted, 9 died, or 5-11 per cent. Belle- vue, New-York, 1791 to 1821, 30 years, of 1553, 154 died, or 9-91 per cent. Bloomingdale Asy- lum, 1821 to 1841, 21 years, of 2598,240 died, or 9- percent. Frankford, Pennsylvania, 1817to 1841, 25 years, of 784 admitted, 108 died, or 13-77 per cent, of admissions.—(Earle.)] 218. Considerable difference exists in esti- mates formed by writers of the numbers of deaths from the prevailing diseases among lu- natics. Indeed, no precise datewcan be furnish- ed on this point; for those who parade numer- ical data or details in this, as well as in other maladies, by no means satisfy us in what man- ner those details have been obtained. Numer- ical results, unless furnished by the ablest and most discriminating observers, and with the utmost accuracy and good faith, may mislead INSANITY—Fatal Termination of. more than instruct; and this is a subject on which it is next to impossible to furnish them with precision. Besides, the comparative prev- alence of fatal diseases in lunatics will neces- sarily vary in different places, with numerous related circumstances and contingencies.* The diseases, also, of the insane are often so com- plicated that different observers may impute the fatal result to different affections or lesions even in the same cases, although the matter may seem to have been placed beyond dispute by a post-mortem examination. Thus, tubercu- lar formations in the lurtgs and extensive ulcer- ations in the bowels will often be found in the same case; or disease of the liver, lesions in the brain, and inflammation of the peritoneum, or of the pleura, in another ; or changes in the heart, effusions into the cavities, and lesions of some other organ, in a third ; and hence dif- ferent physicians may ascribe death to very dis- tinct organic changes. Some, even, satisfied with the alterations presented by one vital or- gan, may leave other important viscera either entirely unexplored, or insufficiently investiga- ted, although they may be equally, or even more affected. 219. Notwithstanding these objections, it may be conceded that the most fatal maladies among the insane occur nearly in the following order as to frequency: more or less sudden deaths from apoplexy, coma, and convulsions ; pulmonary and pleuritic lesions; nervous, ty- phoid, adynamic, and putro-adynamic fevers, usually with predominant affection of the brain; general palsy; general cachexia, frequently with colliquative diarrhoea ; organic lesions of the liver, bowels, and mesenteric glands, caus- ing marasmus, &c.; exhaustion of vital power without sufficient alteration of structure to ac- count for death; structural change of the heart, &c. ; and dropsical effusions into shut cavities, particularly the pleural and pericardiac ; morti- fication, chiefly of parts pressed upon, and of the extremities ; organic changes in the stom- ach and pylorus ; chronic peritonitis, generally latent; alterations of the uterus, spleen, and pancreas, &c. Organic lesions of the brain, lungs, heart, and digestive organs are found variously associated, in most cases, upon ex- amination after death ; those of one organ pre- dominating over the rest in different cases, and * [We are also to bear in mind the dissimilarity in the na- ture of the institutions for the treatment of the insane ; some, for example, are public establishments under the direction of municipal governments ; others are endowed, and under the care of a board of trustees; others, again, are private in- stitutions. Some receive a large number of cases of delirium tremens, or intemperate persons, while others receive few or none ; some receive paupers exclusively, others pauper and pay patients, while a third receives pay patients alone. At Bliomingdale, no application for admission is rejected, what- ever may be the state or condition of the patient, curable or incurable, in ordinary physical health, or in articulo mor- tis (Report for 1842). At the Hartford and M'Clean asy- lums, no patient is admitted for a less period than three months; whereas, in most institutions, there is no restric- tion in regard to time. All these circumstances must ne- cessarily affect the results both of recoveries and deaths, to say nothing of the influence of locality and of prevailing ep- idemics, or particular types of disease ; to these should be added the length of time the asylums have been in opera- tion, as the mortality during the first few years is found to be much less than in subsequent periods, except in those institutions from which the patients are invariably dis- charged at the end of the year. Much will also depend on the nature of the patients first received. In most instances a very large number of chronic and incurable cases are re- ceived on the first opening of an insane hospital, and the ratio of recent cases increases with the lapse of time.] INSANITY—Fatal Termination of. 547 seldom presenting a due relation to the symp- toms or disorders complained of, or manifested during life. Diseases in the abdominal organs, and particularly in the intestinal mucous sur- face, are among the most frequent morbid as- sociations of insanity, but generally contingent upon it, and not until an advanced period of its progress; although, as will appear in the se- quel, they are also important physical causes of it. M. Esquirol observes, that of upward of 600 examinations after death, three eighths die of diseases of the abdomen, two eighths of diseases of the chest, and three eighths of al- terations of the brain and membranes. The proportion here assigned to the first class of diseases is probably too high, and especially in respect of this country. A very able writer re- marks, that the reports of lunatic asylums partly show' that the corporeal ailments under which the patients languish and die are very often overlooked, and are, consequently, not met by proper treatment; and that these establish- ments are made a kind of show-houses, instead of being hospitals for the complicated diseases which involve the functions of the mind. “ We grant,” he goes on to state, “ that the mental malady may often be but the first sign of that total impairment of the frame which phthisis, or hydrothorax, or scorbutus, or paralysis, or marasmus afterward more plainly declare ; but we suspect there are cases in which, if the life of the patient were preserved through some of the maladies supervening on the mental disor- der, the mind would be found to be restored, and the malady to be critical. With the pres- ent management of lunatic hospitals these con- jectures can neither be verified nor refuted. In many of them medical aid is considered to be nearly superfluous; and in some, we are in- formed that the appointment of physicians in ordinary has been, if not rejected by the gov- ernors, at least subjected to grave debate, as if the county asylum were no more than a supple- mentary county jail.” — (Brit, and For. Med. Rev., No. xiii., p. 30.) [Dr. James Macdonald, late principal of the Bloomingdale Asylum, states (New-York Journ. of Med., vol. i., p. 337), that of 160 insane pa- tients who died in the asylum, the diseases of 117 were as follows: Asthenia, 19; phthisis, 17 ; delirium tremens, 10 ; fever, 9 ; apoplexy, 9 ; epilepsy, 8 ; palsy, 8 ; inflammation and softening of brain, 8 ; inflammation of bowels, 5 ; dysentery, 4 ; suicide, 4; diarrhoea, 3 ; drop- sy, 3; concussion of brain, 2 ; cholera morbus, 2 ; cholera Asiatics, 2; strangulation occur- ring to paralytics while eating, 2 ; abscess of liver, 1 ; lumbar abscess, 1; erysipelas, 1; in- flammation of lungs, 1; starvation, 1; total, 117. The term asthenia, Dr. M. states, is used to designate that state of exhaustion or loss of vital force which follows long continued and excessive mental and nervous excitement, and into which the insane often fall. As shown by the above, more die in this state than by any single disease. If all the diseases of the brain, including apoplexy, palsy, inflammation, &c., be added together, it will be found that a larger number have been destroyed by them than by the diseases of any other system. They amount to 32 in 117 deaths. Of 102 fatal cases at Worcester, Massachu- setts, Dr. Woodward gives the following caus- es : Marasmus, 24 ; epilepsy, 14 ; consump- tion, 9 ; apoplexy, 8 ; suicide, 7 ; disease of the heart, 6 ; cholera morbus, 4; mortification of the limbs, 3 ; ha;morrhage, 3 ; inflammation of the bowels, 2 ; disease of the brain, 2; dropsy, 3 ; diarrhoea, 2; brain fever from intemper- ance, 2 ; dysenteric fever, 2 ; chronic dysen- tery, 2; lung fever, 2 ; old age, 1 ; chronic bronchitis, 1 ; gastric fever, 1; land scurvy, 1; congestive fever, 1; erysipelas, 1; disease of bladder, 1 ; total, 102. The term marasmus, in the above, is probably nearly equivalent to the term asthenia, as employed by Dr. Macdon- ald. Dr. W. remarks, that there is an eryth- ematic inflammation of the brain, attended with a bloodshot eye, a hot skin, rapid pulse, dry tongue, and muttering delirium, which is often mistaken for insanity ; and that if these improper cases were deducted from the list of deaths, it would materially lessen the bills of mortality. Of the 102 deaths, 23 took place* within 20 days after admission; 10 of which were recent, and 13 old cases ; 13 males and 10 females. The above will convey a very cor- rect idea of the causes of death in insanity in other institutions, as well as those above men- tioned. The mean average of age at death, of both sexes, was 46 (males, 47 ; females, 46).— (Ninth Annual Report of State Lunatic Hospital, at Worcester, 1841.)] 220. M. Esquirol gives the following tables of the mortality in insanity, according to the ages: Bic£tre. No. of Men admitted from 1784 to 1794, 2405. Salp6triere. No. of Women admitted from 1804 to 1814, 2804. 20 to 30 25 20 to 30 58 30 to 40 176 30 to 40 83 40 to 60 215 40 to 50 143 50 to 60 134 50 to 60 173 60 to 70 90 60 to 70 123 70 and upward . . 05 OD ►£*■ O' O' 70 and upward . . 210 790 Table of the Mortality at the Salpetriere during 10 Years. No. admitted 1 each Year. s 00 O 3 00 CO o 00 © GO 00 o 00 o> © 00 o* 00 00 ©i QO CO QO 271 46 21 15 8 1 6 2 1 1 1 102 301 — 48 29 16 7 2 4 l — 2 109 292 — — 49 22 9 2 1 4 2 1 90 297 — — — 64 25 3 2 2 4 1 101 252 — — — — 35 23 8 1 3 1 71 299 35 31 7 3 1 81 260 30 22 9 3 64 233 26 20 9 55 301 23 10 33 298 2804 26 26 738 Deaths during this period among those admitted be- fore 1804 52 790 Of 790 deaths at the Salpetriere, from 1804 to 1814,382 occurred in the first year after admis- sion, 227 in the second, and 181 in the seven following years. 221. The table of deaths from insanity, and from the diseases of the brain most nearly alli- ed to insanity (p. 548), is made up from the “ Abstracts of the Causes of Deaths registered in England and Wales from ls£ of July to 31s£ of December, 1837, both inclusive." These abstracts, and the remarks accompanying them, by Mr. Farr, are extremely valuable to medical men. 548 INSANITY—Table of Deaths from, etc. Table of Deaths from Insanity, and from Diseases most nearly allied to it, in England and Wales, from ls< of July to 31s7 of December, 1837, inclusive. Insanity. Delirium Tremens. Cephalitis. Paralysis. Apoplexy. ' Epilepsy. Disease of the Brain. Population Names op Places. Area in Acres. according to the Census of 1831. 1 CD 3 m. H3 o p S a Cb s £ S1 I EL o £ £ 2- § E. H o P B EL O £ £ If 1 3 EL |F S1 3 B. H o £ The Metropolis, and parts of Middlesex, Surrey, and 230 489 64 43 107 91 71 162 44,810 1,594,890 33 39 77 30 4 34 159 135 294 161 176 337 259 Manchester and Salford 37,797 236,935 1 1 2 0 0 0 9 14 23 23 17 40 25 6 31 3 4 7 10 8 18 Liverpool and West Derby 38,060 218,233 8 1 9 0 0 0 7 6 13 22 13 35 34 17 51 6 7 13 2 5 25 41,520 135,581 1 0 1 1 0 1 11 9 20 1 7 8 13 10 23 0 1 1 6 16 9 Birmingham , Part of Middlesex, Hertfordshire, Buckinghamshire, and 2,660 110,914 5 5 10 1 0 1 1 5 3 8 39 8 28 13 27 21 14 60 11 61 25 121 4 11 2 19 5 8 5 17 10 25 30 Bedfordshire Kent, part of Surrey, Sussex, Hampshire, and Berk- 1,323,888 515,893 9 4 13 4 5 21 18 55 107 188 168 356 30 32 62 66 35 101 3,861,100 1,351,236 16 14 30 9 0 9 53 37 90 95 202 1,407,913 373,797 3 3 6 2 0 2 10 6 16 42 44 86 33 37 70 9 12 21 5 3 8 1,691,572 503,118 3 2 5 4 0 4 21 11 32 39 32 71 61 64 125 12 8 20 14 12 26 866,474 304,785 1 1 2 0 0 0 8 5 13 18 30 48 25 30 55 1 6 7 4 4 8 987,087 451,252 5 2 7 3 0 3 17 14 31 22 27 49 42 29 71 8 6 14 17 11 28 928,589 304,315 0 6 6 2 0 2 12 9 21 18 17 35 32 35 67 8 ii 19 8 5 13 Norfolk and Suffolk 2,118,867 682^788 7 15 22 2 0 2 21 15 36 39 63 102 58 59 117 u 9 20 n 14 25 Cambridgeshire, Huntingdonshire, and South Lincoln- shire 1,295,379 311,714 0 0 0 2 0 2 7 8 15 22 13 35 24 22 46 4 9 13 5 7 12 North Lincolnshire, Rutlandshire, Derbyshire, Notting- 0 18 78 143 96 72 168 20 21 41 33 26 59 hamshire, Leicestershire, and Northamptonshire . . Oxfordshire, Gloucestershire, Worcestershire (except 3,936,980 1,045,133 5 7 12 5 5 27 45 65 0 83 146 104 87 191 12 21 33 50 32 82 Dudley), and Warwickshire (except Birmingham) . . Mining parts of Shropshire, Worcestershire, and Stafford- 2,355,452 977,108 13 8 21 4 4 41 33 74 63 140,798 223,457 2 1 3 0 0 0 9 7 16 9 11 20 11 21 32 3 2 5 5 4 9 Cheshire, Shropshire, and Staffordshire (except mining 2,216,515 721,555 8 12 20 3 3 6 26 11 37 45 51 96 64 60 124 13 19 32 14 14 28 Lancashire (except Liverpool and Manchester), south of 0 50 1-08 69 44 113 15 14 29 10 6 16 Morecambe Bay 1,131,270 905,501 9 6 15 1 1 36 22 58 58 West Riding of Yorkshire (except the northern part 0 21 54 40 42 82 12 9 21 18 10 28 thereof, and Leeds) 1,250,530 773,254 4 4 8 4 4 26 27 53 33 City of York, and East Riding of Yorkshire Durham, and the North Riding of Yorkshire, with the 730,945 199,515 0 2 2 2 0 2 8 4 12 10 13 23 34 28 12 21 5 remainder of the West Riding (except the mining 0 12 31 54 41 36 77 ii 9 10 19 2,104,736 319,042 1 2 3 4 4 8 20 23 The mining parts of Northumberland and Durham , , Cumberland and Westmoreland, with the remainder of 88,708 318,941 1 2 3 0 0 0 20 12 32 57 34 91 40 30 70 0 1 i 10 5 15 0 13 22 55 21 47 8 15 1,590,448 338,273 1 0 1 0 0 7 20 33 26 3 4 i 29 3 Wales, Monmouthshire, and Herefordshire ..... 1,016,219 6 1 7 3 1 4 7 6 13 73 72 145 60 39 99 13 16 Area in Sq. England and Wales . Miles. 57,805 13,897,187 147 138 285 86 9 95 567 454 1021 987 1052 2039 1447 1264 27U 278 292 570 43g 326 764 INSANITY—Appearances in the Brain after Death 549 It Is to be hoped that the reports of the regis- ter-general will appear annually. Mr. Farr states, that the insane who die in lunatic asy- lums have often been registered, improperly, under secondary diseases, such as apoplexy and diarrhoea. Under the head of violent deaths are included suicides, accidents, &c. ; and it cannot be doubted that the great majority, at least, if not the whole of suieides, are instances of some form or grade or other of insanity. 222. V. Or the Alterations of Structure connected with Insanity.—It is evident, even from what I have already stated, that few dis- eases are connected with so great a diversity of structural changes as insanity, and there is none which has given rise to so much discus- sion and difference of opinion as to the nature of this connexion as it has occasioned. It has even attached to itself a very particular inter- est at present, owing partly to its importance, and partly to the very opposite views enter- tained respecting it by some of the most expe- rienced of recent writers on mental diseases. But little information was furnished on this subject previously to the almost contempora- neous publication of some cases, with the post- mortem appearances, by Morgagni and Meckel. Ballonius, and, long afterward, Bonet, had fur- nished a few particulars ; but these were rath- er of lesions found in the thorax and abdomen than of changes within the head; and it was not until the investigations of Greding, Mar- shall, and Haslam appeared that the appear- ances of the brain in fatal cases of insanity re- ceived any degree of attention. More recently, the researches of Pinel, Esquirol, Georget, Bayle, Lallemand, Bouillaud, Neumann, Guis- lain, Calmeil, and Foville have been most as- siduously directed to this interesting subject; still, the results furnished by them are of such a kind as to prove the necessity for farther in- vestigation, carried on independently of precon- ceived opinions. Although British writers have hitherto contributed but little to this depart- ment of medical knowledge, it is to .be hoped that those who have the management of public institutions for insanity in their hands will see the advantages which will result contingently even to those connected with themselves—will catch a glance of their own interests prospect- ively—from the encouragement of researches into the pathology and treatment of the most distressing of all maladies, not merely for the benefit of the few subjects of the maladies to whom they are guardians for a time, but also for the instruction of those to whom the com- munity have to look for aid in these calamities, and, consequently, for the advantage of all class- es in society. 223. i. Morbid Appearances observed in the Head.—A. The cranium seldom presents any change from the healthy shape, excepting in epileptic or idiotic lunatics. Greding states that, of 220, only 16 had the forehead contract- ed, the temples compressed, and the occiput large and expanded. In a few, the head was elongated and compressed laterally. In some, the head was almost round, or of a square shape: these were chiefly epileptic lunatics and idiots. I have observed, in this class, one side of the head higher than the other, and sometimes, also, more prominent, while the other side receded, giving rise to the diamond- formed obliquity or deformity of the skull de- scribed by me in the article Ckanium (§ 9). Of 26 cases, including epileptic lunatics and idiots, Greding observed 2 belonging to these latter with very small and quite circular heads. Of the whole number of cases (220), the skull was unusually thick in 167; this was observed in 78 out of 100 cases of mania, and in 22 out of 30- idiots. In some cases the cranium was re- markably thin. Numerous foramina were ob- served in the inner table of 115 out of 216 ca- ses ; and, in some instances, bony projections arose from this table. Similar changes in the cranial bones were noticed by Neumann and Georget, the latter of whom has inferred hy- pertrophy of these bones to be still more fre- quent in lunatics than stated by Greding. The bones of the head have likewise been observed more vascular than natural by Calmeil and others. (See art. Cranium, § 9-12.) 224. B. The membranes of the brain are fre- quently altered.—a. Greding found the dura mater adherent to the cranium in 107 out of 216 cases ; in a few instances, of a bluish black colour, thickened, and containing ossific depos- ites. Similar lesions were observed by M. Georget, who also detected the arachnoid some- times thickened, but smooth, and occasionally presenting, in places, additional lamina of a red or gray colour. The pia mater was, according to this pathologist, injected, thickened, and in- filtrated with serum, giving it at first the ap- pearance of a gelatinous deposite. Greding found it thickened and opaque in 86 out of 100 cases of mania, and beset with small spongy bodies in 92 out of 100; these bodies being united to the surface of the brain, and in some instances containing ossific matter. M. Cal- meil has described these excrescences, granu- lations, or spongy bodies, to arise or grow from the pia mater, so as sometimes to penetrate the dura mater and cause absorption of the inner bony surface of the cranium: and he has re- marked, that infiltrations and thickenings of parts are almost constantly found under these excrescences. The above changes in the mem- branes, and particularly in the arachnoid, have been recorded also by Haslam, by Guislain, and by M. Bayle. To these alterations, and to ef- fusion of serum between the membranes and in the ventricles, this latter physician ascribes the chief phenomena characterizing and contin- gent upon insanity. 225. b. Effusions of serum between the dura and pia mater were observed by Greding in 120 out of 216 cases of insanity, and in 58 out of 100 maniacs; and between the pia mater and surface of the brain, in 28 out of 100 cases of mania. The lateral ventricles were full of serum in 29 instances, and remarkably distend- ed in 23. They were equally distended in 10 among 24 cases of melancholia. The third ventricle was quite full in 57 out of 100 mani- acs, and in 16 out of 24 melancholics. The fourth ventricle was distended to the utmost in 80 out of 100 maniacs, and quite empty only in 3. It was greatly distended in every one of 24 melancholics examined. Dr. Haslam found serum effused between the membranes in 16, and in the lateral ventricles in 18 out of 37 ca- ses. Effusions between the membranes and in the ventricles were met with also by MM. Georget, Guislain, and Bayle, the last of 550 INSANITY—Appearances in the Brain after Death. whom ascribes insanity to inflammatory irrita- tion of the membranes; effusion following upon the inflammation, in his opinion, and occasion- ing the cessation or diminution of maniacal vi- olence, the great loss of power in the intellect- ual faculties, and the commencement of gen- eral paralysis, owing to the pressure caused by the effusion. According to this view, the prog- ress of dementia, fatuity, and general paraly- sis indicates a corresponding increase of effu- sion and of pressure on the brain. Other wri- ters, who differ from M. Bayle as to the origin and seat of insanity and general paralysis in chronic inflammation of the membranes, and of serous effusion from them, readily admit the great frequency of these lesions. Lallemand, Calmeil, Bouillaud, Casauvieilh, and Foville have all described similar changes to the above, but have viewed them more in connexion with alterations in other parts, and estimated them differently. 226. c. The choroid, plexus was found in a healthy state by Greding in 16 eases only out of 216, and thickened and full of hydatids in 96 out of 100 maniacs. M. Georget has remarked that the choroid plexus was exsanguineous, and contained hydatidiform vesicles. The lateral ventricles were, in some instances, very small, but much more frequently large and distended, as just stated, with serum, which was remark- ably clear and limpid. The convolutions of the brain were often observed by M. Georget separated by an effusion of serum, and the pia mater thickened. 227. d. M. Foville states that, in acute ca- ses, the morbid appearances discovered in the meninges were chiefly injection of the pia ma- ter ; and that this injection was generally pro- portioned to the degree of inflammation exist- ing in the cortical substance of the convolu- tions. The small arteries and veins passing from the membrane and penetrating the gray matter were distended with blood: the arach- noid, in these cases, generally retains its natu- ral aspect. The chronic changes in the mem- branes, according to this observer, consist, for the most part, in opacity, increased consistence, thickness of the arachnoid, the formation of granulations and false membranes on its sur- face, and the effusion of serum into the cellular tissue of the pia mater and into the ventricles. The arachnoid is often, in patches or more ex- tensively, of a pearly whiteness. The opacity of this membrane is always attended by thick- ening, and in the place where the arachnoid and pia mater are naturally contiguous, they are found to be adherent. The opaque patches result from the deposition of albumen upon the arachnoid. 228. C. The substance of the brain has been more closely examined in cases of insanity, in recent times, than heretofore. Indeed, the progress that has lately been made in the mi- nute anatomy of this organ will necessarily enable the pathologist to recognise many le- sions of its structure, which were entirely over- looked in former times. The researches of M. Foville into the state of the brain in persons who have died insane are of great importance, and were carried on by him in the Salpetriere, aided by MM. Delaye and Pinel Grandchamp, and subsequently in the extensive hospital of St. Yon, near Rouen, which is under his care. The morbid appearances which I pioceed to describe as having been observed in the brain, are chiefly the results of his investigations. 229. a. The gray substance of the brain pre- sents, in the most acute cases, on the removal of the membranes, intense redness of its sur- face, approaching to that of erysipelas. This is still more marked in the substance of the cin- eritious tissue itself; and it is more striking in the frontal region than in the temporal and lat- eral lobes, and in the higher regions than in the posterir parts. In acute cases of insanity, M. Foville states that the changes in the gray matter consist of uniform and intense redness of colour, with numerous mottled spots, vary- ing from a bright to a violet red, and bloody points or minute extravasations of blood ; of diminished consistence of this structure, coin- cident mostly with a slightly increased consist- ence of its surface; and of dilatation or enlarge- ment of its vessels. He has never observed, in these acute cases, adhesions of the mem- branes to the cortical substance, which are very frequent in chronic cases. To this cir- cumstance he ascribes the curability of recent cases, and the incurability of dementia and chronic cases. 230. In these latter cases the gray or cortical substance becomes much firmer and dense in the superficial part; and this part, owing to its uniformity, constitutes a distinct lamina, smooth externally, but irregular internally ; of a light- er colour than usual, and admitting of being torn or peeled off, leaving the remainder of the gray substance red, soft, and mammillated. Sometimes this pale and dense surface, or part of the cortical substance, is rough and granu- lated, containing small grains of a yellowish white. In conjunction with these, the volume of the convolutions remains natural, or is less- ened or atrophied. When it is the latter, linear depressions or irregular pittings exist on the surface of the convolutions; and in the gray substance itself, small yellowish lacunas, filled with a yellowish serum, are found. These lacunae are supposed to correspond with, or to be the remains of the minute extravasations observed in acute cases. In other instances, the diminution of volume is a real atrophy of the convolutions, which appear thin and angu- lar, as if pinched up towards their extremities. This change is very frequent in the frontal re- gions of the hemispheres, and often particular- ly comprises three or four convolutions in each side of the sagittal suture ; a chasm filled with serum, occupying the place left by the absorbed substance. Coexistent writh this alteration, is often observed a limited atrophy of the crani- um, or a circumscribed disappearance of the diploe, owing to which the external table ap- proaches the inner, leaving a superficial de- pression. In this atrophy of the convolutions the diminution of substance is confined fre- quently to the cortical or gray matter; what remains of it being harder than natural, and sometimes presenting, on close examination, a fibrous structure. It is also of a darker colour, and occasionally seems separable into layers, the exterior being pale, and the interior of a rose colour. 231. Softening of the gray substance is also often observed in chronic cases of insanity, ex- tending through its whole thickness, and not INSANITY—Appearances in the Brain after Death. 551 superficial merely. This softening is generally attended by a greater depth of colour, which often approaches to brown, and is frequently so great as to amount almost to liquefaction of this structure. This extreme and general soft- ening of the cortical substance is not necessa- rily attended by a similar change of the white structure, but is sometimes conjoined with a hardened state of that structure. In these ca- ses the gray may be separated from the white substance by the effusion of water. These more extreme alterations are found, especially in the worst cases of dementia, complicated with paralysis and marasmus. MM. Foville and Calmeil have met with instances of this description, in which limited portions of the gray substance had disappeared previously to death. The gray structure in other parts of the brain does not present the same changes as have now been described as taking place in the convolutions, but generally exhibits altera- tions similar to those of the medullary or white substance. The cortical structure, how'ever, of the cornu ammonis is in some cases soften- ed, and in others hardened. 232. b. The white or fibrous structure of the brain is often found altered in colour, density, and texture. It is frequently injected, and its vessels more or less enlarged, exhibiting nu- merous bloody points on sections of it. In oth- er cases it has a mottled appearance, of a deep red or violet hue, owing, as M. Foville be- lieves, to a finer injection of its vessels, as shown by the magnifying glass. These in- jections of the white structure do not always coincide with similar injections of the gray sub- stance. Sometimes the fibrous or white struc- ture is splendidly white, and generally, at the same time, increased in density, or hardened. This induration occasionally amounts to an al- most fibro-cartilaginous state. In two or three cases I have observed the increase of density nearly to resemble the white kind of caout- chouc. The hardened fibrous structure, how- ever, may not be remarkably white ; it is some- times of a yellowish, or of a grayish or leaden tinge. M. Foville accounts for the induration of this structure by supposing that the cerebral fibres have contracted adhesions to each other, so as to render their separation impossible. According to him, the fibrous mass of the hemispheres consists of several distinct layers or planes of fibres applied one upon the other, and connected by very fine cellular tissue. These planes are easily separable in the healthy state, but become inseparable in the course of mania. The occurrence of tubercles and tu- mours in the brain is considered by him as ac- cidental w’hen met with in cases of insanity. 233. c. The cerebellum undergoes alterations similar to those observed in the brain, but much more rarely. 234. d. The nerves sometimes present chan- ges corresponding with disorders of sensation and perception. M. Foville has found the optic nerves hardened, and otherwise altered in persons troubled with hallucinations of sight. 235. e. The morbid appearances found in cases of insanity complicated with general paralysis have especially engaged the attention of M. Calmeil. In this association of mental and of physical disease, it is very difficult to deter- mine, as Dr. Pkichakd remarks, what altera- tions are connected with either morbid state ; and certainly many of the changes met with by M. Calmeil in these paralytic cases are simi- lar to those regarded by various writers as connected with insanity, without reference to its association with paralysis. This patholo- gist concludes that general paralysis is not de- pendant upon compression of the brain by se- rous effusion, as supposed by M. Bayle, but upon the disease of the encephalon, which gives rise to the effusion, and chiefly on inflamma- tion, of which the thickenings, and lesions, and vascular turgescence of the pia mater, and the peculiar condition of the gray structure, afford sufficient evidence. M. Calmeil has succinct- ly enumerated the changes observed by him in the encephalon, in this class of complicated ca- ses, nearly as follows: Injection and absorp- tion of the bony structure; injections of the dura mater, separation of its fibres; effusion of serum into the cavity of the arachnoid ; false membranes, organized or without organiza- tion ; cysts filled with blood in its two laminae ; simple haemorrhages in the arachnoid ; oedema of the meninges ; injections and thickenings of the membranes ; vegetations of the pia mater, and development of its vessels ; adhesions be- tween the pia mater and the convolutions ; disappearance of the gray substance ; soften- ing, induration, and discoloration of this sub- stance ; hardening and injection of the white or fibrous structure ; redness and tumefaction of the ventricular villosities; serous effusion into the ventricles ; apoplectic cysts ; erosions of the convolutions ; softening of the brain, cr of the spinal marrow. These changes are so various, and so far from uniform in occur- rence, that they cannot satisfactorily explain the results imputed to them. M. Calmeil con- siders them all to be proofs of a chronic in- flammation of the brain ; and in this, as well as in his descriptions of many of the altera- tions, he agrees with M. Foville. This latter writer states that, in lunatics affected with gen- eral paralysis, he found the induration of the fibrous structure of the hemispheres, described above (§ 232), wanting only in two cases, and in these the cerebral nerves, the annular pro- tuberance, and the medulla oblongata presented extreme hardness. He states farther, that this induration of the fibrous structure of the brain has been found in old men whose volun- tary movements have become uncertain or vacillating ; but it has never been seen in luna- tics whose muscular powers had remained un- impaired. I have observed induration of the spinal cord, with effusion of serum between the membranes, and other changes, in two cases of general incomplete paralysis unattended by in- sanity, both patients, however, having become delirious shortly before death. 236. The brain has occasionally been so in- filtrated with serum that the fluid has flowed from the surface of the incisions. This infil- tration has been so remarkable in a few in- stances as to constitute a true oedema of the brain. Much more rarely, as observed both by Esquirol and by myself, a multitude of pores or small cavities, containing a limpid serum, have been found in the substance of the brain, a section of the part thus changed resembling that of a porous cheese. In these cases the brain may be also somewhat indurated and 552 INSANITY—Appearances in the Brain after Death. changed in colour. It is by no means deter- mined, as some suppose, that these pores or cavities are the sequelae of vascular extravasa- tions ; it is more probable that they are the con- sequences of softening, the pores being left by the removal of the molecules of the cerebral substance, which have lost their vital cohesion to the rest of the structure, and filled by a se- rous effusion. 237. /. The inferences which may he drawn from these researches deserve a brief notice. It will be seen from these that M. Foville as- cribes the morbid appearances to inflamma- tion, and in this agrees with Calmeil and others. But it will be remarked by many, and not the less by those who may have read the article Inflammation in this work, that this term has been applied, and possibly is applica- ble, to several lesions, attended by changes in the state of capillary and vascular action, each differing more or less from the other, and ac- companied with different, or even opposite con- ditions of organic nervous or vital power ; and that, although these lesions may be apparently quite similar, and be followed by nearly the same results, in different cases or persons, yet may the state of vital power or manifestation, in respect not only of the functions of the brain, but also of the whole economy, differ remark- ably in each particular instance. It is well known that the lesions constituting, as well as consequent upon several kinds of phlegmasiae —upon phlogosis, or simple sthenic inflamma- tion, and upon erysipelas and other forms of spreading or asthenic phlegmasia—nearly re- semble each other; but they are attended by very different constitutional disorder ; and this is independently of grades of activity or inten- sity of action. Besides, something should be attributed, in many cases, to the influence of the moral causes, and to the consequent men- tal excitement upon the cerebral circulation, with reference not only to prolonged erethism or excitement of the capillaries distributed to the organ of mind, but also to constitutional or vital power, and to the various maladies of which the cerebral affection may be only a symptom, or sympathetic disorder. We know that, in other organs or parts, a prolonged irri- tation or excitement of their capillaries by agents which excite chiefly the nerves supply- ing them, will so determine the blood to them, and so enlarge and develop their vessels, as to give rise to appearances which nearly resem- ble the consequences of inflammation. We find, moreover, that the most violent forms of mania and ot delirium, and the most fatal when not judiciously treated, are actually those in which inflammatory appearances are the least evinced, or in which states opposite to inflam- matory really exist. We find, also, lesions in the brain — whether inflammatory or not — equally extensive with those observed in the most general and complicated cases of insani- ty, and without any disorder of mind having existed during life. Can we, therefore, legiti- mately impute insanity, in all cases, to these lesions 1 or may not these lesions be just as legitimately imputed to the insanity 1 There is very probably a connexion between them in most cases; but neither the exact nature of the connexion, nor the intimate relations and source of the morbid alterations observed, have been yet fully ascertained. This is, however, no reason wherefore we should altogether re- ject the conclusions at which able and expe- rienced observers have arrived, until we ob- tain others upon which more implicit reliance can be placed. 238. The morbid changes in the encephalon, M. Foville infers to be the results of inflam- mation ; intense, diffused, and general redness ; in many cases, tumefaction ; and, in passing to the chronic state, the formation of adhesions between the cortical substance of the convolu- tions and the contiguous membrane : besides this, adhesion of the different planes or layers of the cerebral substance to each other in a certain number of cases. As the different tra- ces of inflammation are more constant in the brain than in the membranes, M. Foville con- cludes that the essential change connected with insanity takes place in the brain, and that alterations of the membranes are only acci- dentally connected with it. Among the mor- bid appearances in the brain, lesions of the gray structure are considered by him as the most constant in connexion with the mental disorder. Although M. Calmeil was inclined to ascribe loss of muscular power to disease of this structure, M. Foville contends that the facts upon which he founds this inference do not warrant this conclusion. In all the cases of general paralysis he has examined, there was, besides the change in the gray structure, some alteration, either hardening, serous in- filtration, or softening of the white or fibrous substance; and in most cases, in addition to these, there were adhesions of the principal planes of the cerebral substance to each other. 239. From the circumstance of the gray sub- stance of 'the hemispheres being found in a state of disorganization or atrophy, in cases where intellect was abolished, and the fibrous structure being natural where muscular power was unaffected, as well as from the fact of le- sions or wasting of this latter structure being observed where voluntary motion was lost or affected, M. Foville infers that the function of the gray structure of the brain is essentially connected with the intellectual operations, and that the office of the white or fibrous part is subservient to muscular action ; and, conse- quently, that, 1st, morbid changes in the for- mer part are directly connected with intellectu- al derangement; and, 2dly, those in the latter portion are connected with disorders of the mo- tive powers. He, however, admits that in some affections of the maniacal class succeed- ing the action of debilitating causes—as in the puerperal state—nothing has been discovered in the brain more striking than its extreme and general paleness ; and that, although some mot- tled appearances of a light red or rose colour are met with, these changes are too slight to be considered as idiopathic. M. Foville is there- fore induced to consider this form of mental disorder to be symptomatic of some deep-seat- ed disease of the uterus or abdomen. But, unfortunately for his argument, of several cases of puerperal mania which I have treated, I have not met with one that did present any serious or deep-seated disease in these parts. There can be little doubt, however, that the contradic- tory evidence given by different observers of the appearances of the brain in cases of insan- INSANITY—Appearances in the Brain after Death. 553 ity is partly accounted for, as remarked by an able writer, by the existence of cases in which the affection of the brain is merely functional and sympathetic, the primary disease being in some other organ, especially in some of the ab- dominal viscera. 240. The evidence of those who believe that insanity, although often connected with organic lesions of the brain, especially in protracted and extreme cases, does not necessarily depend upon them, requires some notice. Here the experience of M. Esquirol attaches to itself great importance. He remarks, that the bodies of lunatics offer numerous varieties as to the situation, number, and kind of morbid appear- ances, and that the lesions of the encephalon are neither in relation to the disorders of the mind, nor to the maladies complicated with it. Some lunatics, whose mental and bodily dis- ease indicated extensive organic lesions, have presented slight changes in the brain ; while others, whose symptoms had been less severe, have been subjects of great and numerous al- terations. But even in the most protracted cases of insanity no organic changes whatever have been traced, either in the brain or in its membranes. He goes on to state, “ that path- ological anatomy is yet silent as to the seat of madness, and that it has not yet been demon- strated what is the precise alteration in the en- cephalon which gives rise to this disease.” The various states of the brain, compatible with in- tegrity of the mental faculties, have never been satisfactorily investigated, and probably will never be accurately ascertained; and it is by no means easy to distinguish with sufficient precision the appearances resulting from or belonging to concomitant maladies from those which belong to the mental affection. M. Es- quirol observes, that organic lesions of the brain are declared by symptoms distinct from the mental disorder ; that chronic inflammation produces compression and paralysis, and pa- ralysis results from cerebral haemorrhage ; and that tubercles, tumours, and softening of the brain have their peculiar symptoms, which can- not be confounded with mental alienation. Moreover, the sudden and instantaneous relief experienced in some cases of madness is not to be forgotten; nor the fact that every part of the brain has been found altered, suppurated, destroyed, without chronic lesion of the under- standing. 241. The maniacal form of insanity is rarely fatal, owing to any lesion of the brain ; but from fever, phthisis, and other associated mal- adies, or from sudden exhaustion of the sensi- bility or nervous power necessary to life. In a case which terminated in this latter manner, no lesion was observed in the brain after death; and in a young woman, accidentally killed in recent and furious mania, the brain and its membranes were likewise devoid of change. When a case is watched during life, M. Esqui- rol thinks that the period at which the organic lesion of the brain commences may be known by the symptoms. When mania has existed long, he is of opinion that the weakness of the last days of life disposes to local inflammations. Upon the whole, he concludes that, notwith- standing the labours of MM. Foville, Calmeil, Bayle, and Guislain, the organic reason of mental derangement is still undeclared. “ Thir- ty years ago,” he adds, “I should have writ- ten willingly on the pathological cause of in- sanity : I will not now attempt so difficult a labour—such are the uncertainty and contra- dictions in the results of the examination ot the bodies of lunatics after death up to this day. But modern researches permit us to hope for more positive, clear, and satisfactory no- tions.” In another place, he admits that a dif- ference in the results of researches may arise from the greater care with which the brain is now dissected, and the slightest changes ob- served, and that, at earlier periods of the in- vestigation into the pathological anatomy ot insanity, an account was kept only of obvious alterations. 242. Respecting this matter, M. Guislain appears to steer a middle course in his more recent work on Insanity. After various details, he concludes that, in the greatest number of organic lesions of the brain, a moral origin and functional state of disorder, without alteration of structure, first exists ; and that, when such alterations are present, they consist chiefly of whatever causes pressure of the brain, as effu- sion of serum, or of blood, lymph, or the for- mation of a false membrane ; or of constriction of the organ by its membranes, which, in their state of engorgement, incarcerate or strangu- late, in some respects, the hemispheres ; or of softening or other disorganization, to an extent that is incompatible with the due exercise of the mental manifestations. He adds, that in- duration of the brain has been often observed by him, especially in the parieties of the lateral ventricles, and in the rachidian bulb, or upper portion of the medulla oblongata; that epilep- tic convulsions frequently attend it; that con- vulsions are often also caused by organic le- sions of the membranes, and of the cineritious structure, but not constantly either by these, or by induration ; and that they ffiay occur even without any visible change of tissue. He con- cludes, that absence of organic alterations of the brain is indicated by the full possession of muscular action and motion, and that the ex- istence of them is evinced by lesion of muscu- lar motion and of sensibility—that simple disor- der or excitement of the mental faculties, with- out dementia or palsy, exists independently of softening or compression of the brain ; and that dementia or extinction of the intellectual pow- ers may depend, 1st. Upon sanguineous en- gorgement of the brain ; 2dly. Upon effusion of serum between the membranes or in the ven- tricles ; 3dly. Upon extravasation of blood be- tween the membranes or in the substance of the brain ; 4thly. Upon softening of this organ ; 5thly. On atrophy of it; 6thly. On induration of it ; and, 7thly. Upon exhaustion of its vital influence. 243. ii. Alterations in the Thoracic Yis- cera.—A. The lungs are diseased in a very large proportion of the cases of insanity which terminate fatally. The proportion has been differently estimated by the writers already no- ticed. M. Georget declares that he has found organic changes in the lungs in at least three fourths of the cases which he had examined, and phthisis to have been the cause of death in more than half the lunatics in Salpetriere. He describes the pulmonary disease as always chronic, and often so obscure as not to be de- 554 INSANITY—Alterations in the Abdominal Viscera. tected until the body is inspected. In these cases, the patient neither coughs nor expecto- rates, and he makes no complaint: he wastes, gets weak ; looseness or constipation succeeds; he dies : these changes take place slowly. Yet, notwithstanding the absence of cough and ex- pectoration, excavations are found in the lungs after death. But instances of latent phthisis occur independently of insanity. When, how- ever, both maladies are associated, the latter is more frequently sympathetic, or dependant upon the constitutional disturbance caused by the pulmonary disease, than is generally sup- posed ; and it then sometimes does not appear until the softened and absorbed tubercular mat- ter has contaminated the circulation, and there- by disturbed the functions of the brain. I have observed in persons predisposed to insanity, as well as in others, that, when tubercles are de- veloped in the lungs, and when softening and ulceration follow without any communication having been made with a bronchus, the prog- ress of the disease is generally latent. The tubercular softened matter undergoes changes during its retention ; causes thickening or con- densation of the parietes of the cavity contain- ing it, even while the cavity continues to en- large, and, if it be not evacuated by the bron- chi, neither cough nor expectoration will be present. But the constitutional disturbance caused by the accumulated matter, as well as by the organic lesion of the part containing it, and still more by the absorption of a portion of it into the circulation, will so disturb the or- ganic nervous functions, as to occasion, first, functional disorder, and consecutively even or- ganic lesion of such organs as may be most prone to disease from either an original or an acquired predisposition. 244. B. The heart is often changed in struc- ture in fatal cases of lunacy. Indeed, all the lesions of which this organ is susceptible have oeen found in the bodies of the insane; but hypertrophy, passive dilatation, and softening of the parietes of the cavities, seem to be the most frequent. The proportion of cases in which organic alterations of the heart have been found has been differently estimated by writers. Romberg (Nasse’s Archiv. f. Med. Erfahr., 1817) believed that five out of seven bodies present lesions of this organ; and M. Foville considered that five out of six dis- play alterations either of it or of the great ves- sels. 245. iii. Alterations in the Abdominal Vis- cera.—A. The digestive mucous surface very frequently presents evidence of inflammatory action, especially as respects certain of the con- sequences of this state. M. S. Pinel met with inflammatory appearances in this situation in 51 out of 269 bodies of lunatics ; and of these there were only 13 of disease of the other ab- dominal viscera. These appearances have been also observed in a number of cases by Prost, Percival, and Guislain. The frequency of displacements of the colon, first insisted upon by Esquirol, and especially with reference to melancholia, has already been attended to (§ 119); and has been remarked also by Bergman, Muller, Annesley, and Guislain. In most of the cases described by Esquirol, the displa- ced colon presented none of the consequences of inflammation. In some of the instances ob- served by Percival and Bergman, the colon was contracted, or more or less reduced in cal- iber through a great part of its length; in oth- ers, it was in parts dilated and contracted, as well as displaced. M. Guislain attributes both the displacement and the contractions to in- flammatory action ; the latter most probably arises from this cause ; but the former cannot always thus be accounted for. From the few instances which I have had an opportunity of observing, and from the history of many oi those which I have seen recorded, it seems probable that most of the changes observed in the colon have been consequent upon asthenic inflammatory irritation, with diarrhcea, and oc- casionally with a dysenteric or an irregular ac- tion of the bowels, which had existed at some time or other during the course of the mental disorder, and especially at a late period of its progress. Dr. Percival (Dublin Hospital Rep., vol. i., p. 144) observes, “that, on the dissec- tion of cases of insanity which have terminated fatally from chronic diarrhoea, the intestines generally exhibit an extensive mass of disease. The mucous membrane is inflamed, thickened, and partially eroded, and the area of the canal diminished, often considerably, in the lower in- testines.” The mesenteric glands are often found more or less enlarged and indurated. In addition to these changes, hemorrhoidal tu- mours and fistula in ano are not rarely met with in dissections. 246. B. Although much importance was for- merly attached to disorders of the liver in caus- ing insanity, yet the researches of recent writers do not tend to confirm the frequency of this connexion. Esquirol, S. Pinel, Guis- lain, and Foville found comparatively few cases which presented organic changes in the liver and biliary apparatus. It is probable that lesions of the liver, in connexion with insanity, are more frequent in this country than in France, when we consider the influence of the abuse of ardent spirits in causing both insanity and liver diseases. In a case attended by Dr. Suther- land and myself, at the time of writing this, the liver is greatly enlarged The frequency, indeed, of biliary disorder in the insane cannot be doubted ; and the occasional association of organic lesions of the biliary organs with men- tal disorder will be allowed. The chief doubt, in cases where these organs present altera- tions, will be as to the nature of the connexion ; for it will be admitted that disease of the liver will sometimes affect the functions of the brain sympathetically, and that disease of the brain will exert a similar sympathetic influence upon the functions of the liver; and hence the pri- ority of affection of either of these organs will not readily be ascertained. 247. C. Alterations of the gall-bladder, cal- culi in this viscus or in the hepatic ducts, le- sions of the peritoneum and omentum, of the mesentery and mesenteric glands, of the pancreas and spleen, of the kidneys, and of the uterus and ovaria, have been severally found in the bodies of the insane, by Bonet, Schulze, Marcard, Oberteuffer, Piderit, Jones, Percival, Pow- ell, Stark, and others ; but these have proba- bly been accidental lesions, although they may, in a few instances, have had some influence in causing mental disorder, particularly in persons otherwise disposed to it, by affecting the or- INSANITY—Predisposing Causes. 555 ganic nervous energy in general, and especially that portion actuating the brain. 248. VI. Causes of Insanity.—Few sub- jects are of greater importance than a just rec- ognition of the numerous causes of insanity— of their individual and combined modes of op- eration—of the influence they exert in various forms of succession—and of the progressive changes they induce before the effect upon the mind is fully developed. And the importance of the matter is not limited to its bearing upon the treatment of the malady, but is even still greater in respect of prophylactic measures, and of rational plans of mental hygiene. In discussing this subject, I shall consider, first, the predisposing causes, or the numerous cir- cumstances which render the mind*more sus- ceptible of or prone to disorder than in its natural and healthy state; and, secondly, those causes which more immediately produce or ex- cite the disorder. And it must not be over- looked, that while the individual influences comprised under the former class are often va- riously associated in creating a susceptibility or proneness to mental disorder, the occasions or causes belonging to the latter class frequent- ly act, also, in conjunction, or in immediate succession. 249. i. The Predisposing Causes are the most important objects of study, particularly in respect of their bearing upon hygienic and proph- ylactic measures. The prevention of so ter- rible an infliction as insanity is, must be even of more importance than its cure, since the person who has once been insane seldom whol- ly regains his former social position, but is re- garded with more or less suspicion, and a union with him is avoided by prudent families. The discussion of this class of causes assumes, moreover, increasing interest and importance, when we consider that many of the circumstan- ces comprised by it are of more frequent occur- rence now’ than formerly, and are more influ- ential in exhausting, weakening, and dissipa- ting the mental powers in the present state of society than in former epochs of civilization; and that several of them may be even viewed as altogether arising out of existing social re- lations. 250. A. Constitutional predisposition is among the most predisposing causes of insanity. It may arise, first, from a certain conformation, temperament, or physical and mental constitu- tion, derived from the parents; or, secondly, from an original predisposition or conforma- tion, independently of disease in any of the pa- rents ; or, thirdly, from a state of constitution gradually acquired, or arising out of the contin- ued operation of causes which deteriorate or otherwise change the organic nervous and vital powers, and consecutively the digestive, assim- ilative, and effective functions. In the first of these modes the predisposition is transmitted from the parents; in the second and third, it is generated dc novo, and subsequently admits of transmission to the offspring, although not so certainly as in the first case. 251. a. Hereditary predisposition.—M. Esqui- rol states—and the circumstance is confirmed by the observation of others—that persons born before their parents had become insane are less liable to mental disorder than those born after it has manifested itself; and he farther ob- serves, that the morbid tendency, or the actual disease, where it is transmitted hereditarily, is apt to show itself in different individuals of a family at a particular period of life. Instances illustrative of this latter circumstance have been adduced by him, and by Dr. Burrows, MM. Falret, Georget, and others. The he- reditary predisposition to insanity, M. Esquirol observes, is not more surprising than the pre- dispositions to gout, phthisis, or other diseases. It may be traced from infancy ; and it even ex- plains a number of caprices and irregularities which, at a very early period, ought to put pa- rents on their guard against the approach of in- sanity, and to guide them in the education of their children. In such cases, the education should tend to render the body robust, and to give tone to the nervous system. The consti- tution of the offspring should be changed as much as possible, by placing them in circum- stances different from those which surround them, or which have influenced the constitu- tions of the parents. 252. In some instances one particular form of insanity is transmitted ; either dementia, mania, melancholia, or states of mental disor- der followed by suicide, being thus observed in the same family. The particular variety of insanity evidently depends upon the tempera- ment, which, with the predisposition to this dis- ease, is derived from the parents. Not only the same form of mental disorder, but also the same physical disease complicating it, or ter- minating it, are apt to appear in the same fam- ily, more generally, or even exclusively; yet there are frequent exceptions to this rule. Where an hereditary disposition exists, differ- ent grades of the disorder, rather than different forms of it, are commonly observed—in one, merely various eccentricities ; in another, par- tial disorder of the moral powers; in a third, disorder of the understanding ; and, in a fourth, mania, dementia, &c. In families, also, in which insanity is hereditary, there is occasion- ally observed a greater tendency to diseases of the nervous system than in other families, as, to epilepsy, chorea, convulsions, palsy, &c. Dr. Prichard justly believes that a constitutional tendency existing hereditarily, or arising in the other modes about to be pointed out, is more important, in respect of the frequent occurrence of insanity, than all the other causes taken to- gether. It cannot be said, with propriety, alone to give rise to mental disease, without any ex- citing occasion ; but, if it be very strong, men- tal disorder will follow the operation of ordina- ry or very slight causes. 253. Dr. Burrows remarks, that Esquirol assigns only 152, out of 264 cases, in his pri- vate practice, to this cause, but that an hered- itary predisposition existed in six sevenths of the whole of his own patients. The most ex- empt from this taint were those whose mental disorder had a sympathetic origin ; as in puer- peral mania. Out of 57 cases of this latter af- fection, he could trace an hereditary taint in only about one half; but where it existed, the disorder was more apt to return. Dr. Burrows considers that this cause is more common in the higher than in the lower classes, as the former most frequently marry in their own rank, or even in their own families; and that wherever the system of clanship, or family con- 556 INSANITY—Predisposing Causes. nexion, has been most strictly preserved, there it most prevails. Examples of this are said to have been numerous in the old Highland fami- lies of Scotland ; and Boethius mentions some very stringent measures which they adopted to preserve from hereditary maladies, or, rather, to prevent the procreation of those who might be tainted by them. That hereditary influence is less common in the lower classes than in the higher, is shown by Sir W. Ellis’s report of the Middlesex Lunatic Asylum. There only 214 cases, in which the disease was inherited, were ascertained, out of 1380 patients admit- ted ; and for 125 of these eases no other cause of the malady than this could be assigned. It has been supposed that numerous instances of insanity occur among the Jews, from the cir- cumstance of their having kept themselves more free than all other races, and for a longer time, from intermarriage with strangers. I be- lieve that mental disorders are frequent among them; but other causes may contribute to the frequtency. Dr. Burrows states that the young- est insane patients he ever had belonged to a family of this race, and that in it he has ob- served the father and mother and six of their children insane. He farther remarks, that in- sanity is very prevalent among Quakers, who usually intermarry in their own fraternity. 254. It may be presumed that when an he- reditary predisposition to insanity exists in both sides of a family, the risk to the offspring will be much greater than where it is in one side only ; and that when this latter is the case, the child who bears a very marked resemblance, in constitution and mental character, to the parent exempt from hereditary taint will be most likely to escape the mental disorder; and the hereditary disposition will fail of being per- petuated by him, unless re-enforced by a similar taint, by marriage. But the child that most resembles the tainted parent will be the most liable to experience, and to propagate, the men- tal malady. 255. There are two points respecting which opinions are often required from physicians, namely, whether or not a person born of parents who have never themselves been insane, but who, one or the other, is descended from a family thus afflicted, may propagate the malady to his offspring! and whether or not a child born before insanity had appeared in either pa- rent is as liable to become insane as one born after the malady was developed! The first question, Dr. Burrows believes, should be an- swered in the affirmative, because he has met with insane persons neither of whose immedi- ate parents had themselves been insane, but some of the progenitors, or an uncle or aunt, on one side or other, had been so afflicted. I have known cases where the nearest progeni- tors to the patients, who had been disordered in mind, were grand-aunts or grand-uncles. The second question has been partly answered above ($ 251) by M. Esquirol. But Dr. Burrows considers that a child born, either before or after the accession of insanity in the parent, provided that parent’s progenitors or relations of blood had been insane, is liable to the mala- dy ; but that, if the insanity of the parent were adventitious, and not hereditary, the child born before mental disorder had appeared will not have it by inheritance: how far a child born after the occurrence of adventitious insanity is liable to mental disorder, is decided with dif- ficulty. This writer believes that, whether it be adventitious or hereditary, once occurring, the morbid diathesis is thereby stamped, or generated. 256. b. The offspring may possess a connate predisposition to insanity, although neither of the parents, nor of the grandparents, nor any member of their families, had been the subject of it. Burton long since remarked, upon the authority of the older medical writers, that the offspring procreated of parents when they were far advanced in age are more subject than others to melancholy madness. There can be no doubt,*that whatever produces enervation or debility in the parents will occasion a cer- tain amount of predisposition in their children to nervous affections and to mental disorder; and I believe that habitual drunkenness, or the abuse of spirituous liquors, by either parent, and especially by the mother, during gestation and lactation, causes numerous diseases in the off- spring, and more particularly disorders of the functions of the brain and nervous system in general. It also is very probable that the chil- dren of persons who have been weakened by premature or unnatural sexual indulgences and vices, or who are gouty, hypochondriacal, hys- terical, or otherwise debilitated, will be more susceptible of the operation of the exciting causes than the offspring of those who are con- stitutionally robust and healthy. M. Esquirol affirms, that many facts have been observed by him proving that a strong predisposition to madness has arisen from fright or terror sus- tained by the mother during pregnancy, and that marked cases of this kind occurred during the French revolutions. 257. It has been long and generally supposed that marriages within a confined circle, as be- tween cousin-germans, have the effect of im- pairing both the mental and constitutional pow- ers of the offspring. The opinion seems well founded, and is undoubtedly just, if the breed- ing in-and-in be continued for two or more gen- erations. The children of such families often die in infancy or early youth; are frequently scrofulous, and are liable to hydrocephalic and convulsive diseases ; and, if they grow up, are frail in body and imbecile in mind, or predis- posed to mental disorder. It is doubtful how far the scrofulous diathesis may dispose to in- sanity, but I believe that it has a very consid- erable influence. 258. c. That there may be not only, 1st, an hereditary, and, 2dly, a connate, but, also, 3dly, an acquired predisposition of constitution to in- sanity, I firmly believe. This last state is quite independent of the two former, and of temper- ament or diathesis, and is generally the result of the operation of debilitating causes during infancy, childhood, and the periods of puberty and early adult age. Indeed, many of the mor- al and physical exciting causes may have this effect when acting in a slight but continued or constant manner. But there can be no doubt that early indulgences ; a tender, sensual, and luxurious education ; vicious modes of early in- struction ; masturbation, and premature or vi- cious sexual indulgences; exhausting pleasures, and inordinate mental and physical excitements, relatively to the states of nervous and constitu- INSANITY—Predisposing Causes. 557 tional energy; and various other causes, which debilitate the frame, increase the general sen- sibility, and augment the susceptibility of the brain and nervous system, will often develop, to a greater or less extent, a predisposition to insanity, which may be appropriately termed acquired. 259. It has generally been supposed, and po- ets have sung, that a great genius is closely allied to insanity. This is most erroneous. Persons with a too active and ill-regulated im- agination are predisposed to mental disorder ; but those who possess powerful intellects, and a vast range of powers and of intelligence, are much less disposed to it than others; and if they have become insane, the causes have been of an energetic kind, and overwhelming from their activity or association. 260. B. Temperaments, &c.—Persons of the melancholic temperament are more liable to the melancholic states of insanity than others; those of the nervous temperament, to mania, dementia, and monomania; and those of the sanguine, or sanguineo- nervous, or irritable temperaments, are attacked more frequently with mania than with any other form of men- tal disorder. M. Esquirol observes that, when persons of the lymphatic or phlegmatic temper- aments, or of a pale, exsanguineous habit of body, are affected with mania or monomania, dementia or incoherency is more liable to su- pervene in them than in others. This form of insanity is also likely to follow in persons of a full habit of body, with a thick head and short neck. Mental disease pursues a somewhat dif- ferent course in persons of different tempera- ments. Choleric or warm constitutions, or those with black hair and eyes, and vigorous frames, become violently maniacal, but experi- ence a shorter disorder, and more frequently terminating in a marked crisis than others. In- dividuals of a fair, pale complexion, with light hair, fall more readily into chronic mental dis- ease ; the dark-haired are liable to become gloomy monomaniacs ; red-haired lunatics are disposed to violence, and are treacherous and dangerous. He gives the following table of the general appearances of a number of lunatics : tion of upward of 500 heads in the collection of M. Esquirol. One half of these presented no- thing remarkable, being regular and well form- ed. The other half were more or less peculiar in the form and appearance of the skull, and in the thickness, density, and organization of the bones composing it. Some skulls were une- qually developed, one side being more arched and larger than the other, especially the right. Others were somewhat oblique, one side of the head being too forward, and the other much be- hind. I have seen instances where these two malformations were conjoined. M. Georget found some skulls in this large collection,1'in which the antero-posterior diameter was not more extended than the lateral: in these, the cavity was much elevated, especially in the pos- terior part. The cavities of the base of the skull presented likewise inequalities : those of one side were sometimes larger than those of the other. Persons who have contracted heads, particularly as now described, not only are more liable to insanity than those whose heads are well formed, but lapse more readily into a state of dementia or fatuity, and are consequently less curable than others. It is chiefly in these hopeless forms of general insanity that these irregularities of the form of the head are ob- served. In idiots, as I shall show hereafter, these malformations are still more remarkable. 262. D. Sex.—The ancients, and especially (Lelius Aurelianus, supposed that insanity oc- curred more frequently in males than in fe- males. Recent investigations, however, have shown this not to be generally the case in mod- ern times. Dr. Prichard quotes M. Esquirol as stating the proportion of insane females in France, to insane males, to be 14 to 11. M. Voisin considers the proportion as 13 to 10. In all Italy, the proportion is different, it being about 5-65 males to 5 00 females. M. Guis- lain states, that in Holland and Belgium the number of lunatic females to males is as 34 to 29. Dr. Prichard assigns the proportion in Great Britain and Ireland, of male to female lunatics, as 13 to 12 ; and observes that, in Eng- land, the number of insane men, compared with that of women, is more considerable than in Scotland and Ireland ; and this excess on the side of the males is greater, according to Dr. Burrows, in the higher than in the lower classes of society. M. Esquirol confirms this observation in respect of France ; and farther states that, in the North of Europe—in Ger- many, Denmark, Norway, and Russia—the pro- portion of male to female lunatics is as 3 to 2. Dr. Jacobi furnishes nearly the same results in regard of Prussia. In the United States of North America, the number of insane males is stated to be much greater than that of female lunatics. In the States of New-York, Penn- sylvania, and Connecticut, the proportion of the former to the latter is nearly 2 to 1. In summing up the results of his inquiries obtain- ed from various parts of the civilized world, M. Esquirol finds that the general proportion of insane males to females is about 37 to 38.* 263. The occurrence of insanity among fe- males is partly owing to the nature and vices External habit of j ' Of the medium fulness of habit J Thin or emaciated . 122 body . . . . ( [Fat Height . . . 1 Tall j Short ♦ r Chestnut or brown The eyes . . . • ? Blue and light . 98 t Black | ■ Chestnut The hair . . . < ) Fair or flaxen ...... i Gray or white (aged) .... 1 ' Black 261. C. The form of the head in lunatics has at- tracted the attention of Greding, Pinel, Geor- get, Gall, Spurzheim, and others. M. Pinel believed that there are certain peculiarities in the shape of the skull, frequently observed in the insane, and particularly in cases of demen- tia and idiotcy. The two most prevalent forms which he specifies, are, 1st, a laterally com- pressed shape of the head, giving a very long diameter from the occiput to the forehead; 2dly, a short and almost spheroidal form—the above diameter being shorter than usual. He could not, however, detect any mental condi- tions corresponding with these opposite shapes. M. Georget states the result of the examina- * [From 1821 to 1836 inclusive, there were admitted into the Blooming-dale Asylum, New-York, 1346 males, and 691 females ; at Worcester, from 1833 to 1841, there were 710 males admitted, and 649 females.] 558 INSANITY—Predisposing Causes. of their education ; to their greater sensibility and keener feelings ; to the restraints imposed upon their desires and emotions ; to the cross- es, chagrins, and disappointments to which they are liable ; to reading romances and novels, and thereby exciting the imagination, without improving the reasoning powers ; to the addic- tion to music, and the want of salutary and in- vigorating occupations ; and to the life of cel- ibacy they are often doomed to lead. These, and various other moral causes about to be no- ticed, contribute remarkably to the production of insanity among females. 264. The physical causes also operate ener- getically in producing insanity among this sex; but they are chiefly disorders of the sexual or- gans. Irritation of the uterus, or of the nerves supplying it, and its appendages ; suppression, retention, or inordinate flow of the menses; and various organic lesions of these parts, have a very marked influence, sympathetically, upon the functions of the brain. Many of the moral causes, and emotions of mind, have but little influence, until they have first disordered the functions of the womb ; and as soon as this or- gan is disordered, it reacts upon the brain, and heightens the effects of the moral emotions. In such cases, as well as in many others com- mon to both sexes, the moral causes are often insufficient to induce the mental disorder, until they have first occasioned physical disturbance in some organ ; which disturbance, from its sympathetic influence upon the brain, becomes an additional cause of the disorder. Females, however, are often so circumstanced as to ex- perience very serious disorder of the circulation of the brain, from energetic mental emotions occasioning an immediate effect upon the man- ifestations of thi-s organ, before any disorder can appear elsewhere ; and in some cases the consequent disorder is produced almost sim- ultaneously in both the brain and the functions or state of the uterus. We observe this espe- cially in the puerperal states, and, still more particularly, soon after delivery. 265. M. Esquirol remarks, that females be- come insane at an earlier period of life, are more liable to lapse into dementia, and are more disposed to religious insanity and to erotic delirium than males ; and that all varieties of in- sanity, in them, are generally complicated with hysteria. Males, on the other hand, are more liable to mania and violence ; they are more dangerous, and more difficult to restrain : wom- en are more noisy; cry, and talk more ; are more dissembling, and less readily confide in those about them. 266. E. Age.—-Insanity, in the forms which have been described, is rarely observed before the age of puberty. Imbecility and idiotism are always observed in childhood ; but the instan- ces in which any form of true insanity has oc- curred at any epoch before puberty are very few. They have, however, been recorded by J. Frank, Dr. Haslam, M. Fodere, M. Esqui- rol, Dr. Prichard, and one case occurred in my own practice, and that was caused by fright. Two cases mentioned by M. Esquirol proceed- ed from the same cause. He met with one case of melancholia complicated with maras- mus in a child eleven years of age, remarka- ble for his large head and mental precocity. In- stances, however, more frequently occur of children becoming melancholic, and even delir- ious, from jealousy and envy, than is generally supposed. They sometimes are thus affected, although often only temporarily, by seeing the attentions of those to whom they are much at- tached bestowed upon others, and by being out- stripped in obtaining distinctions at school. 267. After fifteen years of age, insanity ceas- es to be a rare occurrence. About the period of puberty, in females, or when the catamenia are about to be established, melancholia and mania occasionally appear, and especially if the growth be rapid, and the catamenia are Retain- ed, suppressed, insufficient, difficult, painful, or irregular. In these cases, and still more so at a later period, hysteria is generally attendant upon the mental disorder. During the first few years after puberty, in the male, mania and melancholia not infrequently occur ; the former generally from the excitement of sexual desires, the latter from masturbation or venereal ex- cesses. M. Esquirol remarks, that mania, in all its forms of excitement, appears chiefly in early life ; melancholia, in middle age ; and de- mentia in the advanced epochs of existence. In youth, insanity assumes an acute and vio- lent course, and often terminates by a remark- able crisis ; in middle age, it is more prone to become chronic, and is oftener complicated with disorder of the abdominal viscera, but is sometimes resolved by haemorrhage from the haemorrhoidal vessels, or by diarrhoea. At an advanced age, it is apt to pass into dementia, and to be complicated with paralysis, apoplexy, &c., and recovery is much less to be expected. However, dementia may occur in the young, and very aged persons may be attacked by ma- nia, and recover from it; but these are only ex- ceptions from the rule just stated. 268. The ages at which insanity most fre- quently appears, are, that between 30 and 40; next, that from 20 to 30, and from 40 to 60. M. Esquirol, however, states, that the maxi- mum number of admissions of cases of insanity take place from 30 to 35 years of age ; that each five years, from 20 to 35, give nearly the same number ; that the admissions of males are more numerous from 25 to 30, and those of females, from 35 to 40; that the periods from 30 to 35 follow thereafter, for the men, and from 40 to 45 for the women ; and that the admission of males from 20 to 25 years of age occupy the third rank of frequency, while those of females hold only the sixth rank. From this it follows that insanity is most frequent at an earlier age in men than in women. M. Esquirol farther states, that the wealthy classes are much ear- lier attacked—or, rather, are affected in great- er numbers at an early age—than the laborious. M. Georget adduces the following calculation of the ages of insane persons on admission into several institutions in England and France • From 10 to 20 years of age . . 365 20 to 30 . 1106 30 to 40 . 1416 40 to 50 . . * . . . 861 50 to 60 . 461 60 to 70 . 174 . 70 and upward . . . . 35 269. Yet, although a greater number become insane from 30 to 40 than at any other age, INSANITY—Predisposing Causes. 559 still the number may not be really greater, rel- atively to the proportion of persons in society of farther advanced ages; and hence, 174 in- stances of the malady occurring in persons aged between 60 and 70, may actually show a great- er prevalence of it at that age than 1406 cases appearing between 30 and 40 years of age. That this, however, is not the case—and that a greater number, relatively to the proportion of persons existing in the community at that age, actually become insane between 30 and 40 years—is proved by the number of persons sur- viving out of each 1000 at successive periods of life. In this country, 410, out of each 1000 born, will reach 30 ; and 345 will reach 39 ; but 220 will reach 60, and 140 will attain 70; and if the mean number of those between 30 and 40 thus be 376, and that of those between 60 and 70 be 146, it will be at once manifest that the number of instances of the invasion of insanity is, relatively to the proportion of persons between 30 and 40 years of age, actu- ally greater at that period. 270. M. Esquirol, however, believes that a proportionably increased frequency of mental disorder, with the advance of age, really does obtain, although the predisposition, thus arising from advancing age, increases in an irregular manner. The increased number of insane per- sons, he adds, compared with the population of that age, is very striking between 50 and 55 yeafs. From 70 to 75, and from this age to 80, it becomes enormous, owing to the frequen- cy of senile dementia. This is very probably correct; but it must not be overlooked that a very large proportion of the cases of hereditary insanity occurs between 30 and 40, or even earlier; and it is admitted that these cases constitute the great majority. [Dr. Woodward gives the following as the ages of patients when admitted at Worcester : Under 20 years, 79 ; from 20 to 30 years, 356; 30 to 40, 383 ; 40 to 50, 275 ; 50 to 60, 144; 60 to 70, 88 ; 70 to 80, 35 ; over 80, 1. Of these, 715 were single, and 508 married ; 88 widows, and 48 widowers.] 271. F. Education.—There are few causes which more powerfully predispose to insanity than erroneous education and moral discipline in early age.—a. Too great indulgence in child- hood, and previously to, as well as during pu- berty, and a want of moral discipline then and up to manhood, with neglect of that education which inculcates, and, indeed, enforces proper principles of feeling and action, are undoubted- ly among the most deeply laid foundations of insanity. Persons thus brought up have their temper, emotions, and moral affeetions so little under command—are so subject to ebullitions of passion, to caprices, or violent and fugitive emotions—are so liable to act from momentary feeling and impulse—as to acquire a disposition of mind, or moral character, not only most un- amiable in itself, but also most prone to marked disorder, when subjected to its more immedi- ately productive causes. 272. b. The premature and overstrained ex- ertion of the mental powers is another most important cause of predisposition. In the high- er and middle classes of society, the mind is excited much beyond its powers ; and the child, being required to perform too much, with its imperfectly developed faculties, experiences, as a consequence of such premature excitement, increased vascular action in the brain and its membranes, at a period of life most disposed to vascular disorder in this organ ; and the found- ation is thus laid for chronic disorder, and especially for chronic inflammatory action of that part of the nervous system with which the manifestations of mind are most intimately al- lied. The quantity, as well as the diversity and range of mental exertion, now required from both sexes at a too early epoch of childhood, and during the period which elapses from mere infancy to puberty, while both mind and body are only in an early stage of formation, must necessarily prove injurious, both mentally and physically—and especially to those who are either delicately constituted, or tainted by any hereditary disposition to insanity. Therefore, when this disposition exists, not only should premature and overstrained mental exertion be avoided, but also should the feelings, the pas- sions, and the actions be subjected to strict discipline—to a discipline not too harsh or rigid, but rational and consistent. The mind ought to be formed under a kind restraint, and imbued with correct principles, and with a due sense of moral and religious responsibility. In the present day, too much attention is paid to an early cultivation of intellect, and to the mere acquisition of knowledge of facts and phenom- ena, to the neglect of the education of the moral affections, and of just principles of feeling and of acting. The great ends of education, as now conducted, are, as respects the one sex, the at- tainment of that knowledge and of that range of information which may enable its possessor most successfully to compete in the general scramble for wealth, for advancement in socie- ty, or even for existence ; and, as regards the softer sex, the possession of such accomplish- ments, and the acquisition of so wide and so superficial a range of ideas, in a very limited period of time, as may strike or captivate, or may be more readily and generally made avail- able in society, and thus become the current coin of the mind in conversation. These ob- jects are pursued in education in a manner but too well calculated to overstrain the early intel- lect, to exhaust the feeble mind, and to derange the hereditarily predisposed. The mind is en- gorged with food, not of the most wholesome or digestible quality, beyond its powers of healthy digestion and due assimilation, and even before these powers are fully evolved ; and hence but too frequently follow disorders, varied in extent and intensity, of its most impor- tant and effective manifestations or functions. 273. G. Climate and, Seasons.—a. It is very doubtful what degree of predisposition can be ascribed to climate and seasons, especially as most of the differences in the numbers of the insane in different climates may be attributed to various moral and physical circumstances not necessarily dependant upon climate. In warm climates, and even in Turkey, and other Mohammedan countries beyond the tropics, and in hot climates, where the minds of the popu- lation are under the sway of the Romish and Greek churches, insanity is much less frequent than in temperate and highly civilized coun- tries. M. Esquirol, in accounting for the greater prevalence of insanity in temperate climates, attributes too much importance to INSANITY—Predisposing Causes. 560 sudden alterations or vicissitudes of tempera- ture. The greater frequency of the malady in these climates is plainly attributable to other causes than this. I believe, however, that a predisposition to insanity, and particularly to connate and puerile imbecility, and to dementia, is to some extent generated by marshy or mias- matous places, particularly in low districts sub- ject to inundations, and in low valleys placed deep between precipitous mountains. There the mind and body are checked or weakened in the course of development, and the latter early becomes the subject of diseases which impair its vigour and farther weaken the powers of mind. 274. b. The seasons, according to M. Esqui- rol, have some influence in causing insanity; but probably more as exciting than as predis- posing causes. High ranges of temperature seem to have considerable influence in causing or in determining the character or form of the disorder, and particularly mania, or the higher states of the malady. M. Esquirol has given a table of the admissions into the Salpetri'ere, during each month, for nine years, according to which it would appear that the lowest num- ber was admitted in January ; and that the ad- missions increased progressively from March till July, when they reached the maximum. They then progressively decreased till October. From this month to March they varied some- what in number, but not so much as to excite speculation. 275. H. Professions, Employments,pTjv, and dvpoc: the first comprising the intellectual and rational powers; the ond, those operations supposed to belong to the viscera of the thorax ; and the third, those spontaneous functions termed organic or vege- tative, belonging to the organs of nutrition placed in the abdomen. The Latin writers em- ployed the words mens, animus, and anima in senses nearly corresponding with those attach- ed to the terms used by the Greeks ; although Lucretius, in his development of the Epicu- rean philosophy, is by no means precise in the use of them, and more generally employs mens and animus as synonymous terms, or very near- ly as such. [The ancient Greeks, moreover, assigned the peculiarities of the actions of the different organs of the body to their being the residence of several immaterial agents. The Pastophori first alluded to these as genii, or demons, or decans of the air, and their pupils of Greece believed them to preside, under the control of a great master spirit, over the functions of the several organs of the body. By Hippocrates and Galen, these were termed Awdpetc, and were considered to reside, one or more, in each organ, in subserviency to the grand Evoppuv, or nvevpa, and to be the immediate cause of the peculiar function which it performed. Thus, according to Galen, the heart was the -resi- dence of three Avvdpsif, the dvvauig diaoreTJko- pevr), TupLor&Xopevr/, and ovarcAAopEvr], or those by which it attracted the blood from the lungs, retained it for an instant, and propelled it through the body. The same thing was un- derstood by Von Helmont, under the name of Archaii insit.i, the number of which almost equalled the organs of the body, though all were held in subordination by one sovereign Archeus, corresponding to the nvevpa already mentioned, and supposed to preside in the stom- ach. Harvey also admits in each organ a sen- sus proprius, subject to the general anima by which the whole'body was actuated ; and Glis- son speaks of each organ as possessed of a “ spiritus regius, qui aliud in jecora, aliud in liene, aliud in pancreati, aliud in ventriculo, et intestinis operatur.”] 334. Epicurus, according to the explana- tions of Lucretius, was the first who con- structed a system of materialism. He ascri- bed organization, and the vital and mental phenomena displayed by it, to combinations of ultimate and invisible atoms, possessed of va- rious shapes. He does not attempt to show how these shapes co-operate to form either an 576 INSANITY—Its Physiological Pathology. animal or a plant. He merely asserts that the elements produce both from a combination of atoms, and that in his time many animals were formed, by showers and sunshine, out of the mud. This is one of the modes of spontane- ous evolution contended for by some of the modern German physiologists. It being im- possible to explain the manifestations of or- ganization agd mind, and, indeed, of the uni- verse, by means of the doctrine of atoms alone, a being of superior power was introduced, and invested with great authority. This being, who belonged neither to atoms, nor to ele- ments, nor to any of their properties, was called Nature. “ Her existence,” observes Dr. Bar- clay, “ being found indispensable to all the hy- potheses that exclude a deity, she is still pre- served in her high office by many of the mod- erns, and invested with great power, incessant activity, and uncommon prudence. She cre- ates and brings whatever lives to a state of per- fection, and does it all according to method, or agreeably to laws imposed upon her by a high- er power, which some call Fate, and others Necessity.” We perceive the continual want which Epicurus and his followers experienced in their speculations of a first cause, one Su- preme Being, to whom they might ascribe the various laws by which the world is governed ; and we observe the manner in which his place is supplied by properties, powers, or principles, assumed by them to explain phenomena which, notwithstanding this assumption, must be ulti- mately referred to one great first cause. 335. Lucretius, the enthusiastic expounder of the doctrines of Epicurus, after attributing all things to the formative and productive fac- ulties of his atoms, of earth, of the elements, and of Nature herself, thinks, nevertheless, that all must be regulated by diversities of seeds, or of organic particles, each endowed with a peculiar secreta facultas, which makes them both living and organic ; he is also obli- ged to conclude that the soul is deduced from a seed—that it is from its seminal qualities, and from this radical difference of its faculties, and not from a difference of organism in the body, that the lion is fierce, the fox crafty, and the stag timid. He rejected the opinion of those who believed that animating principles organized animal bodies ; and because he could not see how they did it, he therefore concluded that they did it not. Aware, however, that he might fairly be challenged, in his turn, to ex- plain how his seeds were originally organized, he is quite at a loss, and, forgetting the me- chanical properties of his atoms, has recourse to heat, air, and the invisible power of the wind, being, nevertheless, obliged to call in to his aid a certain mobile and active principle, that distributes motion and sensation to them all; but the origin of this principle he cannot explain. The opinions of Lucretius were evi- dently directed against the vulgar notions of the existence of divinities endowed with moral attributes; but they in no way influence the arguments in proof of a Deity, and a purer sys- tem of religion. He admits that it is impossi- ble to disregard the religious feelings and im- pressions which are interwoven with the very stamina of our constitution ; that no nation or individual is entirely without them ; that some notions of divine beings are quite irresistible, and that they will spring up in the human mind as things indigenous, without the adventitious aid of education. “Quae est enim gens, aut quod genus hominum, quod non habeat, sine doctrina, anticipationem quandam Deorum l” 336. C. Ov Modern Materialism.—It has been urged by all the favourers of Epicurian- ism, and by many of the followers of Gassen- di and Hobbes, but more especially by Buf- fon, Priestley, Darwin, Maupertuis, Blu- menbach, Cabanis, &c., that, as the manifesta- tions of mind are never met with, unless con- nected with a brain, and are suspended by compression of this organ, so the phenomena generally attributed to it are the result of its organization. That the combination and re- ciprocal action of the molecules of matter con- stituting the nervous fabric, of themselves, and unaided, produce the various powers of mind, is the proposition which they support, however paradoxical it may seem, but which they can- not explain. The possibility of such combi- nations and reciprocal actions of the molecules of matter producing, unaided, such results, is not shown by any analogy, or by any proof. If mind proceed from certain associations of or- ganic particles, why has not some opinion as to the process been hazarded 1 Does our ex- perience respecting the mutual influence of ei- ther the elements or the aggregate of matter furnish us with resulting phenomena that can in any degree approach to the lowest mani- festations of either vitality or mind 1 If mind be supposed to be derived only from the com- bination of these particles, or from the opera- tion of certain of their products upon each oth- er, it may be asked whether it be possible to conceive that matter, in such a state, possess- es qualities of which the elements, or even the individual atoms, are divested 1 and wheth- er experience has furnished us with any in- stance of mental, or even of vital phenomena proceeding from such combinations when mat- ter is removed beyond the influence of bodies or sources already endowed with life 1 If, on the other hand, properties necessary to the gen- eration of the mental faculties be conceded to every particle entering into the formation of the encephalon, how can the idea of the subdi- vision of the powers of mind, to such an ex- tent as matter admits of, be allowed 1 Can the supposition be for a moment entertained that every molecule of this admirable organ has a fractional part of mind connected with it 1 Many of the materialists, in order to account for the manifestations of mind, have had re- course to so many suppositions respecting the nature and endowments of matter, in respect either of its elements or of its aggregate, as were tantamount to a negative admission ot the principle of vitality against which they had been arguing, with this notable difference, how- ever, that they required the operation of nu- merous agents, instead of more philosophically referring these manifestations to states of this first and noblest constituent of our nature. The genius of Leibnitz saw the difficulty that stood in the way of pure materialism ; and, in order to give the atoms of matter activity, and origin to the mental phenomena, he had recourse to the or spirits of Aris- totle. 337. Cabanis and the later French physiolo- INSANITY—Its Physiological Pathology. gist? adopted the doctrine of organism ; and, in order to supply the want of a foundation to their structure, they seized with avidity upon the opinions of Gassendi respecting the origin of our ideas. Their hypothesis still required sup- port ; and, in order that it might receive such from a name looked upon with deference through- out Europe, they unjustly imputed to Locke opinions which belonged to the two celebrated opponents of Des Cartes, already mentioned. Much of the credit which this doctrine acqui- red in France and in Germany arose also from the neglect with which that class of our ideas derived from reflection was uniformly treated— from the circumstance that the evidence of the senses and the information derived from expe- rience were considered as the sole foundations of our knowledge. It is very justly remarked by Dr. Barclay, that if it be supposed that all knowledge is derived from the senses, and that matter is the only object of sense, it must be evident that, on this hypothesis, we cannot with propriety ascribe phenomena to anything but matter. But on what data is matter, in general, pronounced to be an object of sense 1 Its ultimate particles certainly are not so ; and its aggregates, though many of them certainly are, seem but little calculated to account for life and organization, and, at any rate, they by no means account for their own formation. But, whatever may be their formation or their consequences, they must be ultimately referred to those primary molecules which are utterly beyond the reach of our senses. Besides, if matter be supposed to include a variety of sub- stances, or, rather, everything that has an ex- istence, it is, on this supposition, no explana- tion of a phenomenon to say merely that it pro- ceeds from matter. He who hazards such an assertion should point out the particular spe- cies or the peculiar arrangement from which it proceeds, otherwise he gives us no informa- tion but that it proceeds from something un- known, and which he would wish to be called matter. We may, therefore, safely question the accuracy of the opinion that all our knowl- edge is derived from the senses; as well might we say that arts and manufactures are derived from the doors and windows of the houses by which the raw materials enter, to be afterward prepared by the industry and skill of the work- men. 338. As our senses are prior in existence to our experience, we have still more reason to question another opinion brought in support of materialism, namely, that all our knowledge is founded on experience, for a great number of our ideas are not directly derived from our own experience, but rather from the evidence of tes- timony. Besides, prior to experience, we pos- sess a species of knowledge which, as to self- preservation, is much more essential than any that we afterward acquire, which seems to pro- ceed directly from the Author of our being, and which, so far from being the result of our own experience and observation, is the very ground- work on which they are founded. Of this kind is the knowledge immediately derived from those natural instincts and feelings which reg- ulate the various functions of our system, which stimulate our intellectual powers, and which, according to their strength or their weakness, their healthy or their diseased state, 1 impart a character to our experience, our ob- servations, our reasonings, our conclusions. When we wish but to move a limb, by what experiment or process of reasoning do we come to know the necessary muscles, the particular nerves proper to excite them, or the amount of energy to be imparted to each, so* as neither to exceed nor to fall short of the object in view 1 If we may take a view of the instincts which guide animals to the selection of food suited to their digestive organs—to know the appropriate means to overtake, subdue, or ensnare other •animals—to provide against seasons of scar- city by laying up stores—to know the distant countries and the different climates where food is in plenty, and to which they can migrate—to learn that they can sleep during the winter without any food, and to select their retreats so as to avoid discovery—to calculate the time of sexual intercourse, with reference to the pe- riods of gestation, so that the birth of their off- spring may coincide with the seasons suited to their early and future exigencies; if we consider the age at which most of these phenomena are manifested in the classes of animals to which they severally refer, and the circumstances with which they are generally associated, and if we analyze the entire class of our instinctive de- sires and feelings (see note, § 66), as manifest- ed both in man and in the lower animals, we must necessarily infer that the sources of our knowledge are much more extensive than the supporters of organism would lead us to be- lieve. Let us, therefore, as Dr. Barclay has well enforced, give due importance to these primary causes of action and feeling, for what- ever our reasonings or opinions may be, we will find them linked with some one or other of these original springs or energies of our constitution —with some instinct, appetite, or passion—with some one of those sources of action, which not only are prior to all our experience, observa- tions, and reasonings, but, what is more, are, during our lives, not unfrequently regulated by circumstances, external and internal, over which we have little or no control. 339. If such be the facts, what, then, it may be asked, is the use of experience, observation, and reasoning 1 The use of these in man is still great—great in proportion to the develop- ment of the intellectual powers. These, and the instincts, can, to a certain extent, mutually aid, oppose, and regulate one another, so as to preserve a juster balance in the moral and so- cial system. The instincts, too, as well as the intellectual faculties, may be diseased, may be perverted, or may be deceived, as they have been shown to be in most of the forms of in- sanity ; and in all cases where they point only to immediate objects, or act according to im- mediate circumstances, they give no warning of the snares, the troubles, and the dangprs which are the consequences of indulgence. By following the impulses of instinct, to the neg- lect of experience and reason, passion and de- sire lead to acts of moral insanity. As we are able to ensnare, capture, or destroy the lower animals, by taking advantage of their unguard- ed, unsuspicious instincts, so we ourselves are often ensnared and captured, or ultimately even destroyed, by excessively indulging many of our instinctive desires and moral emotions, and by neglecting the dictates of experience, just rea- 577 578 INSANITY—Physiological Pathology—Phrenology. soning, and rational observation; or, in other words, from a want of that discipline of which the instinctive and moral feelings are suscepti- ble, and which we have the means of adminis- tering by possessing intellectual and reflective powers in a higher degree of perfection. The control of those feelings, however, is in propor- tion, not only to the perfection of these powers, but also to the use made of them. 340. I have been thus particular in noticing the opinions of Epicurus, because they have the same basis, and involve the same princi- ples, as modern materialism; and in showing that the doctrine of Gassendi and Hobbes, which ascribes all our knowledge to our senses, and which has been seized upon by every wri- ter of note who has more recently written in support of organism, is altogether unsound. The scope of this work allows me not to pur- sue farther this part of my subject, or to notice the several modifications of materialism which have been proposed in modern, and even in re- cent times. This is, however, the less neces- sary, as what has been already advanced will show the complete insufficiency of any theory based upon organism to account for the phe- nomena of life and mind.* But I am compelled to examine briefly a modern doctrine which has met with a very favourable reception both in this country and abroad, and which has been applied, by those who favour it, to the study of insanity—I allude to the doctrine of Gall, or Phrenology, or Cranioscopy. 341. ii. Of Phrenology.—Of this doctrine, I may observe generally, that some of its prin- ciples are founded on opinions which have been, and still are, very generally admitted by physi- ologists ; while others, which especially belong to it, are assumptions, which even those who favour it cannot pretend to be proved, or at least expect to be admitted, by sound reason- ers, as data sufficiently established. Those who support phrenology, appeal to facts, assert that it is eminently a science of observation and rational induction, and, with apparent can- dour, call upon those who oppose it to make themselves acquainted with its principles and details, and then to observe and judge for them- selves. This seems rational; but, unfortunate- ly, when the advice is followed, and when the results militate against their theory, they en- deavour to rid themselves of the difficulty by asserting that the observer is mistaken, and (Unacquainted with the principles of their doc- trine ; thus virtually denying that any one can be acquainted with it, unless he be likewise a convert to a belief in it. When, however, press- ed by facts which seem irresistible, they have so many ways of eluding the difficulty, and espe- cially by means oi their notions respecting the activity and volume of the individual organs into which they have divided the encephalon, and the development or activity of controlling, of opposing, and ol co-operating organs, that there is at once an end of all argument with them. But the ability and eminence of many of those who have written in support of this doctrine, as well as the reception it has met with, and especially the very intimate relation in which it stands to the pathology and treatment of insanity, require that I should enter upon a more intimate ex- amination of it. 342. That the seat of mind is the brain, is proved by a general consciousness that this is the case, or by a similar testimony to that of the locality of the various senses ; and it may be farther proved by experiment—as by divi- ding any of the nerves, and by observing the resulting phenomena. The same inference is to be deduced from the injuries and diseases to which the brain is liable ; by the different grades and forms in which the mind is dis- turbed, impaired, or its phenomena cease alto- gether. Whether we can more precisely assign the locality of the mind, or the localities of its different manifestations, than by saying, in gen- eral terms, that the seat of mind is the brain, is a question which has been long agitated ; and it is upon the affirmation and negation of it that the believers and unbelievers in phrenology rest their doctrines. It was formerly supposed that the mind was located in the pineal gland ; but, as no evidence of this could be adduced, and as it could not possibly be proved by experiment, or supported by observation in disease, the opin- ion shared the fate of similar hypotheses. That the several faculties and propensities of mind reside in respective portions of the brain, is the fundamental proposition of phrenology. But, as Dr. Pring (Sketches of Intellectual and Moral Relations, 8vo, London, 1829, p. 71) has well observed, if we seek for the same evidence in support of this proposition, which showed that the brain, in general, is the seat of mind, no part of it will be found. In our perceptions of the objects of sense—in the operations of mind— in the study of music, languages, mathematics, &c.—in the exercise of our passions or pro- pensities—we have no consciousness of the portion of the brain brought into action; and we cannot thereby assign any of these to one part of this viscus, rather than to another, or distinguish whether the seats of these manifes- tations or states of mind are different, or the same for all. 343. The proofs of locality afforded by disease or injury are equally inconclusive, or, rather, are not to be found. Extravasations of blood in apoplexy will suspend the mental phenomena, or cause both them and life to cease, in what- ever part of the brain they may occur. Wheth- er such extravasation take place in the corti- cal, or in the fibrous structure, or in any situa- tion ; whether fluid is effused from the mem- branes, or into the cavities ; and whether the organic effects of congestion, concussion, frac- tures, depressions of the cranial bones, inflam- mations, or softening of portions of the brain, or the development of tumours, be contem- plated—we find only this common result, that all the phenomena of mind are more or less modified or suspended, or they cease altogeth- er. They may, however, be almost unaffected by some of these lesions; or some faculties and propensities survive, while others are lost; still the preservation or the loss does not ob- serve any regular connexion w’ith the integrity or injury of any given portion of brain. But to state with more precision and detail the doc- trine of Gall : It is asserted, 1st. That the mind presents a certain number of faculties, * For an account of the various hypotheses which have been advanced to account for life and organization, see the work of Dr. Barclay on this subject, and two articles by the author in the 17th and 18th vols. of the London Medical R evositorv, 1822. passions, and propensities, all of which are in- dividually exercised by distinct portions of brain, which portions are the organs of these faculties or passions ; 2d. That these functions are performed, in their respective seats, in dif- ferent degrees in the same or in different per- sons ; 3d. That the strength or perfection of these functions or faculties is in proportion, in- dividually, to the size of the organ, and to the activity with which it performs its office ; 4th. That these organs are situated in the superficial parts of the brain ; 5th. That in proportion to their size is the protuberance of the skull over them ; 6th. That by an examination of these protuberances, the size of the organs, and con- sequently the degree of perfection of their re- spective functions, may be estimated; 7th. That the individual functions may be developed or restrained by education ; 8th. That the pre- ponderance of one or more of them may be re- pressed by the cultivation of others ; 9th. That the propounder of this doctrine was fortunate enough to discover the great majority of the situations in which the individual manifesta- tions of mind are located, and that the rest have been since ascertained ; and, 10th. That the system is applicable to the prevention and treatment of insanity, mental disorders con- firming the truth of it. I proceed to remark briefly on each of these assumptions. 344. a. The enumeration of the faculties may or may not be correct. Some of them are not simple, or even original states of mind, but, as certain of the propensities, arise out of sev- eral, which more or less subserve to their indi- vidual formation. Then, as respects others which are considered original and connate, the sphere of action is either too extended or too limited, while no attempt is made to trace them to simpler and more original manifestations. The division of the faculties by the phrenolo- gists, moreover, is such, that explanations of character conformably with it would lead us often to infer that an individual both has and has not a particular genius, faculty, or endow- ment, or that he possesses opposite endow- ments in equal grades of perfection and activity, or that, both being equally developed and ac- tive, the balance vacillates between them till some circumstance affects a related faculty, and thus causes it or its opposite to kick the beam. The division of the faculties is opposed to just views of philosophizing, and is altogeth- er empirical. 345. b. That the faculties and propensities have their seats in particular portions of the brain, which portions are respectively the or- gans of the faculties and propensities, are two assumptions equally ill-founded with the fore- going. As the faculties of the mind are not dis- tinct entities, but merely states or affections, arising out of impressions on the special or gen- eral sensibility, or different modes of conscious- ness, according as these impressions are inter- nally and externally associated or related, so it is unnecessary to inquire whether these facul- ties have appropriate or respective seats in the brain. Our experience of what constitutes dis- tinctness of function, in connexion with organ- ization, does not permit us to extend the ap- propriation of function and organ to the mind and brain any farther than that our conscious- ness instructs us that the brain is the seat of INSANITY-*-Physiological Pathology—Phrenology. mind, or the organ which is most intimately re- lated or associated with its various states and affections; but it by no means informs us, nor even suggests, that these states or affections are the functions respectively of particular parts of the brain, or that these parts are the organs individually destined to perform appropriate of- fices. Having no proof arising out of our phys- ical and mental constitutions, how then are we to obtain any, or is any conclusive evidence to be obtained 1 We cannot obtain it either an- alytically or synthetically, compatibly with the continuance of life. Evidence, therefore, of the loosest kind—analogies, merely, have been ad- vanced in support of this assumption. As dis- ease or injury has been found to destroy the functions of sense, when implicating either the origins or courses of their nerves, so it has been supposed, from this circumstance, that there are particular localities for the powers of the mind. But this, instead of suggesting the existence of such localities, merely indicates that the impression from distant parts, or dis- tinct organs, is conveyed by certain nerves, which, when diseased or injured in any part from their origins to their terminations, are either rendered incapable of transmitting sen- sation, so as to become an object of conscious- ness, or transmit it in a state of disorder, or imperfectly. Without farther pursuing facts which abundantly suggest themselves to every physiologist and pathologist, it may at once be averred that the proofs in support of the local- ization of the faculties of the mind are not merely defective, but altogether wantjng, and that the loose analogies which have been ad- vanced are either inapplicable, or admit of va- rious explanations, none of which come in aid of the proposition. 346. Even admitting that the powers or fac- ulties of the mind exist as separate essences or functions, and that they occupy appropriate seats or spheres of the brain, it by no means follows that these seats are the organs which give rise to these powers. The viscera dis- charging specific offices are denominated or- gans, because they are the agents by the instru- mentality of which certain results or phenom- ena take place when actuated by life; and we perceive a very obvious organization appropri- ated to the office performed in the liver, kid- neys, lungs, heart, &c.; but we are unable to show by what arrangement of the substance of the brain a mathematical calculation, a process in algebra, a philosophical reflection, a cautious action, or a flight of imagination is produced. Indeed, the question whether certain states of mind, which the phrenologists have located in the brain, are really so seated, or should not rather be assigned to different parts of the ner- vous system, as they have been by most of the ancients, and by many modern physiologists, has not been duly considered by them, but at once have been assumed as functions of por- tions of the brain, which they have also assu- med without any sufficient proof as organs indi- vidually appropriated to the performance of a certain function, and to that only. 347. c. It is asserted that the functions are individually exercised in different degrees of activity in the same, or in different persons ; but is this owing, when occurring in the same person, to an accidental change in the state of 579 580 INSANITY—Physiological Pathology—Phrenology. the respective organ 1 or is the organ under the control of volition 1 or both1 How does voli- tion act upon each of the numerous organs1 how is it located so as to bring each or all into play1 and does it run from one to another1 or, seated in the pineal gland or somewhere near, does it reach out certain appliances with which it is provided to each, and thus strike them in every variety of combination 1 If volition acts upon one, it must necessarily act upon all or any in- termediate number, in every possible mode of combination; and if this were the case, and the volition or desire comprehensive, how immense, both intellectually and morally, would be the result! If it be said that-the will can act upon one organ only at a time, how then happens it that several must often be in operation to pro- duce the effects which the phrenologists admit as often occurring1 That persons may have talents for particular pursuits, or certain pro- pensities in a greater degree than others, is one of the oldest and best established remarks re- specting the human mind. Our experience, however, warrants only the expression that there is a stronger or a more favourable dispo- sition in some minds to certain operations, propensities, and passions, than in others. But, as Dr. Pring has observed, that the existence of any one propensity or faculty is independent of all the rest, or requires to be spoken of as more than a disposition of that which is ex- pressed in the gross as the mind, cannot be in- ferred, 1st, because the disposition which makes the propensity related with its objects has the character of a common principle ; 2d, because the objects of a given faculty are presented to it through media—the senses—which are com- mon to all the other faculties ; and, 3d, because one ability is not perfect, or, in reality, does not exist without the concurrence, more or less extensive, of others. In truth, there seems little more reason for supposing that the differ- ent phenomena of mind are produced by nu- merous distinct faculties, than that it requires different hands to play different tunes upon a musical instrument. 348. d. That the strength of the faculty is in proportion to the size of the organ, is another fundamental proposition of the phrenologists ; but an assumption, equally with the preceding, supported only by loose analogy. The only an- alogical proofs, indeed, which can be adduced in favour of it are derived from the muscular and nervous systems—and these do not fully apply to the brain ; for it cannot be stated with truth, even as a general proposition, that mus- cular strength, either in man or in the lower animals, is in the ratio to the bulk of the mus- cles ; nor is it universally true that the largest nerves convey the greatest degree of nervous energy, although they generally may be infer- red to do this, since they are composed of a greater number of fibrils, each of which, or of the fasciculi into which they are arranged, trans- mits a certain amount of power, or, rather, of •stimulus, to already inherent power in muscu- lar parts. Moreover, sensibility, which is a principal property of nerves, is not manifestly greater or more acute in a large nerve than in a small one, or in a branch much less than a trunk. The phrenologists are themselves aware of the weakness of this part of their foundation, inasmuch as they have recourse to activity, or intensity of action, to explain phenomena which they cannot account for by means of volume. That the size and activity of function of the brain may be connected with the degree of men- tal manifestation, either singly or conjoined, may or may not be the case. The affirmative has been believed in for ages—chiefly from the loose analogies already alluded to, and from others presented by various organs or parts. Still, this is the only part of the system which retains any portion of plausibility upon a strict examination. The alternative, however, of size and activity is so readily resorted to against the opponents to the doctrine, and so easily suggests itself, as to preclude all argument re- specting alleged facts in proof or disproof of the system, and to betray the mind of the es- pouser of it into a state of blind belief. It is obvious that, as long as size, relative and abso- lute, and activity and inactivity in every grade, are made bases of the doctrine, no fact, how- ever faithfully observed, can be adduced that will shake the faith of those who have embraced it, although every one who will give these articles of their belief due consideration must come to the conclusion that they actually negative the propositions they are intended to support; for if activity of function be admitted as respects certain of the organs into which they have di- vided the brain, inactivity must be conceded to others, or even to the same organ on different occasions; and if these states are so important, why have recourse to volume or development as the principal indication of endowment or function 1 The shiftings between these states in argument respecting alleged phrenological facts ; the influence of allied or related propen- sities or faculties on those which are most prom- inent or most deficient; the countervailing op- eration of opposing organs ; and the different interpretation that may hence be put upon the ensemble of these organs as manifested by the cranium, must render the study, even if toler- ably based in truth, as one, at the best, furnish- ing opportunities of vague guessings into char- acter, in which no two speculators out of many may agree, or arrive at anything like a just con- clusion.* 349. e. The localization of the organs, and, consequently, of the faculties, in the external or more superficial parts of the brain, whether suggested merely by a desire of detecting their volumes, or by the circumstance of these parts presenting a greater diversity of arrangement, or structure, or form, is immaterial, inasmuch as they both equally fail in supporting the as- sumption. That the superficial and cineritious portions of the brain are more intimately rela- ted with, or instrumental to the manifestations of mind, may or may not be the case. We have no proof of a conclusive nature, either one way or another, although various circumstances and considerations, not amounting to evidence, have induced several writers to suppose that these parts are actually more especially sub- servient to the mental powers. Yet, that two or three convolutions, or two and a half, or one and a half, or half or three fourths of one only, should be devoted to one faculty or propensity, * The author, before he was much known as a writer, had his head examined by several of the most eminent phre- nologists of the metropolis, but there was no near agreement between any two of them as to his disposition. INSANITY—Physiological Pathology—Phrenology. 581 while the next convolution, or those severally surrounding the portion thus devoted, and even the fractional parts of convolutions not belong- ing to that portion, should be very differently, or even oppositely employed, the ultimate ar- rangement of structure being the same in all, is certainly, if not the extreme flight of imagi- nation, at least the highest pitch of hypothetical conclusion. Numerous other arguments may be adduced against this assumption, but they seem quite superfluous. 350. /. That the protuberance of the cranium marks, and is proportionate to, the develop- ment or size of the particular organ of the brain underneath, often obtains, but not universally, or even generally. But this concession in no way supports the general doctrine, even al- though the protuberance of the cranium truly and constantly expressed the volume, or, rath- er, prominence of the part of the brain under- neath. However, this correspondence very oft- en does not exist, even in early life, for reasons that will suggest themselves to every anato- mist. We find, moreover, and not infrequent- ly, that there are prominences in the cranium where there are underneath no corresponding development of brain; and that the skull is impressed internally by irregular enlargements of the convolutions of the brain, and yet no ex- ternal projection can be observed correspond- ing with the concavities in the internal surface. But the phrenologists contend, as we have seen, that the size of an organ is in proportion to the strength of the faculty; and, farther, that a faculty, not naturally very strong, may be great- ly strengthened by education or habitual exer- cise, even at advanced periods of life. Now, it may be asked, is it to be expected that, at adult or advanced age, as the faculty gained strength, and as the organ, as they suppose, becomes increased in volume, the portion of cranium placed over it will be protruded before it, so as to indicate the amount of increase 1 None but phrenologists could even dream of such a change as this in the skull at these pe- riods of life. Here, howevei, they may shelter themselves behind activity instead of bulk, or, if they still stick to the latter, and it evidently appearing that the bone does not yield to the growth of the subjacent organ, either the organ itself or those around it must be damaged by the consequent pressure—those in the vicinity must be atrophied in proportion to the hyper- trophy of the exercised part, and their functions injured accordingly, or even altogether annihi- lated. 351. g. It is evident that the proposition di- rectly based on the foregoing—namely, that the strength of the faculties may be estimated by an examination of the projections and depres- sions of the skull—requires no farther remark. That faculties and propensities may be devel- oped or restrained by education, is, and has long been, admitted within certain limits. That the faculties acquire facility of action from exer- eise, provided that the exercise be neither ex- cessive nor too long protracted, has been gen- erally allowed. The passions and propensities, also, acquire strength from indulgence ; but this is not regularly or universally the case ; for, as remarked by Dr. Pring, a passion which, in the earlier periods of its gratification, was vehe- ment, might give place, after continued indul- gence, to an apathy with respect to the same objects ; and, in other instances, the excessive indulgence of almost any passion or propensity may terminate in disorder of it, or even in its imbecility or total extinction. That the pre- dominance of one passion or faculty may be restrained by the cultivation of another is an old observation, which is not so universally correct as generally supposed, but which is re- ceived as an established axiom by the phrenol- ogists, as it agrees with the belief in the dis- tinctness of the individual mental functions and of their respective organs. As respects the passions, we generally observe, that when cer- tain feelings are frequently called into action, those which repress them, or are incompatible with them, are inactive, and less disposed to manifest themselves. This, however, does not extend to the purely intellectual powers ; for, as regards them, we do not find that the culti- vation of one power enfeebles the others; it merely tends to the formation of opinions un- favourable to the employment of another pow- er. All that our existing knowledge permits us to advance on this topic is, that certain modes or states of conscious sensibility or mind, being called into existence and action by their respectively rela- ted internal or external causes or occasions, these states continue to manifest themselves with an ac- tivity generally corresponding with the intensity, character, repetition, and duration of these causes ; and that a disposition thus to manifest themselves exists in proportion as they have been called into action or thus exercised, other states of mind be- coming inactive from the absence or insufficiency of those causes or occasions which arc especially related to them, but assuming activity whenever these causes come into operation. 352. This proposition is equally applicable to the intellectual faculties, and to the propensi- ties or passions—to imagination, and compari- son, and reasoning—to the benevolent and to the malevolent emotions; and is aptly illustrated by Dr. Pring, who remarks, that a disposition to cruelty may be repressed for many years by a cultivation of the sentiments of benevolence, &c. ; these sentiments may prevail until the age of thirty, when, from injurious treatment, or unfavourable observations of human nature, it may be suggested, that mankind are altogether unworthy objects; that they merit hatred rather than love ; that, instead of the kinder offices, no species of cruelty is too bad for them. The original propensity would then be resumed, per- haps, even in greater force, from the contrast- ed sentiments which had been previously enter- tained, or from having been so long repressed. 353. h. It is obvious that, before the seats or organs of the faculties and propensities can be respectively assigned in the brain, it must be shown, first, that these faculties are severally distinct; and, secondly, that each occupies an appropriate and equally distinct portion of the brain. These propositions, however, have been already examined, and rejected for want of proof. Notwithstanding this, the phrenologists assert that those persons who have certain faculties and propensities in a high degree have certain protuberances on the skull by which these faculties are denoted, these protuber- ances being the external signs of the cerebral organs, and of their respective offices ; and they support this assertion by the formation of the 582 INSANITY—Physiological Pathology—Phrenology. crania of those who had certain faculties and propensities in an unusual degree—these crania, as they aver, all having a protuberance for the same faculty in the same part or situation. But this practical application of their doctrine, upon the truth of which its utility entirely de- pends, altogether rests upon the facts which have been adduced in support of the proposi- tion that the same faculties are always indi- cated by the same external signs, in respect of situation and development. The number and correspondence of the facts, however, are de- nied by those who do not believe in phrenology. It is obvious to those who think that all physi- ognomical systems—that all attempts to estab- lish a doctrine by which the character shall be known from the external appearances of even a part, or of the body generally—may be sup- ported, however bizarre, by a certain number of coincidences, which may be viewed as facts proving its truth. When we take into account the number of the mental affections and facul- ties, the diversity of intellectual and moral character, and the endless varieties of form of the head, face, and body, and of their expres- sions, it must be obvious that any theory in which there is a reference of faculty to form will necessarily find support in a large number of coincidences—it cannot possibly be other- wise ; and if these coincidences be assiduously sought after, recorded, and marshalled as proofs of its truth, to the neglect of facts which dis- prove the connexion attempted to be establish- ed, the theory will appear to many, and espe- cially to those who are seldom at the trouble to think for themselves, a most brilliant dis- covery—and the more so, that it promises an almost intuitive knowledge of character, and the most useful practical application. It is not denied that some skulls present, in connexion— but, as far as the thing is yet proved, only in coincident connexion—certain propensities and faculties with certain external signs ; neverthe- less, it is confidently averred that others evince no such correspondence between the mental character and the external form, and even con- tradict it in all, or in the most remarkable of their respective parts. In the alternative, how- ever, of activity, the cranioscopists have a ref- uge from adverse facts—and, as I have already hinted, from sound argument; and behind this and various circumstances, as controlling, de- ficient, inactive, and concurring organs—they endeavour to intrench themselves. There are numerous other circumstances and considera- tions which strongly militate against the doc- trine of Gall; but the scope of this work will not permit me to adduce them. The reader will find this topic more fully treated of in the able work of Dr. Pring, already referred to. 354. i. The applications of cranioscopy to the pathology and treatment of mental derangement that have been made by those who believe in it cannot be entertained; for as it appears, from the reasons assigned above, and from others that might be adduced, not to be based in truth, such applications of it can only mislead or interfere with juster views, or even be pro- ductive of irreparable mischief. 355. Having thus disposed of a doctrine which has received very considerable support, and which has been viewed by those who entertain it as being of the greatest utility in understand- ing and managing mental disorders ; although, even if most firmly based in truth, the utility of it in this respect is neither so great nor so obvious as they would wish it to appear; it farther remains briefly to consider the probable nature of the connexion of the mind with the brain and nervous system. [It was a remark of the profound and saga- cious Cuvier that, as “certain parts of the brain attain in all classes of animals a devel- opment proportional to the peculiar properties of these animals, one may hope, by following up these researches, at length to acquire some notion of the particular uses of each part of the brain.” This philosophical mode of inves- tigating the physiology of the brain has been attempted by the school of modern phrenolo- gists, and, it is believed, not without some de- gree of success. Believing that the functions of the brain could only be established by an ap- peal to facts, these have been assiduously gath- ered on every side, so that, by means of busts, charts, museums, collections, lectures, and pub- lished essays, a belief in the doctrines of Gall pervades every part of the civilized world, and in our own country embraces a very large pro- portion of the population. We have no desire to enter here on a defence of phrenology, so called, for we are yet to be convinced of some of its doctrines ; but we may remark, that to oppose it with success requires a specification of facts and details, not a general statement that the experience of the writer is against the alleged concomitance of mental faculty and cer- ebral organs; for a multitude of positive ob- servations cannot thus be got rid of. Facts, we believe, will warrant the belief that the brain consists of a plurality of parts, or organs, each performing a distinct function; although the parts concerned in each function may not all, as yet, have been correctly ascertained, we can scarcely avoid such a conclusion, when we see how the brain receives successive additions as animals rise in the scale of intelligence—how its successive parts are successively developed, as the human being advances from the fcetal to the mature state ; not simultaneously, as a unit would be, but irregularly ; when we regard the phenomena of partial insanity and injuries of the brain, attended with a partial affection of the mental powers, and many other facts, known to all whose attention has been called to this subject. Considered as the organ of the mind, we suppose few will deny that it may be divi- ded into three great regions : the first, compri- sing the anterior lobes, and serving for the op- eration of the intellectual faculties ; the second, comprising the coronal region, and more imme- diately connected with the moral sentiments ; and the third, comprising the posterior lobes and base, and serving for the manifestation of the propensities common to man with the low- er animals. Many of the principles of phrenol- ogy are common to it and physiology in gen- eral ; but the proposition that organic size is, cceteris paribus, a measure of functional pow- er, is peculiar to phrenology, and lies at its very foundation. No phrenological writer claims that size alone is a measure of the functional power of an organ, but that it is only when oth- er circumstances are equal. This principle per- vades the whole science of comparative anato- my, as well as animal physiology, and it is noi INSANITY—Physiological Pathology—Phrenology. 583 to be supposed that the brain forms the only exception to the rule. Camper’s facial angle as- sumed this principle as its basis, against which, we believe, no objections were offered until the wider generalizations of Gall attracted the at- tention of the scientific world. Cuvier lays it down as an axiom, “ that there are always cer- tain relations between the faculties of animals and the proportions of the different parts of the brain,” and remarks, that “ their intelligence appears to be always great in proportion to the development of the hemispheres and their sev- eral commissures.” When the phrenologist maintains that size alone is not a measure of power and intensity, he merely adopts and car- ries out a law, which is admitted to apply to all other organs, namely, that the power of the brain may be defective from disease, original malfor- mation, or defective constitution; just as we see large muscles in persons of little strength, in lymphatic and relaxed constitutions, and where due nervous energy is wanting. Whether ob- servations can be so carefully made and so extensively repeated as to establish on an im- moveable basis the generalizations of Gall and Spurzheim, may, perhaps, admit of doubt; and yet we suppose it will be admitted that there is no other mode of settling this question but by carefully observing large numbers of cases, in which the same part of the brain predomi- nates in size over all the other parts, and as- certaining what particular quality of mind is exclusively in excess in the same individuals. If we cannot in this manner obtain any clew to a knowledge of the functions of the brain, it is difficult to perceive in what manner we are to arrive at it. Whether, then, we consider phre- nology as an exposition of the physiology of the brain, or as a theory of the philosophy of mind, it seems equally worthy our investigation, the first, to be determined by careful observa- tion of the concomitance and connexion of cer- tain functions with certain portions of the brain; and the latter, by the facility and consistence with which it explains mental phenomena, and admits of practical application to the purpo- ses of life. It is worthy of note, that some writers, who reject the doctrines of phrenolo- gy, yet inadvertently admit some of its funda- mental doctrines, as, for example, that the sev- eral faculties and propensities of the mind re- side in respective portions of the brain. Thus, Fletcher (“ Elements of General Pathology,’’ Edin., 1842, p. 431) remarks, that “ the various forms of hypochondriasis and monomania can be explained only on the presumption, that, in each, a certain part of the brain, the seat of that form of thought, the excessive energy of which gives rise to the prevailing delusion, is preternatu- rally excited, and in a state, probably, of chron- ic inflammation. Thus, an over-excitement of the organ of form, size, colour, &c., may con- jure up to the imagination of the hypochondri- acal, not merely spectral illusions, of the falla- cy of which he is conscious, but forms and modes of personal existence, by which the im- pressions derived from the senses are more or less obscured, and they become stamped with the impress of reality ; and a similar over-ex- citement of the organs of destructiveness, pride, caution, veneration, &c., may, in like manner, cast over the monomaniac the prevailing crotch- et under which he labours. Such, then, appear to be the chief peculiarities of the faculty of thinking, dependant on a preternatural excite- ment of certain parts of the brain ; and it is easy to understand that too little excitement of these or other parts may equally give rise to a defect of certain natural faculties and propensi- ties. Thus, some persons have no sexual de- sire ; others, no love of offspring, nor of coun- try—no spirit, no pride, no anything,” &c.— (Loc. cit.) Assuming then, as ascertained facts would seem to warrant, that the brain is not only the organ of the mind, but that the manifestations of every primitive faculty depend on a peculiar part of the brain, it follows, as a matter of course, that we must look for the cause of in- sanity in the brain, and the cause of the de- ranged manifestations of every special faculty in a peculiar part of the brain. We are to look, then, we suppose, for physical changes in the organ of the mind, and not for disease of the mind itself, as the proximate cause of mental derangement; for, as Spcrzheim has well re- marked, the idea of derangement of mental functions must not be confounded with mental disease ; the manifestations of the mind may be deranged, but it is difficult to imagine any disease or derangement of an immaterial be- ing itself, such as the mind or soul is. Theo- logians and metaphysicians, who believe in the non-dependance of the mind on material or- gans for its manifestations, are not, perhaps, aware that they concede the mortality of the soul itself; for if it can fall sick, it may, doubt- less, also perish. It is a much safer doctrine, that in this life the mind and body are insepar- ably connected ; that the manifestations of mind are dependant on certain corporeal instru- ments ; that they cannot appear without them; and are modified, diminished, increased, or de- ranged, according to the condition of these in- struments, or organs. That the proximate cause of insanity is always corporeal, would appear to follow from considerations already adduced, namely, that it is often connate and hereditary; that it is influenced by age, sex, climate, season, and weather ; that it is brought on by injuries of the head, and various other causes which affect the body, as pregnancy, too rapid growth, stimulating drinks, mastur- bation, long fasting, &c.; that it is periodical, and has exacerbations ; that it is often accom- panied, or alternates with other corporeal dis- eases ; that it causes disturbance of sleep; is influenced by temperament, &c.: moreover, as has been observed, if the mind itself were dis- eased, it ought to be cured by reasoning. The character of individuals is also often entirely changed by blows, or other injuries, inflicted upon the head, as well as by diseases affecting that organ. Dr. Brigham, in his late work, en- titled “An Inquiry concerning the Diseases and Functions of the Brain, the Spinal Chord, and the Nerves'’ (New-York, 1840), thus sums up what he believes to be the ascertained functions of the brain : 1st. That the cerebral lobes, or the hemispheres of the cerebrum, are the seat of intelligence; 2d. That the cineritious portion of these lobes, probably, is the seat of the men- tal faculties ; 3d. That the fibrous or medullary portions of the brain are connected with the motive powers, and transmit volition and sen- sation ; 4th. That the lobes of the cerebellum- 584 INSANITY—Its Physiological Pathology. are not connected with the manifestations of the mental powers, but are with the motive, and appear also to be with the sexual propen- sity, and that the sympathy between them and the stomach is intimate ; 5th. That all the fac- ulties of the mind may be manifested by one hemisphere of the brain; 6th. That different parts of the brain have different functions, and that the anterior portion of the cerebral lobes play the most important part in manifesting the mental powers, and appear to be the seat of the memory of words, events, and numbers ; 7th. That the striated bodies and the thalami are intimately associated with the motive powers of the extremities ; 8th. That parts in the middle and at the base of the brain, such as the fornix, corpus callosum, septum lucidum, pituitary body, and pineal gland, are not connected with the mental faculties.—(Loc. cit.) To these might be added, that the corpora striata and their an- terior radiations preside over the movements of the lower, and the optic thalami and their radiations over the movements of the superior extremities. The above deductions have been derived from pathological investigations, and are worthy of candid consideration.* The objections brought forward by our au- thor to the main conclusions of the phrenolo- gists, although plausible, do not seem to us ir- refragable. We suppose it will now be gener- ally admitted that there are no insuperable dif- ficulties in the way to prevent the size and con- figuration of the brain from being pretty cor- rectly ascertained during life by observing the outward form of the head. The want of paral- lelism between the tables of the skull and the existence of the frontal sinus, except in the case of two or three of the smaller organs, are now known to influence the results too slightly to affect the important conclusions of phrenol- ogy, and are consequently abandoned as valid arguments against the science. All observa- tions made during old age or disease, were re- jected by Gall as inconclusive, and though af- fording valuable illustrations, have never been received as valid proofs by any of his follow- ers. Farther observation, and the accumula- tionofa greater number of facts, are still want- ed to place phrenology on a secure and perma- nent foundation. We bespeak for it an impar- tial investigation on the part of medical men ; for, as there is no branch of scientific inquiry that has been more misrepresented, ridiculed, and calumniated by enemies, so there is none that has suffered more from the weak and in- judicious support of its friends.] 356. iii. Of the Connexion of the Mind and Nervous System.—A. Those who have reasoned against the possibility of the exist- ence of the mind separately from the body have referred to the general agreement of the state of the former with that of the latter, and to the effects produced in the manifestations of mind by disease and injuries of the brain, as proofs of the truth of their doctrine. But the infer- ences drawn from these two classes of facts, as Dr. Pring justly observes, are by no means legitimate. As to the first class of facts, show- ing a correspondence of vigour at different pe- riods of life, between the mental powers and the corporeal functions, it may be remarked, that the changes in these severally, although to some extent simultaneous, are not so univer- sally, nor always in corresponding degrees: the faculties of the mind are sometimes unim- paired at far advanced periods of life, and the brain is fully developed long before the mental powers are in full vigour. Admitting, even, that the progress of the mind from infancy to old age is in general agreement with corporeal de- velopment and strength, yet it does not on this account follow that the changes of the mind in the course of age are dependant upon those of organization. There may be a simultaneous development without a necessary dependance. Besides, if the mental powers are entirely owing to the brain—are merely functions of this organ —wherefore are they not displayed at an equally early period of life with those of the liver, stom- ach, and other organs, all of which manifest a perfection of function, either soon after birth, or, at least, long before the mental powers are fully developed 1 According to the doctrine of organism, no answer to this question can be given; while those who believe that, in the present state of our knowledge, it appears im- possible for matter to give rise, of itself, to life or mind, and that a principle of vitality is ne- cessary to the attraction of material or inor- ganized molecules into specific organized forms, and to be allied and associated with them for the purpose of enabling them to discharge ap- propriate functions, will readily respond, that in the early part of their existence the brain and nervous system are the instruments chief- ly, under the dominion of life and mind, of sen- sation, and of the instinctive feelings and emo- tions ; and that, as fast as the mind is stored with the reports of the senses—as fast as con- scious sensibility is called into action, so as to form perceptions, and to perfect the results ol sensation—so it becomes also capable of re- taining and comparing the objects of its con- sciousness, of reasoning and reflecting upon them, of suggesting new forms or combinations of them, and of drawing inferences from va- rious sentiments or feelings arising out of the internal and external causes or occasions which influence or excite it. 357. The class of facts, consisting of modifi- cations or suspensions of the mental powers, * [According to Solly, one of the ablest anatomists of the age, and who has recently adopted the doctrines of phrenology, as founded in nature (The Human Brain, its Configuration, Structure, Development, and Physiology, &c. Lond., 1836), the functions of the cerebrospinal axis are as follows: The spinal cord has a two-fold office, first, it is a conductor of motion and sensation, the anterior columns being the organs of motion, the posterior of sensa- tion ; 2d, it is a centre from which power emanates, inde- pendently of the great cerebral ganglia, with which it is connected. The office of the corpora olivaria is to preside oyer the functions of the respiratory muscles. The poste- rior pyramidal bodies are devoted to the function of hearing ; the optic ganglia, or quadrigeminal tubercles, to that of vis- ion ; the olfactory ganglia to that of smell ; and there is every reason to believe, that the impressions received by the extremities of the auditory nerves in the one case, and by the optic and olfactory in the other, are converted into sen- sations in the respective ganglia in which they terminate. The cerebellum is one of the centres which influence and generate power, and most probably in connexion with the functions of the voluntary muscles. The pons varolii is the commissure, or instrument for establishing a communication between the different parts of the cerebellum. Moreover from the fact that, it has a quantity of cineritious matter distributed through it, it is believed to be, also, a generator of power of some kind, of the precise nature of which we have no knowledge ; and, lastly, individual portions of the great hemispherical ganglia, or cerebral lobes, perform sep- arate offices in correspondence with the different kinds of mental manifestations, as stated by phrenologists.—(hoc. eit.)} INSANITY—Its Physiological Pathology. 585 from organic lesions and injuries of the brain, has been considered by the supporters of or- ganism as conclusive proofs that the mind is a function merely of this organ that can exist no longer when the fabric of it is destroyed. But it by no means follows that, because those powers are destroyed by disease of the brain, they are, therefore, the product of the organi- zation of this organ. All we know is, that a certain degree of soundness of the latter is usually necessary to mental sanity, and that the mind shall be, in one case, severely dis- turbed by a slight change of structure; in a second case, but slightly disordered by most extensive disorganization; in a third, unaf- fected by very remarkable lesions; and, in a fourth, most violently affected, without any ap- preciable alteration. Here, although the facts contended for are numerous, yet they neither correspond with one another, nor do the le- sions produce corresponding or co-ordinate ef- fects on the mind ; nor are the modifications of mind always to be referred to morbid con- ditions of the brain—the results are neither uniform, nor correspondent, nor universal — and hence the intimate dependance of mind upon the brain is not a legitimate inference from this class of assumed facts. The de- pendance of one thing upon another, it should be recollected, may be of different kinds : 1st. It may be that of absolute cause and effect, the latter existing only in consequence of the former, and ceasing with it. 2d. The depend- ance may be one of association or connexion, in which state the one cannot be manifested without the other, and any disturbance of ei- ther will have a reciprocative influence. The dependance may be either of the foregoing kinds, and be greatly affected by the contingent interference of a third, or foreign influence, not requisite to the existence of either, and espe- cially of that which suffers a change from such interference. While it is the first of these that is contended for by many, the second appears to be the kind of dependance that naturally subsists between the mind and the brain, the contingent interference of morbid action in the brain disturbing the states of the mind, and the structural conditions of the brain itself. 358. The exercise of the faculties of the mind is dependant upon a cause which is al- lied with, or which actuates the brain, and is modified or suspended in consequence of dis- ease or injury of the brain, not because the in- tegrity of this organ produced, these faculties, but because the exercise of them is prevented by the foreign influence of a preternatural state of the organ with which they are allied. On this topic, Dr. Pring justly remarks that, in the case of disease or injury of the brain, fol- lowed by suspension of the functions of the mind, we do not know the agents or the mode by which such suspension is produced. We perceive a change in the condition of the struc- ture, but whether the action of the mind ceases because a material arrangement is disturbed, upon the precise state of which the action of the mind depended as upon an essential cause, or whether this action ceases because it is im- peded by the foreign or preternatural influence of a fabric with which it is allied, we are pre- cluded the discrimination of experience. Yet the alternatives have this important difference, that, in the former case, the mind cannot exist without a precise arrangement of a material structure ; in the latter, it may exist inde- pendently of such organization ; and, although liable to be disturbed or suspended by change of organization, in the same manner as any oth- er effect may cease under a foreign influence, yet its exercise may be resumed when this in- fluence is withdrawn. 359. The dependance of the mind upon the organization of the brain is said to be most un- equivocally shown by the effects of compression of the organ; but compression, like organic lesions, may impair or suspend the manifesta- tions of mind, whether they are a result of a certain state of organization, or whether they are only allied or associated with it. In the former case, the effect is one of necessary dependance upon its cause, the function ceas- ing upon a certain preternatural condition of the organ ; in the latter, the foreign interfe- rence disturbs or suspends the condition of the material fabric with which mind is associated, and as soon as this interference and its mate- rial consequences are removed, the manifesta- tions of mind are restored more or less com- pletely, according as the removal of the foreign cause of disturbance is complete. 360. It follows, from what has been advan- ced above, that disorder or suspension of the manifestations of mind, from disease or injury of the brain, is no proof that the mind is neces- sarily a function, or an effect or product of this organ ; but merely that the brain is the organ, instrument, or medium of communication be- tween the mind and the external world. 361. In favour of the belief that the mind is independent of the material fabric with which it is intimately allied or associated, or is a re- sult of vital properties superadded to and ac- tuating this fabric, numerous considerations and satisfactory evidence, if my limits could permit, might be adduced; but it may be re- marked, 1st. That the circumstance of the op- posite doctrine, or that of organism, having been found fallacious and untenable, the only other doctrine by means of which the phenom- ena of mind and organization can be explained appears the more entitled to credit; 2d. That mind ceases to be manifested in consequence of an organic lesion in a particular or limited part of the brain—if the mind were the result of the organization, there is no reason why it should not still be produced wherever the or- ganization is perfect; 3d. That the principle or properties of life, endowing living animals from conception to death, and the structures which life endows and actuates, are undergoing a per- petual change, and, as existence advances, a perpetual consumption, without any loss of identity; that both the original vital endow- ment, and its associated structures, are perpet- uated from inorganic or from broken-down ve- getable or animal substances, as from their el- ementary sources, these substances containing the constituent properties or elements of life and of structure ; that this conversion and ap- propriation of the elements of life and struc- ture are performed by the changes produced in, and by the affinity or attraction exerted on these elements contained in dead or inorganic substances by life ; and that this attraction is one of assimilation, by which a living principle 586 INSANITY—Its Physiological Pathology. separates, adopts, and unites its own properties or elements, and those of its allied structures, from the various materials furnishing them, thereby perpetuating their forms, as long as their own identity or existence is preserved, and as long as their elements are submitted to the influence or brought within the sphere of the vital endowment or principle, which alone is capable of thus acting; 4th. That it is ob- served of functions generally, that they are the results of life in conjunction with structure— of organization built up and actuated by the vi- tal principle endowing it; that the function of every organ is dependant upon the continuance of its life ; that it is not produced by the organ- ization—for the material elements composing the individual tissues and the general organi- zation are held together in a state of affinity or attraction and cohesion opposed to that which their chemical affinities dispose them to assume ; that this predominant affinity and co- hesion are owing to a vital endowment, and are therefore aptly denominated vital; and that, while it thus holds the material elements in a due state of attraction, appropriately to the con- stitution of the several tissues, it also enables them to discharge specific or peculiar offices or functions ; 5th. That, this dependance of func- tions upon vitality existing throughout the body, a similar dependance of function upon vital en- dowment may reasonably be extended to the brain ; and, 6th. That the evidence we possess as to life being the cause of the organization of material elements, and of its own perpetuation or renewal, as well as that of its allied struc- tures ; and as to its being a principle superadd- ed to, intimately allied with, and actuating a material fabric, and of which evidence such no- tice as the scope of this work will permit has been taken above (§ 336, et seq.), and in the ar- ticle Disease ($ 2, et seq.), is sufficient to show that the mind is the result of the vital endow- ment of the brain, without which endowment this organ would not only cease to be the in- strument of mental manifestation, but would also fall into dissolution ; its material elements, no longer being held together by the attraction of life, assuming those forms to which they are chemically disposed. According to this view, the evidence in favour of the immaterial- ity of the mind is the same as that upon which the doctrine of vitality, or the primary agency and controlling influence of life upon structural arrangement or organization, and upon func- tion, is based ; and mind thus appears the high- est manifestation or property of life, in connex- ion with, and through the instrumentality of the brain—that particular congeries of tissues, in alliance with which only could its wonderful faculties become apparent. 362. Matter is known to us only by our sen- ses ; mind, by our consciousness. We know quite as little about the essence and occult qualities of mind as we know of matter; and, as far as our most profound conceptions of them can carry us, we have no ground for believing that they have anything in common beyond their derivation from parents, and the support or renovation they derive from surrounding media and materials furnishing the properties and elements of their development, perfection, and perpetuation. The principle which thinks, as Dr. Abercrombie remarks, is known to us only by thinking ; and the substances which are solid and extended are known to us only by their solidity and extension. When we say of the former that it is immaterial, we simply ex- press the fact that it is known to us by proper- ties altogether distinct from the properties to which we have given the name of matter, and, with the exceptions just adduced, has nothing in common with them. Beyond these proper- ties, we know as little about matter as we do about mind; so that materialism is hardly less extravagant than would be the attempt to ex- plain any phenomenon by referring it to some other altogether distinct and dissimilar—to say, for example, that colour is a modification of sound, or gravity a species of fermentation. 363. We have, in truth, the same kind of evidence for the existence of mind that we have for the existence of matter, namely, that furnished by its properties ; and of the two, the former appears to be the least liable to decep- tion. Of all the truths we know, says Mr. Stewart, the existence of mind is the most certain. Even the system of Berkeley, con- cerning the non-existence of matter, is far more conceivable than that nothing but matter exists in the universe. To what function of matter can that principle be likened by which we love and fear, are excited by enthusiasm, eleva- ted by hope, or sunk in despair 1 These and other mental changes may be equally independ- ent of impressions from without, and of the con- dition of the bodily frame. In the most quiet state of every corporeal function, passion, re- morse, or anguish may rage within ; and while the body is racked by the most distressing mal- adies, the mind may repose in tranquillity. The mind thus being so frequently uninfluenced by the state of the bodily organs, and so dissimilar and distinct from the functions of these organs, what reason have we to believe that it is de- pendant upon organization, farther than in be- ing intimately allied with it, for the purposes of intercourse with the external world 1 When these purposes are fulfilled, this alliance is di- vorced ; and as mind, the highest grade of vital endowment, is insusceptible of decay, although liable to be variously disturbed by diseases of its allied fabric, the connexion ceases general- ly, in consequence of the state of this fabric having become incompatible with its manifes- tation. As soon as the organic life, or lower grade of vital endowment, or the properties of life actuating the organs of digestion, assimila- tion, circulation, respiration, and nutrition, and giving rise to functions subservient to the dis- play of mind, by means of the brain and nervous system, cease to be exerted on their respective organs, the vital cohesion of all the structures ceases, and changes take place in the arrange- ment of their constituent elements. These structures, however, are not annihilated; their elements have only changed their forms; there- by furnishing an analogical proof, as remarked by Dr. Brown, of the continued existence of the mind or thinking principle—that it survives the disorganization and changes experienced by its allied fabric, by means of which its prop- erties or powers are displayed, and the various relations subsisting between it and the rest of the creation are established and preserved. 364. B. If we endeavour to inquire into the origin of mind, all the information which our INSANITY—Its Physiological Pathology. 587 faculties enable us to obtain amounts merely < to the following: that, in common with the ! other properties of life of which the structures i are possessed, it is derived from parents ; is developed by the changes in the constituents of the ovum; is matured by the processes of growth ; is allied with an appropriate organiza- tion, or material fabric ; and, like the other vi- tal properties, subsequently manifests the phe- nomena which result from its own nature, and the agency of related causes. It is alone suf- ficient to establish, as Dr. Pring well remarks, the derivation of the mind from parents ; that the being who exhibits the possession of it is a production from parents ; that he is so endowed by an internal conformation; the materials of which are obviously from parental sources; and that he is not cotemporary with parents, Dut is a production peculiar to a more or less advanced and perfect period of their existence. The peculiar features, also, of the mind of the offspring are often found to resemble conspicu- ous ones which belonged to the parents; or, like the hereditary peculiarities remarked in the structures, the mental characteristics of parents are not manifested in the succeeding generation, but remain latent, and are display- ed by the one which follows. Thus, insanity is as conspicuously transmitted from the pa- rents to the offspring as any one of the hered- itary corporeal diseases. The association, however much or little, with the good or with the bad, w'ith the well-informed or with the vulgar; the being familiarized with scenes or sentiments which captivate the imagination, or with topics which exercise the reason ; or con- finement to a sphere in which the mental im- pressions and exercises are little more varied than those of a horse in a mill—will individu- ally have an effect upon the character of the mind, and will concur with previous relations of growth to disguise its resemblance to the original from whence it proceeded. 365. From these and various other consid- erations, it may be inferred that the embryo derives its vital properties from both parents, those of either parent somewhat predominating in certain cases, and as respects certain prop- erties ; that these properties vary in grade in different classes of animals, the highest of which furnish incontestable proofs of the pos- session of several of those faculties which we attribute to mind ; and that the same grade of vital properties is communicated to the embryo as characterize the parents—these properties developing in the embryo the material fabrics or structural arrangements about to become the instruments or media of their manifestation; mind, and especially the powers of association and reflection, being the highest grades of these properties, and requiring a more complete de- velopment of the brain for their display. 366. C. If, then, the conclusion that the mind is not a mere result of structural arrangement, is deducible from satisfactory evidence, it re- mains to inquire still farther for the relation sub- sisting between the mind and the material fabric with which it is associated. A perfect account of thi3 relation is most probably beyond the reach of our faculties ; but, among various oth- er topics, it comprises much of what has already been alluded to, as well as a statement—1st. Of the circumstances upon which the existence of a mind or intellectual principle depends; 2dly. Of the mode of its connexion with the material fabric; and, 3dly. Of the mode by which changes or conditions of the mind, and of the organization, affect each other: but to these topics I can only briefly and imperfectly allude. 367. a. Most of the circumstances upon which the existence of mind depends have been noticed, as far as they are known to us. It has been shown above that the powers of mind are the highest properties of life evinced through the medium of a perfect nervous sys- tem ; that these powers, with the other prop- erties of life, are derived from parents; that they are developed during the early stages of existence ; that they become known to us only through the instrumentality or medium of a cerebro-spinal nervous system, actuated by the vital endowment of the frame; that the phe- nomena of mind are produced chiefly by rela- tions subsisting between it and external ob- jects—by sensations transmitted to the brain and there disposed of, according to their rela- tions with the other properties or powers con- stituting the intellectual principle or mind, and partly, also, by its powers of suggestion, ab- straction, comparison, and reflection ; and that the connexion of mind with its material fabric is one of alliance, and not of necessary depend- ance, or of dependance only as far as the struc- ture may be required as a medium between the mind and external objects, or may concur to its support or phenomena. 368. b. The bond or connexion subsisting be- tween mind and organization can be viewed only as one of affinity or alliance; and the sole reason we can assign for this connexion is, that it is a law1 of nature. We have seen that this alliance is of such a kind as that the exist- ence of mind is not necessarily dependant upon the material fabric, but that we are rather en- titled to consider the organization to be depend- ant upon life, mind being those manifestations of life evinced by the cerebro-spinal nervous structures, and resulting from the vital endow- ment actuating these structures; for it is im- possible to conceive that an organized body could have come into existence without a vital or animating principle ; and it is equally impos- sible to conceive how an animating principle, and more especially its higher properties, or powers—the faculties of mind—could have been manifested or duly exerted, unless in most in- timate alliance with matter, the molecules of which it could so build up and actuate as to render them the media and instruments of com- munication with the other materials constitu- ting the visible world. When, however, the molecules of matter are thus built up, variously formed and actuated, they are incapable of perpetuation, in their numerous and wonderful states, or even of more than a momentary ex- istence, unless in alliance with and endowed by life—by that life which organized the mole- cules of matter, developing and perfecting them in their respective forms and grades of being. As soon as the alliance of life and organization is divorced, the former escapes the cognizance of our senses, our unaided reason being inca- pable of acquainting us with its subsequent states of alliance or existence, and the latter returns to its elementary states. Thus we per- 588 INSANITY—Its Physiological Pathology. ceive that organization, with all its phenomena, is dependant upon life from its commencement to its termination—its commencement resulting from the vital endowment bestowed at first by parents, and perpetuated afterward by assimila- tion ; its termination, ultimately, being conse- quent upon the loss or departure of this endow- ment, without which it can no longer exist. But while organization, with all its functions, is the result of, and is necessarily dependant upon a vital endowment, in all its grades and manifestations, this endowment is not neces- sarily dependant upon organization, although associated with it in such a manner as fully and duly to actuate it; and this latter conclusion is supported by the reasons assigned above ($ 356), as well as by the consideration that life, in all its grades, may exist independently of the material fabric which it actuates, although pla- ced beyond the spheres of our senses. This is not above the range of conception or of prob- able existence, but admits of belief equally with other remote causes of visible phenomena; whereas the dependance of life and of its high- est manifestation, or mind, upon organization is incompatible with our experience of the nu- merous objects composing the external world, with our conceptions of possible phenomena, and with their causation, perpetuation, and ter- mination. 369. c. The mode in which changes of the mind and of the organization affect each other can be only obscurely or imperfectly recogni- sed ; but, still, enough is manifested to show, 1st. That changes in the manifestation of the mind affect the organization by primarily dis- turbing the functions of life in organs intimately related to the nervous system ; and, 2dly. That changes in the organization affect the mind, in consequence either of the molecular arrange- ment of the material fabric, necessary to the healthy state of mind, being disturbed, or of the affinity or alliance existing between this fabric and its vital endowment being weakened or de- ranged, or of disorder of this endowment occa- sioned by the changes of its associated material fabric, these changes deranging the manifesta- tions of life usually evinced by the brain. Each of these propositions requires farther remarks. 370. 1st. In illustration of the influence of the mind upon the organization, it may be sta- ted that the depressing passions impair the functions of digestion, and weaken the action of the heart; and, if these effects are intense or prolonged, the organization not only of the digestive and circulating viscera, but also of the brain, becomes affected through the medium of the nervous and circulating system. Here we perceive that changes in the functions of an organ affect both that organ itself, and also other organs related to it, by means of nervous and vascular connexions. 371. 2d. If the structure of the brain be changed, the consequences are not uniform either as to extent or character: there may re- sult disorder, 1st, of the mind ; or, 2dly, of con- nected or related functions; or, 3dly, of both mind and related functions. Yet these conse- quences are not necessary or absolute, they are merely contingent; they are not constant or uniform, but uncertain and frequent: for nu- merous facts prove that the fabric of the brain may be most palpably and variously changed without the mind being appreciably disordered, and that the most severe mental disturbance may suddenly occur, and as suddenly disappear where no lesion of the organization of the brain can be detected, or even inferred. These facts lead to the conclusions, 1st. That changes in the mind, or vital manifestations of the brain, do not result uniformly, or even generally, from a disturbance of the molecular arrangement of this organ ; and, 2dly. That changes in the mind depend either upon impairment or other derangement of the affinity or alliance subsist- ing between the fabric of this organ and its vi- tal endowment, or upon alterations in the state of this endowment, whether occasioned by le- sions of its associated structures, or occurring independently of such lesions. To either or both of these alterations disordered states of mind may be imputed ; and either of them will explain the fact that these states of disorder proceed in some cases from alterations of struc- ture, and in others without any appreciable al- teration. They both, especially the latter, ex- plain those sympathetic states of mental disor- der which are of so frequent occurrence. Thus, the organization, or even the function of a re- mote organ, is seriously disturbed, and the vital manifestations of the brain, or the mental pow- ers, suddenly become more or less disordered, and as suddenly are restored to their healthy state. There is, however, no reason to con- clude that the material fabric of the brain is altered in such cases. All that we are entitled to infer is, that the change in the primarily af- fected organ has so disturbed the vital endow- ment of the frame as to disorder in a special manner the manifestations of this endowment in the brain and nervous system ; or, in other words, so as to derange the states of mind, or the various conditions of conscious sensibility, in relation to its internal and external causes. From the preceding observations, and from nu- merous facts and considerations which my limits would not admit of being adduced, I may state the following inferences, as possessing more or less of practical importance, especially with reference to mental disorders, although their practical bearings may not be very obvious to the empirical or routine practitioner. 372. (1.) An organized being did not organize itself; the creature did not create itself, but was created ; and all we know with precision, especially in respect of the origin of the more perfect animals, is, that they have proceeded from parents or anterior living existences. 373. (2.) Our present knowledge warrants the conclusion that the derivation of organized bodies from parents depends upon certain ma- terial elements which proceed from both pa- rents, and which are endowed, or associated with a vital emanation from these parents, the combination or mutual influence of these ele- ments and of their vital endowment producing the new animal; and that the material elements furnished by the parents towards the production of their offspring, and vitally endowed by them, are of such a.nature as to admit of conversion, under the influence of life, into those tissues more immediately required in the early stages of development, and of separate existence of the offspring. 374. (3.) Every consideration of the subject confirms this inference—that not only does a INSANITY—Its Physiological Pathology. 589 vital emanation proceed from each of the pa- rents, in connexion with the material elements furnished by them towards the formation of the new animal; but also that this emanation, or vital endowment, is possessed of properties, al- though in a latent or non-manifested state, similar to those possessed by the parent which furnished it; and that the vital emanations or endowments proceeding from parental sources combine in producing the new animal, and form and develop the material elements with which they are allied or associated. 375. (4.) There is every reason to infer that the embryo derived from these sources requires to be furnished, for a time, with those elements of assimilation necessary to its development, and to its future state of independent existence; and that such assimilation and development are accomplished by means of the vital endowments derived by both parents, although re-enforced or promoted, or, at least, favoured by the cir- cumstances in which the embryo is placed in respect of one of its parents. 376. (5.) The animal, being thus organized by means of vital endowments •derived from these sources, is afterward supported by these endow- ments ; the offices performed by each and every part of its frame, whether tending to the con- tinuance of its existence, to the perpetuation of its species, or to communication with ob- jects external to and remote from it, depend- ing upon these endowments being weakened as they become impaired, or disordered as they are disordered, and ultimately ceasing immedi- ately when they disappear or depart from the body which they thus preserved and actuated. 377. (6.) An organized body thus vitally en- dowed presents an assemblage of organs, each of which performs, while actuated by life, cer- tain offices or functions ; their tendency or pur- poses being, 1st, to continue the existence of the animal, by assimilation of the elements of matter external to itself; 2dly, to perpetuate the species ; and, 3dly, to hold relations, more or less extensive, with the physical, and, in man, also with the moral or social world. These organs or viscera are respectively en- dowed with life, which is either intimately as- sociated with a general system or tissue, sup- plying all organs and parts of the frame, or is more generally diffused to all the structures, and even partially also to the circulating fluids ; and they manifest this endowment in various modes, according to their organization ; their offices or functions being performed under the influence of life, and only by means of its influ- ence, but through the instrumentality of the organization. The functions of a living animal being thus altogether or entirely dependant upon life, these functions may be viewed as the manifestations or properties of life through the intervention or medium of the structures. Thus, irritability is a manifestation or property of life by means of the muscular system, and the va- rious modes of sensibility are manifestations or properties of it evinced by a cerebro-spinal ner- vous system. 378. (7.) Conscious sensibility, in all its forms, and the intellectual and moral states, in all their varieties, arising from the relations of consciousness with its numerous external and internal occasions, are the highest properties or manifestations of life through the instrument- ality of the brain ; perfected, however, or called into existence or activity, by sensation, educa- tion, and reflection. These manifestations of vital endowment by means of a perfect nervous system are the properties, powers, or faculties of mind, which are known to us only in alliance with this system. 379. (8.) The powers of mind being, then, the highest properties and manifestations of life, through the medium of a perfect nervous sys- tem, are dependant upon the vital endowment of the frame, or result from this endowment while actuating its allied material fabric; the states of conscious sensibility, or of the mental principle, depending as much upon it as upon changes in the organization of the brain itself. The faculties of mind are, therefore, manifest- ations of the vital endowment, through the in- strumentality and medium of the encephalon : this endowment, in actuating this particular part of the fabric of the body, evincing these faculties or mental phenomena. In this pro- cess, it is obvious that the particular conditions of the general vitality, whether as to power, or character, or quality, must influence the results or the manifestations of mind, independently of any change of an obvious or appreciable nature in the fabric of the brain ; and that disorders of mental manifestation will proceed as much from the conditions of the general vital endowment as from alterations of the structure of the organ. 380. (9.) It having been shown above that the vitality of the frame, as it endows and ac- tuates the brain, is not necessarily dependant upon, but is merely allied or associated with the brain, it follows that changes of the struc- ture of this organ may or may not affect the mental powers, so long as they are not of such a nature as to seriously disorder the vitality of the frame; and that, when the mental faculties are deranged in consequence of alterations in the fabric of the brain, the disorder is owing to the disturbance which such alterations produce in either the general or the local vital endow- ment, or both ; the local lesion affecting either the general vitality, or that part of it endowing the encephalon more particularly, or both, con- tingently and frequently, but not necessarily oi uniformly. 381. (10.) The alliance of the vital endow- ment with the material fabric being intimate, it may be inferred that affections of the one will disorder and ultimately change the other, when intense or prolonged; although, in persons pos- sessed of robust frames and much vital energy, the disorder of either may be severe, without its associate being seriously changed. Intense affections of mind hence may or may not change the allied fabric, and vice versa, according to the susceptibility of the system, and various other concurrent circumstances. This being the case, much of the structural lesion observed in old cases of mental disease is as probably the result as the cause of such disease; the pro- longed disorder of the vital endowment of the brain ultimately modifying the organization of that structure or fabric which was the instru- ment or medium of the disordered manifestation. In such cases the mental affection will influence the general as well as the local vital endow- ment, although it is primarily merely a disorder- ed state of that endowment, either generally or locally, and react upon it to such an extent as 590 INSANITY—Treatment. ultimately to change the allied fabric either of the brain or of remote organs. 382. (11.) As the powers of mind are mani- fested only through the medium of the enceph- alon, and are not the products of its organiza- tion—as they are the higher properties or man- ifestations of life only in alliance with, and through the instrumentality of this organ—and as affections of the vital endowment, or disor- ders of these manifestations, and changes of the intimate fabric of the encephalon, only con- tingently and frequently, but not necessarily or generally, disorder each other—so it follows, that the amount of the disorder evinced by Ahe mental power is no index to the extent or na- ture of the change existing in the brain, nor even a proof of the existence of any such change ; and farther, that the extent of change in the encephalon produces no correlative, dis- order of the mental powers ; and that most ex- tensive lesion may be present in the former without the latter being materially, or even at all, disordered. 383. (12.) Although lesions of the brain are often evinced by disorder of the mental powers, they are more generally and certainly indicated by the physical disorder, or by phenomena dis- played by distant but related parts. When lesions of the brain exist in connexion with dis- orders of the mind, these lesions, in respect both of their nature and extent, are indicated rather by the physical than by the mental phenomena ; the states of the general vital power, or endow- ment, being kept in view. 384. (13 ) Disorder of the vital manifestations of the brain being as dependant upon the states of the general and local vital endowment as upon alterations of the fabric of the encephalon, or even more so, it follows that the states of this endowment, generally and locally, and in connexion with changes of structure in various or remote, but related parts, should form the bases of our pathology of mental disorders, as much as lesions of the fabric of the encephalon ; and ought, moreover, to be the grounds and guides, as much as they, of our therapeutical indications, and the guides of our intentions and means of cure, whether hygeienic, moral, or strictly medical.* 385. VIII. Treatment of Insanity.—There are few maladies which are more successfully treated than insanity, when the means of cure are promptly employed, and appropriately to the varying forms and features of individual cases ; and there is none which requires, in or- der that all possible success should be obtained, a more comprehensive knowledge of morbid ac- tions, of the disorders, not only of the brain, but also of the other viscera, and of the intellectual and moral manifestations, as variously modi- fied, influenced, or disordered, by the predomi- nant feelings, the manners, the prejudices, the dissipations, and the vices of society. In at- tempting to give a full exposition of the treat- ment of mental disorders, as far as the existing state of our knowledge will enable me, it will be necessary, first, to offer some observations generally applicable to the treatment of insani- ty ; secondly, to state the means which seem most appropriate to the different forms of the malady; thirdly, to estimate the value of the principal remedies in the several states of de- rangement ; and, fourthly, to consider the moral management of the insane. 386. i. Remarks more generally applicable in the Treatment of Insanity.—It was for- merly too much the practice to treat the in- sane according to a certain routine or system, without reference either to the causes, or to the form of the malady; and the routine or system followed was generally based upon some prevalent doctrine applied to it, or some generally adopted system of pathology. Thus, the ancients had recourse to drastic purga- on the material fabric, but believe that it is a principle super- added to matter, on which, however, it depends entirely for its manifestations in our present state of being'. If this is not proved by everything that we know of mind and body, in health and disease, then it would be difficult, we imagine, to find any physiological truth demonstrated connected with the human organism. So far as liability to the charge of materialism is concerned, we consider the theory of our au- thor quite as objectionable as that of the phrenologists, for he supposes the mind owes its manifestations to the influence of the nervous system ; whether the bond or connexion be one of affinity, or whether it be explained in some other manner, matters not. We call attention to this point, be- cause we conceive that it lies at the very foundation of the true pathology and treatment of the various forms of insan- ity. We believe it necessary to place derangements of the internal faculties in the same relation to the organic affec- tion producing them, in which physiology places the de- rangements of the external senses. As sight and hearing are not impaired without disease of the organs on which these functions depend, so there is every reason to believe that thought and feeling are never deranged unless the cer- ebral organs, by which they are manifested, have undergone some morbid change. These views lead us to regard de- rangement of the mind, not as a specific disease, but a symptom attending many different affectfions, having the brain for their seat; neither does this doctrine, sustained as it is by observation, experience, and pathological investi- gations, confound mind and matter, nor militate against a belief in the soul’s immortality ; it leaves this great doctrine to be decided by Divine revelation, on which, after all, it must ultimately rest. We do not deem it necessary to go into an examination seriatim of the conclusions to which our author has arrived in relation to this subject; on one point, however, we may remark briefly. Mr. C. admits that the “ brain is the organ, instrument, or medium of commu- nication between the mind and the external world” ((') 360), and he supposes that “changes in the organization affect the mind in consequence of the molecular arrangement of the material fabric necessary to the healthy state of mind being disturbed,” &c. But, in I) 382, he states that “ most extensive lesion may be present in the brain without the mind being materially, or even at all, disordered.” This statement, so far as we know, can hardly be sustained in the present state of our knowledge in cerebral pathology ; it, moreover, clashes with previous admissions, and, if admit- ted, would go to sustain a belief iff the entire independence of mind on matter in our present state, a doctrine which is rejected by our author.] * [If the “ mind is the result of the vital endowment of the brain,” as contended for by our author, it is difficult to understand how “ the mind is independent of the material fabric with which it is associated,” a doctrine which, if we mistake not, is advocated in the preceding sections. The views and arguments of Mr. Copland, on the nature of mind and the mode of its connexion with matter, appear to us less clear and satisfactory than those advanced on most other subjects ; and we apprehend it would not be difficult to find a satisfactory answer to the questions he raises and the difficulties which he suggests. Mr. C. has al- ready admitted that the brain “ is the seat of mind” (Q 342) ; how, then, can it be said that the “ doctrine of or- ganism has been found fallacious and untenable ?” (t) 361.) Phrenology not only claims that the brain, in our present state of being, is the instrument with which the mind acts ; that material organs are necessary for the mental manifest- ations, just as eyes and ears are necessary for sight and hearing, or a stomach for digestion, but it even goes far- ther than this, and contends that the opposite doctrine, viz., that the mind acts independently of organization in this life, militates against the immortality of the soul, making it a changeable essence, and subject to infinite alterations ; weak and fickle in infancy, strong in manhood, imbecile in old age, and liable at all times to be afflicted with idiocy and madness. The truth is, that the theory of Mr. Copland only removes the difficulty a step farther back; it substi- tutes another link in the chain—vital endowment—which is also presupposed by those whose views he strenuously op- poses. The phrenological school by no means support the doctrine that the existence of mind is necessarily dependant INSANITY—Treatment. 591 tives, and especially to hellebore; the discov- : ery of the circulation of the blood led to the i employment of sanguineous depletions ; and the general adoption of the humoral pathology, at a still more recent period, was followed by a revival of the use of purgatives in this class of disorders. It must be obvious, however, to all who have observed the very different forms, the varying phases, and the numerous compli- cations of these disorders—who have viewed them in connexion with their causes, and with their effects upon the organization—that they, of all maladies, require not only the most di- versified, but also the most opposite means, according to the different causes and kinds of disorder, and to the changes observed in par- ticular cases. 387. Each case of mental disorder presents certain circumstances, all which require calm consideration, in order that it may be success- fully treated. 1st. The causes, whether moral or physical, predisposing or exciting, should be viewed, in respect of their individual and com- bined operation—of their action on the system generally, and on the brain, or any other organ, particularly—and whether acting primarily anil immediately, or secondarily and sympatheti- cally. 2d. The state and stage of morbid action ought to be ascertained, as regards both the grade of action, generally and locally, and the influence which such action seems to exert upon the manifestations of mind; and, 3d. The condition of the organic functions, not only as it may be the cause of general and local morbid action, but also as it may be the consequence of such action. On these circumstances are based those indications of cure which should be proposed when entering upon the treatment of every case of mental disorder. 1st. The causes should be removed in ways appropriate to their nature and combinations. 2d. General or lo- cal morbid action ought to be moderated, controlled, or removed, according to its nature, whether it be increased, or excited, or imperfect, or deficient. 3d. The several organic functions should be promoted, when impaired ; and restrained, when inordinately excited, either individually or collectively. It is unnecessary to state here how these intentions are to be severally carried into effect. The method or plan of procedure must necessarily vary with the circumstances characterizing the different forms of the malady, and the individ- ual cases of these forms ; but the remarks which I have to make may be referred to each of these indications, and in their respective order. 388. A. The seclusion of the insane is a ques- tion of the first and greatest importance, not merely as respects the removal of the causes of disorder, although this is one of the chief points in which it should be viewed, but also as regards the physical and moral treatment. That every person who is more or less disor- dered in mind should be separated from those with whom he has been accustomed to live, and from his family and friends, and restrained from his accustomed habits and manners, and confided to the care of strangers, in a place al- together new to him, may not be affirmed uni- versally ; but the exceptions to this rule are not numerous, and should be made, in prac- tice, with care and discrimination. As to the propriety of this measure, the most expe- rienced physicians in Great Britain and in for- eign countries are agreed. M. Esquirol re- marks, that recoveries are comparatively more numerous among the patients who come to Par- is to be treated than among those who inhab- it that capital, for the latter are less complete- ly isolated than the former. 389. a. The first effect of this measure is to produce new sensations, to change or to break the series of morbid ideas of which an insane person cannot divest himself: unexpected im- pressions are made upon him, arrest and ex- cite his attention, and render him more access- ible to counsels which may restore his reason. Generally, as soon as he is thus secluded, he is surprised and disconcerted, and experiences a remission of the disorder, that is of the ut- most consequence in the treatment of it, and in acquiring his confidence. The change is not the less useful, observes M. Esquiroi., in com- bating the disorder of the moral affections of the insane. The disturbance of the nervous system renders the sensations morbid, and oft- en painful; their natural relations with the ex- ternal world are no longer the same as in health ; all things seem disordered or overturn- ed. The patient cannot believe that the cause of these phenomena is in himself. He is per- suaded that every one wishes to contradict and irritate him, because they disapprove of his ex- cesses : not understanding what is said, he be- comes impatient, and puts an unfavourable construction on what is addressed to him. The most tender expressions are taken as offences, or for enigmas that he cannot comprehend. The most assiduous care is vexatious to him. The insane patient, having become timid or sullen, suspects every one who approaches him, and especially those who are dearest to him. The conviction that every one is inclined to tor- ment, defame, and to ruin him, increases the moral disorder. With this symptomatic sus- picion of those about him—which generally in- creases, without any motive or cause, from in- evitable circumstances or opposition, and with the change in the intellects—to allow the pa- tient to remain in the bosom of his family might soon be followed by the most disastrous con- sequences, not only to himself, but also to others. 390. Where the husband suspects the cares and assiduities of the wife, or the wife those of the husband, and supposes that he or she is in league with those who conspire against him; where the lunatic believes that the members of his family are the slaves destined to obey his sovereign commands, or are the ministers or . apostles of his mission ; where the cause of the : mental disorder exists in the patient’s own fam- ily, or arises from dissensions, chagrins, re- ' verses of fortune, or privations ; where the in- sane person entertains an aversion, hatred, or dislike to any member of his domestic circle, i and particularly to any one who had been most dear to him ; or where the parent, or the son, the lover, or the friend, is impressed with . the sentiment of his incapability of fulfilling the duties which he conceives to be imposed upon him, the necessity and advantages of removal, and complete separation from the object of his aversion, of his anxieties, or of his fears, are especially obvious and indisputable. The dis- like entertained by the insane to those who had 592 INSANITY—General View of its Treatment. once been most dear to them, without either cause or motive, imperatively demands the re- moval of the patient, who generally readily be- conjes calm before, or attaches himself to, an agreeable stranger, owing either to the circum- stance of his presence being unattended by any unpleasant association or suggestion, or to a feeling of self-love which induces him to con- ceal his sentiments and his state, or to the nov- elty of the impressions produced by strange persons and objects. While these are the chief inconveniences and difficulties in the way of the treatment of the insane while they remain in the bosom of their families, there are great advantages to be derived from removal to a place suitable to the management of this class of patients. 391. b. But how should the seclusion or the separation of the insane be carried into effect 1 That it should be effected by means of an asy- lum or institution devoted to their treatment, in the great majority of cases, is generally ad- mitted ; although removal to such a place may be unnecessary in some instances, or unadvisa- ble in others, owing either to the character of the disorder, or to the peculiar position of the patient—to the circumstances connected with certain cases. Partial seclusion or separation may be resorted to in some cases, and espe- cially in those which are slight. A partial sep- aration is when the patient remains in his own house, and is separated either partially or alto- gether from the members of his family and his friends, and is placed in the care of one or more suitable persons. Seclusion is more complete when he is sent to travel, or to make a voyage, in the custody of proper persons, or of one or more of his relations or connexions. And it is complete when he is removed to a residence al- together new to him, and surrounded by stran- gers, to whose care he is committed. Of this last kind of separation there are several modi- fications, the chief of which are : 1st. A private residence, devoted to the patient and to those placed in charge of him; 2d. A private asylum, containing several or many inmates ; and, 3d. A public or large institution, destined to the reception of a great number. In the great ma- jority of cases, the seclusion, in order that it may be fully successful, should be complete; and the last of these modes, when provided with all the appliances and advantages which many of these now possess, is the most useful, as it conjoins, with complete separation from the relations of the insane, several arrange- ments and circumstances obviously beneficial. M. Esquirol remarks, that the patient should be removed to an institution devoted to the treatment of mental disorders, rather than to a private asylum or residence. Partial isolatipn is much less successful than that more com- pletely afforded in a well-regulated institution. The chief objection which has been urged against the latter is the association with a num- ber of companions in misfortune; but this is not injurious, is no obstacle to recovery, but is even of service, inasmuch as it causes the pa- tient to reflect upon his condition ; and, as the objects around cease to impress him, he is amused or distracted by those about him, is oc- cupied by the objects passing around him, and thereby abstracted from what is apt injuriously to engage his thoughts. Large institutions, moreover, present greater facilities for the pro- tection of the maniacal and furious, without having recourse to injurious or irritating means of coercion and restraint, and the attendants are more experienced in their management than in a private house of detention. The advan- tages, however, of treatment in institutions of this kind depend entirely upon the medical ac- quirements and the characters of those intrust- ed with their management; upon the nature and completeness of the arrangements, thera- peutical, hygeiertic, and moral; and upon the organization and discipline of the whole estab- lishment. Still, there are cases to which re- moval to institutions or asylums for the insane is not applicable, however ably they may be managed, and their inmates treated; and, to these cases especially, removal thence might be productive of injury, particularly if the seclu- sion were not modified according to the sus- ceptibility of the patient, to the character of the disorder, and conformably with the pas- sions, the habits, the feelings, and the modes of living and manners of those subjected to it. It is not to be considered as a measure which should be universally employed. In this, as in all other departments of medical practice, experience—that is, close observation of phe- nomena, a knowledge of all matters related to individual cases, and a comprehensive view, and weighing of circumstances—will generally decide correctly as to its propriety. 392. Example, which has so great power over the opinions and actions of man, also influences the insane, who are often not deficient in saga- city and in the power of comprehending what is passing around them. The recovery or the departure of a patient creates confidence in others, and a hope of recovery and restoration to liberty. The convalescents, by their con- duct and advice, console and encourage those who suffer, and thus are of the greatest bene- fit ; one class of inmates of such institutions acting beneficially on the other, and favouring the success of the treatment. The calm, also, enjoyed by all; the moral repose arising out of removal from the habits, the business, the per- plexing cares, the domestic anxieties and cha- grins, and the irritating contrarieties to which they were previously exposed; the regular mode of living, the judicious discipline, and the regi- men to which they are subjected, and the neces- sity of duly comporting themselves—of conduct- ing themselves with propriety before strangers and before one another—all tend to suggest ra- tional reflections, and become powerful auxiliary means of recovery. The cares and attentions which the insane receive in their own families are counted as nothing ; but the attentions paid them abroad, or by strangers, are appreciated, because they are novel, and are neither due nor exacted. Hence the control readily obtained by those to whose care they are committed, when they are kindly and judiciously treated. 393. c. For melancholic and various forms of partial or slight insanity, complete separation is sometimes unnecessary, or even injurious. Partial separation, travelling, and various modes of exerting moral control, according to the pe- culiarities of the case, are often best suited to these states of disorder. Mania, and several states of monomania, demand complete seclu- sion. Demency, imbecility, and idiotcy require INSANITY—General View of its Treatment. 593 more or less complete separation—at least from society. Complete seclusion is generally ne- cessary to the poor lunatic, as he would other- wise be unprovided with the aid required to re- store him to his family. 394. d. Separation and isolation act directly on the brain, composing it to tranquillity, shut- ting out irritating impressions, repressing ex- citement, and moderating the exaltation of the passions and ideas. The sensations of the ma- niac are thereby reduced in number and inten- sity ; and his attention arrested, and even fixed, by thus being reduced, by the novelty of those which are excited, and by their frequent repe- tition. The melancholic and monomaniac are torn away by it from their morbidly concentra- ted thoughts and ideas, and are directed to dif- ferent objects or topics—especially when prop- er means of distraction are had recourse to— when judicious moral management is conjoin- ed with enlightened medical treatment. 395. e. In separating the insane from their families, the place of residence selected for them should be healthy, airy, and protected from cold winds, as well as from humidity and offensive exhalations. Their constitutions are generally more or less impaired and enfeebled, and they are consequently the more obnoxious to depressing influences and contaminating agents. They are generally predisposed to cu- taneous eruptions, enlargements of the glands, and general cachexia; and they therefore re- quire the more a dry and temperate, or even moderately warm air. It is a grievous mistake to suppose that they are insensible to cold and atmospheric vicissitudes. Although they may not give expression to their sensations, their constitutions, and even the. states of their minds, are remarkably affected by cold, humid- ity, and sudden changes of weather and sea- son, against which they should be completely protected. 396. /. The period at which the seclusion of the insane should terminate is not easily de- termined. Experience of a diversity of cases and circumstances is the chief guide to a just conclusion. When this measure is found to be unavailing, after having been duly employed, the visits of near relations, friends, or former connexions, may be tried, great discretion be- ing used in the selection of those who are the first to be admitted to the patient. In such cases, the visit ought to be sudden and unex- pected by him, in order that it may make the stronger impression. The utmost care should be taken in the admission of the visits of friends to convalescents ; and, with them, suddenness and surprise should be guarded against. Upon the whole, it is preferable that seclusion should be prolonged, rather than that it should cease prematurely. This measure, moreover, ought not to be had recourse to in any state of delir- ium consequent upon, or symptomatic of febrile diseases, and seldom in puerperal insanity. 397. B. To establish the medical treatment upon a sure basis, it is necessary to obtain as com- plete a knowledge as possible of the predispo- sing and exciting causes of the malady ; to as- certain the physical as well as the moral sour- ces and relations of it; to determine whether the physical occasions the moral, or the moral causes the physical derangement; and to rec- ognise the cases which will recover spontane- ously upon separation or isolation, and upon the removal of the causes; those which require chief- ly judicious moral management; those which demand medical treatment; and those for which a combination of these means will be requisite. Regardless of these and various other impor- tant considerations, the medical treatment of the insane has too generally been conducted either empirically, dr in the spirit of a narrow and exclusive system. Influenced by theory, or a predominant doctrine, some have referred mental disorders to inflammation, and have abused the various modes of blood-letting ; oth- ers have believed that these disorders proceed from a morbid state of the biliary and digestive functions, and have disordered still more these functions and their respective organs by emet- ics and drastic purgatives; and many have con- sidered the nervous influence solely in fault, and have attempted to correct it by means of antispasmodics and stimulants ; hence the treatment has been nearly as often prejudicial as beneficial; and recovery has taken place in many instances, notwithstanding the means that have been used, rather than by the aid of them. 398. a. When called to a case of insanity, the obvious duty of the physician is to ascertain the predisposing and exciting causes ; the sev- eral circumstances co-operating with these causes, or contributing to their influence and intensity ; the particular form or character of the: disorder, its duration, and physical rela- tions ; the states of the several functions, or- ganic and cerebro-spinal, and the connexion that may exist between the mental disorder and the states of these functions, or of their respect- ive organs. He will, moreover, observe what- ever may exist of a pressing nature, or what- ever indication there may be urgently requiring to be fulfilled; as, for example, whether or not the signs of vascular determination to, or ex- citement in the brain be obvious, and indicate impending risk to the organ ; whether there be general vascular plethora or vascular inanition ; whether some accustomed discharge, evacua- tion, or eruption has been suppressed; and whether or not the patient has been subject to some constitutional disorder, as gout or rheu- matism. It is manifest that these are matters most necessary to be known upon commen- cing the medical treatment of every case of mental disorder; and, without they are assid- uously investigated, in no one instance can such disorder be appropriately treated. Where these more urgent indications exist, they re- quire instant attention ; where the blood is strongly determined to the brain, the usual means of subduing the morbid action—local de- pletions, the cold affusion, or tepid douche, or shower bath, external and internal revulsants and derivations, suitable diet and regimen, &c., are requisite ; where the vascular system is plethoric or inordinately excited, sanguineous depletions, refrigerants, sedatives, evacuations from the bowels, the skin, and urinary organs, and low diet are necessary; where the cata- menial or the heemorrhoidal discharges, and eruptions or evacuations, either sanguineous or serous, or of other characters, have been sup- pressed, or have ceased to appear after the ac- customed interval, the most active means must be prescribed, in order to reproduce them, or as substitutes for them. 594 399. b. Having removed the cause and con- curring circumstances of the malady—having thus fulfilled the more urgent and pressing in- dications, and having remedied such morbid conditions of the organic functions as may have existed, the more acute symptoms or stage of the malady will subside in about 8, 14, 21, or 28 days, or generally within 40 days, and a re- mission, or even an intermission, will occur. At this period, judicious and appropriate mor- al means should be brought in aid of the phys- ical treatment, while the causes, moral, hy- geienic, and pathological, ought to be removed or combated. If the recovery does not proceed satisfactorily, or if these means, varied accord- ing to the particular circumstances of the case, do not produce beneficial results, other reme- dies, sanctioned by experience, must be tried. These, however, will be fully noticed in the se- quel. 400. C. As the malady thus lapses into a more or less chronic form, local or general man- ifestations of morbid action, which occasionally appear, return, or even remain, should be re- moved or suppressed by the usual and gener- ally obvious means ; and signs of disordered sensibility should be traced to their sources, and their pathological causes removed. When- ever disorder or disease of any organ in the ab- dominal or thoracic cavity is evinced, the fact of such disorder being frequently connected, either as cause or effect, with that state of the brain which occasions the disorder of its as- sociated mind, should be kept in recollection; and an appropriate treatment ought to be di- rected to the quarter thus manifesting disor- dered sensibility or function, always bearing in mind that morbid action in the substance of the brain is more frequently indicated by mor- bid sensations and disordered movements and functions in remote than in adjoining parts. 401. During the whole course of the treat- ment, the several organic and reproductive functions require attention. The state of the digestive organs, and especially of the biliary and the intestinal secretions, and, indeed, the whole of the excretory functions—the faecal, the urinary, and the cutaneous—ought to be duly, or even daily observed, and promoted whenever scanty or suppressed, or restrained when they become so excessive as to debilitate. More frequently, especially at the earlier peri- ods of the malady, these functions require to be promoted ; and as the defect, as well as the dis- order of these functions, is often owing to im- pairment of the organic nervous or vital ener- gies, the restoration of their healthy states should be attempted chiefly by means which will also invigorate these energies. With this intention, stomachics, tonics, or restoratives should be conjoined or alternated with purga- tives, chologogues, or alteratives ; and the bow- els ought never be allowed to be confined, or the biliary secretion to be deficient. The ap- pearances and sediments of the urine should be ascertained, and alkalies or acids adminis- tered accordingly, with gentle stomachics and diuretics ; and the action of the skin ought to be duly regulated by the cold, the shower, the tepid, or the warm bath, and by frictions and clothing, according to the form or stage of the malady, and the particular conditions of the cu- taneous function. The states of the reproduc- INSANITY—General View of its Treatment. tive organs also require observation, espe- cially of the uterus. And it should not be over- looked, that these organs are often abused by solitary indulgence, in such a manner as both to cause and to perpetuate the malady. Where this is detected, or even suspected, means should be contrived to prevent it. In advanced stages of insanity, although the treatment should be conducted, with reference to the removal of existing pathological states and of disordered mental manifestations, according to rational principles ; still, when means thus devised fail of success, other and more empirical remedies, sanctioned by experience, ought not to be neg- lected. To these, however, sufficient refer- ence will be made hereafter. 402. D. The clothing of insane persons, par- ticularly of the melancholic, should be warm. In general, flannel may be worn next the sur- face ; and dry friction every morning will be useful. The patient should sleep on a hair mattress and hair pillow'. His head ought to be somewhat elevated, and generally uncover- ed. The insane epileptic ought to sleep in a very low bed, to prevent accidents during a paroxysm. The propriety of devoting strict attention to cleanliness, in respect both of his person and clothes, is obvious. 403. E. The food, and diet of the insane must necessarily be varied with the nature, compli- cations, and stage of the disorder, and with the circumstances of particular cases. In the more acute attacks or stages of the malady, the diet and regimen ought generally to be antiphlogis- tic ; at a later period, and in more chronic ca- ses, and particularly in states evincing vital de- pression or exhaustion, the food should be more nutritious, in larger quantity, and easy of di- gestion ; but hot spices and stimulants ought not to be allowed. During convalescence, the diet may be more substantial, but not heating, and duly regulated according to the exercise that is taken. The meals should be at regular periods, and deliberately partaken of, and well masticated. A sufficient quantity of fluids should be allowed to assuage the thirst of the patient, which is generally urgent in mania, and in some cases of monomania; but they ought not to be given, unless w'hen necessa- ry, or when, in certain cases, a profuse use of them forms a part of the treatment. 404. F. The management of convalescence is one of the most difficult parts of the treatment of the insane. If the patient be not placed in favourable circumstances for some time after the subsidence of the malady ; if he be not care- fully and kindly watched; if contrarieties of mind, family dissensions, and all the remote causes, moral and physical, be not sedulously avoided ; and if the diet, regimen, and mode of living be not suited to his constitution and the peculiarities of his late disorder, the risk of a relapse will be great. At this period, and for long afterward, much mental exertion or appli- cation, sudden bursts of passion, and excesses of every description must be shunned ; and the earliest manifestation of physical disorder—of headache, of disorder of the digestive organs, and of interruption of accustomed evacuations or discharges—should be met with local deple- tions, purgatives, revulsants, diaphoretics, and other means appropriate to the nature of the disorder. As convalescence proceeds, change INSANITY—Treatment of its Partial Forms. 595 of air and of scene, and travelling with a suita- ble companion, or one capable of amusing, for- tifying, and even of controlling the mind, will be most beneficial; and such mineral waters as will promote the secretions and excretions, and, at the same time, strengthen the constitu- tion, without exciting or heating the circula- tion, or determining the blood to the head, will often prove of essential service. 405. G. The measures proper to prevent insan- ity, and more especially a relapse or return of it, are most obviously presented to the reader in the full exposition I have given of the predispo- sing and exciting causes. The avoiding of these constitutes the chief, and, indeed, the only proph- ylaxis. Young persons whose parents have been the subjects of this malady should have especial attention paid to both their physical and their mental development; and while the former is promoted by exercise in the open air and healthy occupation, the latter should be cul- tivated without being over-exerted, and sound religious and moral principles ought to be in- culcated, care being taken to avoid indulgence of the caprices, passions, and selfish feelings. The instruction of these persons should not be premature ; but the desires and passions ought to be early restrained. The judgment should also be early aniPjudiciously informed, without fatiguing the mind ; and the control of parents or guardians ought to be prolonged for a con- siderable period after puberty, and until the mind, conduct, and constitution are fully formed. 406. ii. Of the Treatment of the Specific Forms of Insanity.—A. Partial Insanity.— The simpler forms or slighter grades of insanity severally require a moral management, as well as a medical treatment, appropriately directed to tfieir different states and characters, which, however, are so diversified as to preclude the possibility of my considering the subject wdth reference to any but those which are the more common and prominent.—a. In the various states of moral insanity (f 69, et seq.) in which the pa- tient is not labouring under any illusion, or er- roneous conviction, or disorder of the under- standing, the propriety of seclusion cannot be decided upon, excepting with reference to the features of, and the circumstances connected with individual cases. Many of these states of moral disorder, consisting chiefly of errors in action and conduct, are not of that grave and well-marked kind which is considered, in the eye of the law, to require the privation of lib- erty, although, in the majority of such instan- ces, the conduct of the patient may be such as will prove the most injurious to himself and to those depending upon him. In other less ques- tionable cases of derangement, and where the disorder is so restricted as to leave the patient, according to appearances, the exercise of a great portion of his reason, it is often difficult to come to a determination as to the propriety of seclusion. The opposition which the patient may experience may endanger the portion of intelligence that remains. It is as unnecessary as it is cruel to deprive a person oppressed by distressing feelings, or prone to terror or alarm, of his friends and relatives—of the attentions of his family—as long as he entertains no vin- dictive feelings or dislike to them, and espe- cially as long as his actions may be reasonably controlled by them. 407. a. In the state of gloom arid mental de- pression to which some persons, the subjects of moral insanity, are prone (§ 73), seclusion may be productive as readily of mischief as of benefit. For these, travelling, visiting water- ing places, medical treatment, the kind inter- course of those to whom the patient is partial, and the watchful attentions of the members of his family, or of those accustomed to attend upon persons in this state of mental affliction, should be tried before seclusion be resorted to. When suicide is contemplated, seclusion and control in an asylum will prove more success- ful than the most careful attentions in the bo- som of the patient’s family. Still, in the ma- jority of such cases, this measure will be more successful chiefly in respect of the safe custody of the patient; for none besides will be equal- ly secure. The most vigilant keepers may be deceived by him when he is otherwise at large. 408. (3. When the disorder is characterized by unnatural excitement (§ 74), seclusion and confinement are often requisite, and are gener- ally successful by inducing reflection. When persons thus affected have a propensity to in- toxicating liquors, accessions of mania being thereby occasioned, seclusion is necessary ; but upon the restoration of liberty the morbid disposition returns. In all cases of moral in- sanity where the morbid propensity is danger- ous to the patient or to others, this measure becomes indispensable. When the disorder as- sumes a religious character (§ 75), travelling, society, and a suitable moral and medical treat- ment are preferable to seclusion ; and confine- ment ought not to be resorted to unless suicide have been attempted or contemplated. 409. The treatment of all the forms of moral insanity ought to be essentially, although not exclusively, moral. Comparatively few instan- ces of these do not present more or less of phys- ical disorder, seated either in the head itself, or in some organ with which the brain sympathi- zes. Of this I have already adduced sufficient evidence (§ 92-94). The moral treatment in all these must be based upon a knowledge of the remote causes of individual cases, and should vary with the circumstances of each. It is im- possible to state here in what this treatment should consist with reference to such circum- stances ; the subject will be as fully treated of hereafter as my limits will permit. Wherever physical derangement can be detected, or to whatever organ it can be referred, appropriate medical means should be directed against it, while the patient is enjoying the advantages of a suitable moral management. The general health should receive due attention ; and the functions of digestion, secretion, and excretion be duly promoted. Due restraint ought to be, as far as possible, imposed upon the passions and emotions, and change of air, wholesome exercise, and interesting occupations be pre- scribed. 410. y. The treatment of erotomania should have reference chiefly to disordered circulation in the brain occasioned by an excited imagina- tion and protracted desire, in connexion with great susceptibility of the nervous system gen- erally. If this affection be not alleviated, it will pass into more general disorder of the mental powers; especially into melancholia, mania, or 596 INSANITY—Treatment of its Partial Forms. some form of dementia. When it occasions emaciation and hectic fever, thereby menacing the life of the patient, marriage may be sug- gested. In this, as in nostalgia, the accom- plishment of the desires of the patient is the chief or only remedy. When the object of de- sire is concealed, every art should be tried to ascertain its nature and source, as the ef- fects upon the mind that will consequently re- sult may be of much service, and a moral in- fluence may be exerted over the patient with greater advantage. Where marriage is impos- sible, change of scene, travelling, society, and the amusements of watering places, a tonic and restorative treatment, healthful and pleas- ant occupations, exercise in the open air in agreeable company, and suitable diet and regi- men, are chiefly to be depended upon. When there is any evidence of increased determina- tion of blood to the head in this, as in other forms of moral insanity, and especially when the scalp is hot or the eyes injected, the tepid or cold shower bath every morning will be found of great service. 411. <5. The morbid propensity to intoxication {() 86) is often attended by symptoms indicating not only a state of irritation of the stomach, but also a general depression of the nervous power. In this state, tonics, with small doses of ammonia, may be used with advantage ; and, in order to counteract the injurious effects of the intoxicating fluids upon the system, to pre- vent the disorder from leading to more general and severe derangement of mind, and to dis- gust the patient with these fluids, tartarized antimony, ipecacuanha wine, or other nausea- ting drugs, and even the extract of elaterium or croton oil may be added to them before they are partaken of by the patient. In two cases, one, of which I attended with Mr. Hood, this method was found successful in causing a loath- ing of these fluids, in moderating the mania consequent upon the use of them, and in per- manently restoring the patients. In both these cases, seclusion, and a sufficiently permanent and close restraint, could not be conveniently put in practice : this plan was, therefore, tried in the fh-st instance, and succeeded in causing a distaste of all kinds of intoxicating liquors. To succeed, however, by means of it, requires great care and management on the part of the friends of the patient. 412. e. Homicidal insanity (j> 89) and incendi- arism {() 88) are generally dependant upon an irregular activity of the circulation, or a morbid state of vascular action, especially in the brain. They are both frequently connected with disor- der of the uterine organs, or suppression of the catamenia ; and, in males, with derangement of the digestive organs, and with sanguineous determination to the head. Medical treatment in these cases is mainly to be trusted to; fot the morbid impulse to commit these crimes is often so violent as to be instantly carried into effect, either before moral restraint can be ex- erted to counteract it, or because this restraint is habitually so feeble as to be inefficient, or is not roused to the least degree of activity. The impulse to perpetrate such crimes may, indeed, be looked upon as one of the modes in which physical disorder of the brain, arising either primarily or sympathetically, deranges the man- ifestations of mind—those sentiments or pro- pensities which circumstances have called into* activity being thereby disordered or morbidly exalted. In many instances, also, there is rea- son to believe that the morbid impulse to com- mit crime is only the climax of an habitual in- dulgence of passion and feeling, to the constant neglect of moral principle and restraint, and is a tolerably obvious consequence of cerebral ex- citement, the effects of which are determined or manifested in this particular manner or di- rection, owing tb various predisposing and con- curring sentiments and circumstances. 413. In these cases, local or general deple- tions, according to the amount of local or gen eral fulness, or of increased vascular action the cold douche, cold affusion, or shower bath ; active purgatives, revulsants, and derivatives ; antimonial and other diaphoretics ; digitalis and other sedatives ; and the promotion of the se- cretions and excretions generally, constitute the chief principles of treatment, aided, how- ever, by a due moral influence, and by proper mental and physical occupation. 414. b. Partial disorder of the understanding (§ 95) appears under so various and numerous forms as to require a treatment appropriate, not only to each of these, but also to individual ca- ses. Each patient should be a particular sub- ject of study, and the moral and physical treat- ment directed according to the character and stage or duration of the disorder, and the vari- ous circumstances connected with its develop- ment.—a. Hypochondriacal monomania is gener- ally an extreme state of hypochondriasis, and more or less intimately connected with physical disorder, commonly commencing in the digest- ive organs, and consecutively affecting the brain. The treatment should not be materially different from that which I have recommended for that disease; and the hygienic means there advised (see Hypochondriasis, <) 50), especially, should be adopted. In the majority of cases, complete seclusion will not be necessary, un- less the patient contemplate or attempt suicide. More generally, however, travelling, change of scene and of air, horse exercise, agreeable oc- cupations, hunting, the amusements of society and of places of resort—especially when at- tended and controlled by friends or suitable per- sons—will be found most conducive to recov- ery, particularly if an appropriate medical treat- ment, and the use of mineral waters of a resto- rative and deobstruent or laxative kind, be pur- sued at the same time. Every method should be tried, and especially those just mentioned, to abstract or seduce the patient’s attention from those feelings and ailments with which his mind is exclusively and morbidly occupied. The strictly medical means should be varied according to the peculiarities of individual ca- ses ; and the more urgent symptoms should be palliated by suitable remedies. The bowels ought never be allowed to become costive, and their functions should be promoted by aperi- ents, conjoined with tonics, carminatives, and deobstruents. All the secretions and excre- tions should be duly promoted. Flatulence and gastrodynia must be allayed by magnesia, the hydrocyanic acid, gentle tonics, &c., variously combined ; and by spare diet, consisting chiefly of warm milk, with bread or boiled rice, or other farinaceous articles. 415. (3. The treatment of melancholic monoma- INSANITY—Treatment of Melancholic. 597 nia (§ 106) is most difficult, and, to be success- ful, requires a strict examination of the physi- cal and moral causes of each case, and an ap- propriate employment of moral, hygienic, and medical means.—(a) Moral treatment is of the greatest importance in this form of insanity, and in all its modifications, whether religious, or demonomaniac, or misanthropic, melan- cholia, or any other it may assume; but this part of my subject will be more appropriately considered hereafter. 416. (h) The hygienic measures that may be resorted to consist chiefly of attention to cli- mate, residence, exercise, clothing, and diet. The patient should reside as much as possible in a moderately warm, or temperate and dry air, or in a mild climate and a clear atmosphere ; and if he must abide for a time in a place where these advantages are not enjoyed, he should choose spring and summer, and migrate during autumn to the milder climate, where he should reside during the winter and early spring months. The patient’s clothing should be warm, and consist of flannel nearest the skin; and this should be frequently changed. As melan- cholics are subject to cold feet, these parts should be carefully protected. 417. (c) Seclusion—at least complete seclu- sion—should be prescribed with great circum- spection. There can be no doubt of its propri- ety when suicide is contemplated, or has been attempted. But in other cases, partial seclu- sion, particularly in connexion with agreeable and interesting occupation and amusement, is more safe and beneficial. Seclusion, however, even when complete, often re-establishes the moral powers and the reasoning faculties wrhen they are exhausted by indulgence of the pas- sions and desires. 418. (d) Exercise and suitable occupation are very important parts of the treatment of mel- ancholia, and of all the states of partial insan- ity. Travelling, voyaging—especially to a con- siderable distance, and with a fixed object, or with feelings of interest in what may result or occur—is one of the best means that can be devised. Exercise on foot or on horseback, regularly taken, so as to promote the cutane- ous excretion ; occupations in the open air, which are attended by moderate physical exer- tion and mental excitement; hunting, shoot- ing, and games of skill and activity, as cricket; and farming and gardening, are severally of great benefit. The chief objection to the last of these is the occasional stooping necessary to several of its duties. Billiards are also use- ful means, both of exercise, interest, and amuse- ment. Whatever moderately excites, interests, or occupies the mind, is serviceable in the treat- ment of melancholia; and especially if it, at the same time, abstracts the attention or imagi- nation from the object of its illusion. When music is properly selected, and prosecuted so as to accomplish these objects, the advantages that may be derived from it are great. As to the selection of modes of occupation and exer- cise for individual cases, much should depend upon the patient’s previous and existing tastes and habits. A principal intention in this class of disorders, in all forms of partial insanity, is to detach the patient’s attention, his mental de- votion, from the object on which he has mor- bidly fixed it, to seduce it to other objects, and to engage it with different subjects and matters of interest and importance. 419. (e) The diet of melancholic patients should be light, digestible, and moderately nu- tritious. Salted, highly-spiced, irritating, and oily or fat articles of food ought to be always avoided. The food should be simple, plainly dressed, consisting of very few articles at the same meal. Ripe and fresh fruits, in due sea- son, may be allowed. The quantity and kind of food should have reference to the amount of exercise. When this is so great as to freely promote the cutaneous, biliary, and alvine evac- uations, a more liberal diet may be permitted than in other circumstances. Great circum- spection is requisite in allowing this class of patients restorative or exciting liquors. If the head be cool, and the action of the carotids rather below thau above the healthy standard, these may be tried in small or very moderate quantity, and their effects observed. General- ly, however, the influence of gentle tonic and restorative medicines should be previously tried. [It is believed that a rather generous diet of a mixed kind is more generally adapted to the treatment of the insane than one of a lowering or antiphlogistic nature ; but it is, of course, to be conformable to the general curative plan of the individual patients. Much will depend on the previous habits and manner of living. The diet should, of course, in all eases be ordered by the physician, and, as in other diseases, adapted to the state of the patient and his di- gestive organs, which vary according to tem- perament, age, previous manner of living, and particular idiosyncrasies.] 420. (f) Medical Treatment.—The physical disorder requires, simultaneously with the adoption of the foregoing measures, and of suitable moral means, a judicious recourse to remedies calculated to promote or to correct the functions of the digestive organs, and, in- deed, of all the abdominal viscera. There are very few of these viscera which have not be- trayed more or less of disorder even long pre- viously to the development of the mental affec- tion. The functions of the skin are usually im- paired, and often require the tepid or the warm bath for their restoration. The alvine excre- tions, especially the intestinal, are generally re- tained, or voided imperfectly or with reluctance, owing manifestly to relaxation of the muscular tone of the bowels, and especially of the colon. The secretions are also deficient, and morbid from their retention. These physical condi- tions require for their removal the frequent use of aperients and laxatives, conjoined with ton- ics and other restoratives ; for their continu- ance would increase that state of excrementi- tial plethora of the vascular system in which melancholia and hypochondriasis often origi- nate, by depressing and disordering the vital manifestations of the brain. Even the urinary secretion is deficient, the discharge of the more excrementitious materials from the blood by the kidneys being partially interrupted, or defi- cient in respect of certain of the constituents of the urine. In most instances, the morbid materials carried into the circulation, or accu- mulated in it, owing to defective powers of di- gestion and assimilation, are not sufficiently discharged from it by the action of the kidneys, 598 INSANITY—Treatment of Melancholic. bowels, liver, and skin ; and thus the impure state of the blood influences the manifestations of the nervous centres. In such circumstances, the restoration of these functions, by suitable hygienic and medical treatment, is always a principal indication of cure. 421. The chances of recovery from melan- cholia may be almost said to be great in pro- portion to the manifestation of disorder in the organs of digestion. As the pathological causes of the mental affection show themselves the more evidently, the greater hopes may be en- tertained of the disappearance of the latter with the removal of the former. Where these ex- ist, the therapeutical intentions should be di- rected accordingly. If the function of any or- gan be impaired or interrupted, the restoration of it is indicated ; if the hasmorrhoidal or cata- menial evacuation is suppressed, means should be taken to re-establish it; if a cutaneous eruption have disappeared, or an accustomed ulceration or issue ceased to discharge, the skin should be acted upon, or some analogous mode of derivation and counter-irritation be adopted. It is, however, not always, nor even frequently, that melancholia can be referred to these, or equally manifest sources, and where such very obvious indications of cure as these present themselves. Still, there are generally to be observed certain conditions of the abdom- inal organs, of the cerebral and general circu- lation, and of the nervous system, which sev- erally require attention, and furnish the basis of a rational method of treatment. 422. Where the functions of the digestive organs are sluggish, the bile is morbid, dark, irritating, or scanty, and the various secretions and excretions insufficient for the due purifica- tion of the blood, or for the preservation of it in a healthy condition, it is clearly indicated to restore these functions by means which shall impart a new impetus to the vital endowment of their respective organs, and enable them regularly to perform their offices. In a very large proportion of cases, not only is the bile morbid, but the whole abdominal secretions are disordered, and certain of them are retained on the intestinal mucous surfaces, or even accu- mulated in the caecum and colon. The fre- quency of these changes, and the benefit re- sulting from the more certain means of remo- ving them, induced the ancients to have re- course to black hellebore, and the moderns to milder cathartics, to purgatives or to laxatives, in the treatment of this malady ; and the pro- priety of the practice, when the means are well selected and combined, and judiciously man- aged, cannot be disputed. In some cases, es- pecially where there is much torpor of the bil- iary apparatus and of the bowels, with accumu- lated sordes on the digestive mucous surface, a brisk emetic, or even an emeto-cathartic, is of great service early in the complaint and at the commencement of the treatment. When the strength of the patient will permit, a continued action on the bowels—an artifical diarrhoea should be kept up, by means of chologogue or stomachic purgatives or aperients, for a con- siderable period; and purgative enemata may also be employed. A combination of the com- pound infusions of gentian and senna, with a neutral salt, and an aromatic spirit or tincture (F. 266), will be appropriate in these cases, and the spirit of turpentine, with castor or olive oil, may be prescribed in enemata. A similar means to these, of which a variety will be found in the Appendix, and in the articles Hypochondriasis and Indigestion, may be employed according to the peculiarities of individual cases. When the patient believes that his physical health is not in fault, or when there is a disposition to sanguineous determination to the head, James’s powder, or tartarized antimony, may be given in small and frequently repeated doses, so as to keep up an action upon the skin or bowels, and to induce a feeling of bodily ailment, so as to dispose the patient to pursue a suitable treat- ment. 423. When indications of congestion of the brain, or of determination of blood to this part, or of general vascular plethora, or of inflamma- tory irritation of the gastro-intestinal mucous surface, or of fulness of the portal system, are observable, and especially if they have become more evident after the disappearance of an ac- customed evacuation, general or local blood- letting should not be delayed. Local depletions are generally most appropriate in these circum- stances, and ought to be decidedly employed, particularly in the more robust. per- mitted blood-letting only in the young and ro- bust in this complaint, and in small quantity, and chiefly in spring; Cullen considered that it was rarely useful; Pinel seldom employed it; and Esquirol advised it in nearly the same circumstances as I have recommended it. The application of leeches, and even the repetition of them, to the vicinity of the vulva, or around the anus, when the catamenial or haemorrhoid- al evacuations have been interrupted, or the portal system congested, and to the epigastri- um or hypochondria, or behind the ears, when uneasy sensations are referred to the enclosed organs, is generally attended with benefit; and this evacuation may be repeated even oftener than once, and commonly with advantage, al- though it may be requisite to administer ton- ics, antispasmodics, or restoratives at the same time. 424. Many cases of melancholia present a morbid susceptibility and sensibility of the ner- vous system. The patient is remarkably ner- vous, and his distress is evidently heightened by sanguineous depletions, however moderate, and by purgatives if too frequently exhibited, or even if they operate beyond the mere evac- uation of the bowels. Lorry has well descri- bed this form of melancholy, and very properly recommended for it calming measures—opiates, with gentle stimulants and restoratives. In these cases, the warm or vapour bath, the te- pid or warm douche, the affusion of warm or tepid water on the head, and the tepid bath, ac- cording to circumstances, will be of great ser- vice. Small doses of camphor, with opium, morphia, or hyoscyamus, or with the extract of poppy or lactucarium; the infusion or the ammoniated tincture of valerian, or both con- joined ; the infusion or tincture of hop ; and other antispasmodics and diffusive stimulants, variously conjoined with sedatives, narcotics, &c., and a pure, dry air, change of scene, and light food, are generally beneficial in this state of disorder. If there be watchfulness and ir- ritability, the hop-pillow, or the sirup of pop- pies, or the compound tincture of camphor, in INSANITY—Treatment of Maniacal. 599 a small enema, will afford relief. When the s disorder has been caused by masturbation, the ( cold affusion or shower bath, the cold plunge 1 bath, and tonics, especially the muriated tine- i ture of iron, should be prescribed. As the en- i ergy of the nervous system returns, more per- manent and energetic restoratives and tonics 1 may be employed ; but during their use the se- i cretions and excretions ought to be carefully ; promoted, and the bowels kept freely open, care 1 being taken to prevent congestions of the brain or portal system. 425. In many instances, a combination of the several indications based upon the condi- tions of the abdominal organs and of the vas- cular and nervous systems, and the association of more or less of the means required to fulfil these indications, are often both necessary and successful. Thus, it is frequently of the great- est advantage to act energetically upon the bowels by means of stomachic or chologogue purgatives; to deplete the vascular system, either generally or locally; and, at the same time, to give stimulants, antispasmodics, and tonics, the choice of the several means depend- ing upon the characters and symptoms of indi- vidual cases. As to the propriety of exhibit- ing the more active tonics in melancholia, much doubt may be entertained; but if accumula- tions of morbid matters in the bowels have been removed; if the tongue be clean, moist, or watery ; if the secretions and excretions have been improved, and if a trial of them be not productive of headache, of increased heat of the scalp, or of feverishness, the use of them may be persisted in, care being taken to keep the bowels freely open, and to guard against local fulness or determination of blood. The diet, regimen, and the management of con- valescence, require no remarks beyond those which have already been made (§ 402-405). 426. c. Demonomania, in its different forms, and especially theomania, or various states of religious insanity (<) 121, et seq.), require a some- what similar plan of treatment, and the same indications of cure, as have been recommend- ed for melancholia, with which they are more or less closely allied. Moral treatment is par- ticularly necessary, but, equally with the phys- ical, should be varied according to the peculiar features of individual cases. In all the modi- fications of religious insanity, the consolations of religion, administered by sincere, moderate, and rational ministers of it, are of the greatest service. I have witnessed this in several ca- ses; and, when judicious moral and religious management is aided by a sound physical treat- ment, recovery will take place in the great ma- jority of instances. In no form of insanity is greater care requisite than in this, to protect the unfortunate patient, and his near relatives, or members of his family, from his insane im- pulses to commit suicide or murder. Pinel states that a person, after listening to an alarm- ing sermon, considered himself as irretrievably lost, and murdered all his children, in order that they might not experience eternal damna- tion. Esquirol mentions the case of a wom- an who entertained a similar idea, and attempt- ed the lives of her children to preserve them from punishment in a future world; and nu- merous other instances of the same kind might be adduced. When persons thus disordered succeed in their horrible design, they rarely re- cover ; for no sooner is reason restored, than the distress experienced by them, when reflect- ing upon the act they have committed, occa- sions a return of the malady. 427. The physical disorder, both antecedent to, and coetaneous with the mental disorder, should be carefully investigated ; and particular attention devoted to the states of the brain, of the digestive organs, and of the uterine func- tions ; and determination of blood to the head prevented by local depletions, the shower bath, or douche; by derivatives and aperients. In the more robust and young, the preparations of antimony, in small doses, and occasionally in larger quantity, so as to produce vomiting, are often of service. 428. In those cases where the patient enter- tains the belief that he is changed into some animal, or that he has changed his sex, or that he has lost a portion of his body, or that he car- ries about with him a living thing, or some strange substance in his abdomen, or that some singular matter is substituted for one of his or- gans or members, and acts from this impres- sion, the success of treatment is often not great. In many of these there is reason to suspect physical disorder, if not structural dis- ease, in the organ or part to which the insane delusion is referred ; and to that organ the in- vestigation and the treatment should be espe- cially directed. 429. B. Treatment of General Insanity. —a. Of Mania.—In treating mania, it is ne- cessary to have a most intimate regard to the stage of the disease—to the degree of general and cerebral vascular action and vascular ful- ness—and to the state of the secretions and excretions. The means which will prove most beneficial during the acute stage, and especial- ly in the early part of it, will be inappropriate, or even injurious, in the chronic period of the malady. The treatment of mania is both hy- gienic and pharmaceutical. The former com- prises various moral, intellectual, and physical means ; the latter, the internal remedies in- tended to subdue morbid action, and to restore the healthy functions.—a. At the commence- ment, and during the early or acute stage of the • malady, the patient should be placed in a large, darkened, and well-ventilated apartment, the air i of which should be fresh and cool. Unless his , violence is extreme, he ought to be allowed the ; full range of that, or even of an adjoining apart- ■ ment, in the watchful care of sufficient attend- i ants ; and the restraint even of the strait waist- • coat should be dispensed with, unless urgently ■ required. Complete seclusion is most neces- > sary, and it should be preferably conducted in t a large institution, conformably with what has , already been advanced on this subject ($ 391). ■ All means of irritation or excitement should be . prevented, as far as may be compatible with - safety to the patient and those around him. r The visits of relatives, connexions, or even of r acquaintances, should be prevented, and the - patient ought to be exposed to the smallest • possible number of impressions and causes of ■ excitement. The diet should be rigidly anti- i phlogistic, and cooling diaphoretics, refriger- • ants, and diluents prescribed. The nitrate of t potash, the muriate of ammonia, the solution 1 of the acetate of ammonia, the spirits of nitric 600 INSANITY—Treatment of Maniacal. sether, the solution of tartarized antimony, camphor julep, &c., may be severally used as refrigerant diaphoretics, or administered in the patient’s usual drink ; or any of the articles prescribed in the Appendix (F. 588, et seq.) may be employed with this intention. 430. In this form of insanity, patients ought neither to be retained in their own houses nor confined to their beds. If they are turbulent, vociferous, and violent, their extravagance should be allowed to exhaust itself without being perpetuated by the excitement of contra- diction, irritating coercion, or violence, unless in as far as coercion is indispensable ; and, as soon as it shall have served its purpose, it should be relaxed. . Soothing means, with firm- ness, and decision when circumstances require it, should always be tried, and never be depart- ed from, even when the utmost restraint is also imposed. The perceptions of the maniac are seldom so entirely obscured as to render him incapable of understanding kind and soothing treatment, or to make him altogether insensi- ble of considerate modes of having recourse to coercion : this has been proved by the able management of cases of this malady in the County Asylum, by Dr. Conolly. M. Esquieol also observed that coercive means should not be resorted to until the maniac risks his own life, or the lives of others ; and even then they should be temporary, and be laid aside as soon as a calm takes place. When the patient will not pass the night in bed, it is better to leave him unrestrained than to coerce him, if he evince no mischievous tendency. This writer has found that the more that liberty has been granted to maniacs, without compromising their safety, the fewer have been the instances of furious mania, and the more rare the instan- ces of the supervention of apoplexy and paral- ysis : complications not infrequently produced by the irritation and excitement caused or per- petuated by unnecessary or prolonged restraint, or by restraint imposed in a harsh, unfeeling manner. The moral treatment should be con- ducted conformably with the principles which will be stated hereafter. 431. The diet may be more liberal as the disease passes from the acute to the more chronic stage; but in all periods, hunger or thirst, if not appeased, augment the irritation and violence of the patient. The food should be of the most digestible and least exciting kind. In some cases, at the commencement of the attack, all food is refused; but this re- pugnance wears off in a few flays. Coercion, in such instances, is unnecessary, as the dis- like arises either from gastric disorder, or from excessive cerebral excitement; and, in both circumstances, abstinence is a necessary part of the treatment. At a more advanced period, the farinaceous and leguminous articles of diet, warm milk with bread, rice and milk, ripe and seasonable fruits, and the white meats, are the most appropriate. The drink should’ always be cooling and febrifuge, as already advised (f) 429). 432. /?. The strictly medical treatment requires the calmest consideration; the spirit of sys- tem, and an irrational method of routine, should be altogether banished; the means of cure should be appropriate to the peculiarities of each case at the time of prescribing for it. The exact pathological or physical conditions should be ascertained as correctly as possible, and remedies prescribed accordingly ; and with due reference to the age, habit of body, tem- perament, modes of living, and occupations ol the patient; to the predisposing and exciting causes, to the season, and to the stage and previous character of the disease. At the com- mencement of the attack, and if gastric disor- der is manifest, one, or even two, emetics of tar- tarized antimony, dissolved in barley water, or in any other diluent, should be exhibited ; but if there exist general plethora, as well as inordi- nate vascular action in the head, a full blood- letting should precede the emetic. After the operation of this latter, increased action should be moderated by the continued exhibition of the solution of antimony with liquor ammoniae acetatis. It is sometimes requisite to repeat the blood-letting, especially if redness of the face or eyes, noises in the ears, a pulsating pain in. the temples, or increased heat of the scalp, or augmented action of the carotids, still continue. When the first blood-letting has been copious, a local depletion may be suffi- cient, as cupping behind the ears or in the nape; or the application of leeches to the tem- ples, or around the base of the head, or even to the anus. Great care is requisite not to bleed too much; for if maniacs be too much reduced by sanguineous depletions, they are apt to lapse into dementia or imbecility. 433. After the operation of the emetic, a full dose of calomel, either alone or with James’s powder, may be given, and its operation promo- ted by some active purgative taken a few hours afterward, and preferably, according to my ex- perience, by half an ounce, or six drachms each of castor-oil and spirits of turpentine, in any suitable vehicle. If the action of these be tar- dy or insufficient, it may be promoted by the same or other active cathartics prescribed in enemata. If the cerebral excitement continue after these, or return, the warm or tepid bath, or a bath of an intermediate temperature, may be used, the patient remaining in it for a con- siderable time; cold lotions being applied to the head, or cold water being affused upon it. The bath may be resorted to, in this manner, every time that the delirium becomes violent. The bowels should be kept freely open during the attack, and the cooling diaphoretics already noticed, with diuretics, should be taken every four or five hours, particularly the solutions of the acetate of ammonia and of tartarized anti- mony with the spirits of nitric aether. The pa- tient’s head ought to be kept cool by the usual means; and if the heat be at any time con- siderable, the ice-cap or the cold affusion may be used. 434. When the violence of the symptoms is abated, the patient may be allowed more liber- ty, and permitted to enjoy the open air, where he may give vent to his excitement, which will the sooner pass off by being unrestrained. The diet, which was heretofore extremely re- stricted, may be more liberal; and, if intervals of reason occur, the utmost kindness and in- terest should be manifested for the patient, the moral treatment coming in aid of the physical and medical during the whole course of the malady. If critical evacuations are manifested, they should be promoted by a more nutritious regi- INSANITY—Treatment of Maniacal. 601 men, by gentle tonics, or by means appropriate to the crisis that may appear. 435. The treatment is no longer rational, if all the periods and all the modifications of the disease are treated in the same manner. If mania have occurred after the suppression of an accustomed sanguineous discharge, early blood-letting, and, subsequently, local depletions, repeated at intervals, and in situations having reference to the accustomed evacuation, are indispensable. If it have appeared after deliv- ery, or upon the suppression of the lochia, or of the milk, purgatives, blisters, derivatives, and revulsants, setons, or issues, &c., are necessary. If it have followed some acute disease, upon too rapid growth, or on masturbation, the warm bath, with cold applications to the head ; a nu- tritious and milk diet; the use of asses’ milk, tonics, cinchona, or quinine, with acids ; the cold shower bath, or salt-water bathing, will be most useful. But in all cases—and especially when the mental disorder has supervened upon the disappearance of some cutaneous eruption, or of gout or rheumatism—aperients, purgatives, blisters applied to the nape and kept open, or setons there, or other permanent irritants of the skin, will be found of service. 436. When mania appears in persons of a highly nervous temperament, it is generally in- dependent of vascular fulness, or sometimes is even owing to a deficiency of blood, a larger proportion being determined to the brain than to the rest of the body. In this case, the cold affusion on the head, while the lower part of the body is immersed in a warm bath, or the shower bath, the patient standing in a pan of warm water, is generally beneficial. If the disease be attended by irritation of the repro- ductive organs, tepid baths, cold enemata, and the internal use of the acetate of lead with hyoscya- mus, or of ipecacuanha with opiates, or camphor with vinegar, will be of service. In most cases characterized by nervous symptoms chiefly, the infusion and other preparations of valerian, small doses of camphor or of asafeetida, and prussic acid or laurel water, will be of use, when cau- tiously administered. In these especially, the cold douche, or affusion on the head, has both a physical and a moral effect in calming the patient. 437. If the disease resist these means, ra- tionally and appropriately employed, other rem- edies, of a more perturbating or empirical kind, may be tried, but these require the utmost cau- tion, and their effects must be carefully watch- ed. In strong, young, plethoric, and well-fed persons, blood-letting, generally or locally, may be repeated. When the propriety of venajsec- tion is doubtful, small and repeated local deple- tions should be adopted, and those which may have a derivative effect ought to be preferred ; as four, five, or six leeches applied to the anus, and repeated every ten or fourteen days, ac- cording to the strength of the patient. The semicupium., cold application to the head, and purgatives with colocynth or aloes, will also be required ; and if these occasion a haemorrhoid- al affection, the circumstance may have a fa- vourable influence on the mental disorder. 438. Drastic purgatives are often of service, and particularly in the more obstinate states of mania. They frequently bring away brown, greenish, tenacious, and otherwise morbid se- cretions, which had been long adhering to the intestinal mucous surface, or lodged in the cells of the colon and in the caecum, and which had either predisposed to or perpetuated the men- tal disorder. In some instances, a long course of purgatives is required fully to evacuate these accumulations ; but when this is neces- sary, the patient’s strength should be«prevented from sinking by a fuller diet and a more resto- rative regimen than would otherwise be requi- site. It is often difficult to administer these medicines so frequently, or in such quantity as may be necessary, as maniacs are often per- suaded that they are given to poison them ; but such substances as may be taken in their food—as calomel, croton oil, elaterium, &c.— may be employed. Croton oil may also be rub- bed over the abdomen, and cathartic enemata liberally administered. In cases of this kind, the croton oil may be prescribed in small doses, with the extract of colocynth, or the compound camboge pill; and, when the patient has no reluctance to medicine, the compound infusions of gentian and senna, with the sulphate of pot- ash, and some purgative and carminative tinc- ture ; or a draught containing equal parts of castor-oil and spirits of turpentine may be pre- ferred. If the purgatives occasion any increase of irritation, or are sluggish in their action, the warm or tepid bath will be found of great ser- vice. 439. When the integuments of the head ap- pear engorged with blood—and when, in the advanced course of the disease, or in its chron- ic state, the head or scalp seems congested— small and repeated cuppings behind the ears, or on the shaved scalp of the occiput, will often be serviceable ; or free incisions may be made in this latter situation, as advised by Dr. Prich- ard, and kept open by lint, or by pease, in the manner of a common issue. In chronic cases, moxas and the actual cautery, applied to the oc- ciput and to the nape, have been recommended by many Continental physicians ; but the other measures just named, or setons or issues in these situations, are equally efficacious. 440. The propriety of exhibiting opium in mania has been much doubted. But, when sanguineous depletions have been duly prescri- bed, and morbid accumulations in the bowels freely and entirely evacuated, if the scalp be neither remarkably hot, nor congested with blood, and if there be great restlessness, irrita- bility, and want of sleep—the maniacal excite- ment being the result rather of nervous disor- der than of vascular action—the judicious ex- hibition of opium, or of morphia, especially in conjunction with other appropriate medicines, will often be productive of the greatest benefit. The opium or the morphia, however, should be given in a full or very large dose ; and, accord- ing to the peculiarities of the case, it may be conjoined with camphor, or digitalis, or James’s powder, or ipecacuanha, or calomel, or with an alkaline carbonate, or with aromatics. There can be no doubt of the benefit which camphor may produce in this state of mania, although this also has been disputed. Those who pos- sess weak powers of discrimination, whose knowledge of morbid actions and of the opera- tion of remedies is deficient or limited, will frequently fail in obtaining the usual advanta- ges from medicines, and will hence parade their 602 INSANITY—Treatment of Imbecility. skepticism as a mask for their ignorance; but camphor is a valuable remedy in the circum- stances of the disease now under consideration, yet it requires caution; and, when conjoined with nitre, and given in small doses in the more doubtful cases, or where heat of the scalp is still present—or when prescribed with hyos- cyamus, opium, or digitalis, or with vinegar, and in larger doses in the chronic states, and after evacuations have been energetically em- ployed and exhaustion is about to supervene— it generally is productive of the greatest bene- fit. If the premature or inappropriate use of it should increase the restlessness or heat of the scalp, cold applications to the head, and dilu- ents with vinegar internally, will soon remove all disorder, or even develop its good effects. Vinegar was much praised by Aretreus, Lo- cher, and others in this malady; but Chia- ruggi advised it to be given with camphor. One drachm of the latter may be dissolved in about two ounces of distilled vinegar, and from an eighth to a fourth part of the solution may be taken in any suitable vehicle every four, five, six, or eight hours. Digitalis has been recom- mended by Dr. Locher, of Vienna, and by sev- eral British physicians, in this and similar states of mania; and when exhibited in full, or even large doses, it sometimes is of great service; but its effects require most careful watching, especially when employed in the way most likely to prove beneficial. The surprise bath, or sudden immersion in the sea, or in a cold bath, as advised by Van Helmont and others, as well as the rotatory machine of Darwin, although recommended by some writers, are dangerous and highly empirical modes of treat- ment, which are now justly abandoned. 441. y. When mania assumes an intermittent form, the same principles of treatment as have now been advocated should be followed during each attack; and, when an intermission takes place, means should be used to prevent the ac- cession of a paroxysm. Cinchona and sulphate of quinia have been employed with this latter intention. Where vascular fulness and in- creased action, generally and locally, have been removed, and morbid secretions and faecal ac- cumulations have been entirely evacuated from the biliary organs and intestinal canal, the sul- phate of quinine, conjoined with camphor, and with as much of the purified extract of aloes as will promote a free action of the bowels, and occasionally, also, with hyoscyamus, will prove useful during the intervals, if neither heat of scalp, headache, nor want of sleep, follow the use of it. My opportunities of re- sorting to this combination of means, in this particular state of disorder, have been few; but I have found the following of service: No. 270. R Quinse Disulphatis, Camphorse rasse et sub- actae, 55 ~ks. ; Extr. Aloes purif., 3ss. ad 3ijss. • Extr Hy- oscyami, 3j.; Sirupi Simp., q. s. M. Fiant, secundum ar- tem, Pilulse L., quarum capiat duas vel tres, bis terve indie. 442. When the patient has become calm, and begins to recognise his position and state, al- though some delusion or delirious excitement may remain or recur, or the moral affections may not be altogether restored, it will gener- ally be proper to remove him from the place to which he had been confined, and to surround him with novel objects, by which he may be amused, or his mind more agreeably engaged, and where he may enjoy the advantages of air and exercise. In this stage of the disorder a more nourishing and strengthening diet and regimen maybe permitted. But at all periods the strictest attention should be paid to the se- cretions and excretions, as well as to calm the mental irritation, and to diminish the number of impressions and causes of excitement by which this irritation is perpetuated. 443. (5. The convalescence of maniacs is often prolonged and difficult; sometimes it is rapid. Some patients, when restored to their friends, to society, and to their natural habits, do not recover a complete state of health until many months have elapsed. These, especially, man- ifest great susceptibility and sensibility: they are readily vexed or irritated, are ashamed of their former condition, and often entertain fears at meeting with former friends. Some enter- tain a dislike, or a hostile feeling, to friends or persons who interested themselves in their behalf during their illness. Where this is evinced, the probability of a relapse, or of an attack of melancholia, or of an attempt at sui- cide, is great. Convalescents are generally very greatly benefited by travelling some time, or by a sojourn in the country, or in some suit- able place, before they are restored to their families, and are brought in intimate communi- cation with their relatives and friends, or with those who were witnesses of their malady. 444. h. Treatment of Dementia and Fatu- ity.—The various states of dementia and fatu- ity generally present little hopes of success from either hygienic, moral, or medical treat- ment.—a. That variety which M. Esquirol has denominated Acute Dementia (§ 152) is, however, very generally remedied by a resto- rative method of cure : by walking and horse ex- ercise ; by the shower hath, followed by frictions of the surface ; by light and nutritious diet; by stomachic aperients, and attention to the secre- tions and excretions generally ; and by the ex- hibition of antispasmodics and tonics; especially valerian, musk, cinchona, ammonia, camphor, sulphate of quinine, &c., combined according to circumstances. The sulphate of quinine, con- joined with camphor, hyoscyamus, and as much aloes as may preserve the bowels gently open, is often of great service in these cases. The preparations of valerian with ammonia are also most useful. When evacuations have been suppressed or eruptions have disappeared, these should be recalled, or others substituted in their place. 445. /?. The chronic or confirmed forms of de- mentia and fatuity ($ 152, et seq.) require a diet and regimen suited to the peculiarities and cir- cumstances of each case, and to the amount of exercise which is allowed, or the patient is ca- pable of taking. In addition to strict attention to the states of the secretions and excretions, the shower or cold bath, or sea-bathing, followed by frictions of the surface ; blisters applied be- hind the ears, or to the nape, and either fre- quently repeated, or kept open ; setons or issues in the same situation ; moxas applied to the oc- ciput ; incisions of the scalp, or the production of pustules on the shaved scalp by means of the tartarized antimonial ointment, are the chief remedial means. In many cases, these should be conjoined with the restorative treatment just advised ( 162, et seq.) is the most hopeless, es- pecially when any of the forms of dementia are associated with general paralysis.—a. The means which have been just enumerated (§ 445) are usually required in this complication ; and care should be taken to prevent the bowels from be- coming too constipated on the one hand, or too much relaxed on the other. In either case, in- flammation, rapidly passing into sphacelation, generally results. In some instances, the re- moval, by mechanical means, of hardened faeces from the rectum becomes necessary when the constipation has been prolonged. Retention of urine is an equally frequent and dangerous oc- currence in the paralytic form of imbecility and incoherency, and requires a frequent recourse to the catheter. Incontinence of urine, or a fre- quent dribbling, owing to over-distention of the bladder, is also a common symptom. In this latter case especially, care should be taken to keep the patient dry and clean, as unconscious or involuntary discharges of either the urine or faeces soon occasion gangrenous sores of the sacrum, or adjoining parts, in this class of pa- tients. Care is also requisite to preserve them from falls, and from injury from fire. 447. b. The complication of insanity with epi- lepsy or convulsions {f 174) does not admit of any precise mode of treatment. The means should vary remarkably, or even be opposite, according to the form of the mental disorder, and to the evidence furnished by particular ca- ses of the existence of general or local fulness of blood, or of increased action, or of organic lesion of the brain. When the convulsive par- oxysm occurs in the course of mania or monoma- nia, or is in any other way associated with ei- ther, general or local plethora, or increased vas- cular action, or even both, is generally present, and requires sanguineous depletions, the cold affusion or douche, derivatives, cathartics, low diet, and permanent revulsants, or counter-ir- ritants. The principles of treatment stated in the article Epilepsy, and those advised for ma- nia {() 432, et seq.), are usually appropriate in these cases : the application of the means to individual instances must depend upon the dis- crimination and judgment of the physician. When the paroxysm is connected with demency, or imbecility, or melancholia, an irregular distri- bution or congestion of blood, or organic lesion of the brain or of its membranes, or even a de- ficiency of blood, may exist, and require the in- ternal and external means already recommend- ed for dementia (<) 444), with many of those pre- scribed for the cerebral from of Epilepsy (§ 61, et seq.). 448. c. Apoplectic seizures occurring in any form of insanity should be treated according to pathological principles. If they take place early in mania, or in its acute state, general or local depletions, or both, and the other means already advised in apoplexy, as well as in acute mania, are generally requisite. But when sei- zures of this kind, or resembling it, appear in INSANITY—Treatment of its Complications—Remedies. the course of demency or fatuity, a want of vi- tal power in the brain, with or without local or general deficiency of blood, or inanition, and, in some instances, with some degree of con- gestion, is most probable, and sanguineous de- pletions are then injurious ; advantage being often derived from restoratives, when these can be administered, from blisters on the scalp, and from enemata containing asafcetida, camphor, &c. The coma or lethargy, and the vertigo, oft- en associated with incoherency and imbecility, require the same principles of treatment as now advised, in conjunction with the means recom- mended for dementia and fatuity. 449. d. The other complications of insanity (tf 181, et seq.) require but little remark. When the associated visceral disease is of such a kind as to perpetuate the mental disorder, es- pecially when the digestive and reproductive or- gans are deranged, the removal of such disease becomes an important indication of cure re- quiring instant adoption ; but the means which should be adopted for its removal must vary, or even be different, in different cases. No gen- eral principle can be stated that can apply to all. The secretions and excretions, however, should be promoted ; and the processes of as- similation and defsecation—of supply and waste —duly regulated, according to the wants of the economy and the physical exertions of the pa- tient. 450. iii. Of the Remedies used in the Treat- ment of Insanity.—My remarks on this head will be as brief as compatible with the due con- sideration of some points respecting which the opinions of the most experienced writers on insanity are greatly at variance, and which could not be so appropriately discussed as in this place. And, at the same time that I thus consider the different or opposite views enter- tained as to the efficacy of certain remedies, I shall also notice other medicines, which have been employed in some states of mental disor- der, but to which I have yet either not suffi- ciently, or not at all, directed attention. 451. A. Bleeding.—a. Great difference of opinion exists as to the propriety of general blood-letting in insanity. Dr. Cullen advised it in the early stage, especially where there are fulness and frequency of pulse, and marks of increased impetus in the vessels of the head ; but he admitted that, when the disease has sub- sisted for some time, he has seldom found it of service. Dr. Rush carried this treatment far- ther than any other writer of eminence ; and urged numerous arguments in support of it, some of which are deserving of attention. He advised large blood-lettings, in the standing or sitting posture, early in mania ; and, if the pa- tient bore the depletion without syncope, he di- rected from twenty to forty ounces of blood to be taken. He was of opinion that this evacua- tion ought to be carried farther in madness than in any other acute disease whatever ; and recommended it to be followed by local deple- tions, by low diet and refrigerant medicines, by cold applied to the head, and by tepid or warm baths. Weber, Bruckmann, and J. Frank car- ried blood-letting nearly as far as Dr. Rush. Dr. Haslam is also favourable to a decided re- course to vascular depletion in madness, though he does not advise it nearly to the extent di- rected by Dr. Rush and Dr. J. Frank ; and he 603 604 INSANITY—Of Remedies advised for. considers it equally beneficial in melancholia as in mania. He, however, judiciously limits it to recent cases and plethoric habits, and pre- fers cupping on the scalp to venesection ; the quantity of blood to be taken varying from eight to sixteen ounces, and the operation be- ing repeated as circumstances may require. 452. On the other hand, Pinel considered the signs of vascular action in the head, and of determination of blood thither, as very decep- tive ; and that bleeding, even in maniacal ca- ses, accompanied by symptoms supposed to in- dicate plethora and determination to the head, tends to retard recovery, and to render it more doubtful, and to cause mania to degenerate into dementia. M. Esquirol coincides with Pinel in believing madness to be sometimes changed for the worse by bleeding. He has seen it in- creased even after an abundant flow of the cat- amenia ; and has observed melancholia pass into furious mania after venaesection. He, how- ever, approves of moderate blood-letting in plethoric cases, and when some accustomed sanguineous evacuation has been suppressed. Dr. Burrows has stated that, following exam- ple rather than experience, he tried blood-let- ting for several years ; but discovering his er- ror, he became more cautious, and ordered ven- aesection scarcely in six cases of simple mania or melancholia in as many years; and that, since he changed his practice, more patients have recovered, and the cases have been less tedious and intractable. Nevertheless, Dr. Bur- rows, as well as others who condemn general blood-letting even in mania or melancholia, is favourable to local bleedings, which, he believes, can seldom be dispensed with in recent cases. M. Guislain observes, that most of the cases admitted in the institutions for the insane in Belgium have been treated by blood-letting be- fore their admission ; but that, with few excep- tions, the disorder has been aggravated by the practice. He, howTever, admits the propriety of this measure in the circumstances in which I have advised it in the foregoing section. Dr. Seymour states, as the results of his inquiries of Messrs. Beverley and Philips, the medical attendants in the Asylum on Bethnal Green, which receives about 400 patients, that the number ot those admitted with vascular excite- ment, requiring blood-letting, are very few in- deed ; and that the lancet is very seldom used in cases of excitement, if there be no evident effect upon the brain from increased arterial action, so as to induce the fear of approaching apoplexy or paralysis. The reason they as- sign ior not resorting to blood-letting is, that, having done so in several instances, the result was very unfavourable. The patients were re- duced from the loss of blood, and the excite- ment was not abated; the tongue became ty- phoid, and the patient sank into a state of col- lapse, and died. Dr. F. Willis also condemns both general and local depletions; and Dr. Prichard states, on the authority of Mr. Hitch that Dr. Shute has proscribed the use of the lancet, leeches, cupping-glasses, blisters, dras- tic purgatives, and the practice of shaving the head, at the Gloucester Lunatic Asylum ; and yet, that the proportion of recoveries in this hospital is very large, and that no cases of sud- den apoplexy or hemiplegia have happened. Before this practice, however, can be correctly estimated in respect of the treatment of insan- ity generally, the circumstances connected with the cases for which it was employed should be detailed ; and it should be remembered, that a very large proportion of cases sent to lunatic asylums has undergone a more or less active treatment before their admission into these in- stitutions. [Dr. Conolly, who has had great experience in the treatment of the insane, remarks (Lec- tures in Lond. Lancet, Jan., 1846, Am. ed., p. 10), that in certain cases in which the patient is of a vigorous constitution, and a first attack of insanity has come on suddenly, like a sudden delirium, and is not the consequence of intem- perance, he has no doubt that a single bleeding, with the administration of an aperient, follow- ed by a few doses of antimonial medicine, will effect a speedy cure ; but that this is not a fre- quent form of attack. It may also be allowed, where there is danger of death from apoplexy, and where there is great vascularity of the face and scalp ; as a general rule, however, as al- ready remarked, bleeding from the arm is rare- ly applicable to the treatment of any form of insanity, except in its very earliest stages.] 453. b. Local blood-lettings have been more generally adopted in the treatment of insanity than vena?section ; and they admit of less mark- ed difference of opinion as to the propriety of resorting to them, many of those who object to the latter adopting the former. Nevertheless, even local depletions require caution, and are most appropriate in recent cases of mania and of melancholia. The latter form of disorder requires this mode of depletion almost as fre- quently as mania, although not generally to the same extent. The situation of local bleeding is often of importance ; and I believe that the occiput, or the spaces behind both ears, and the nape of the neck, should be preferred. The circumstances indicating the amount of deple- tion, and the frequency of its repetition, are the same as those which show the propriety of the practice on its first adoption. The discrimina- tion and judgment of the physician must guide him in these particulars; but the presence or absence of certain symptoms, about to be no- ticed ($ 460), will generally guide his decision. [Some of the highest authorities at the pres- ent day, although opposed to general blood-let- ting, recommend local depletion as highly use- ful and necessary. Dr. Conolly states that he has found leeches extremely serviceable at Hanwell, relief being almost always obtained by applying from 12 to 24 to the forehead, W'here pain is generally complained of, and sometimes behind the ears or neck. He also remarks, that he has never known such application produc- tive of mischief; and that it may be repeated in a fewr days, and occasionally afterward, with almost invariable'benefit. When pain and heat of the head are present, or recur after the first or second application of leeches, this writer recommends a blister to the back of the neck. If the excitement continues, he advises the head to be shaved, and the ung. tart. ant. to be rubbed upon the scalp night and morning, un- til pustules make their appearance.—(Loc. cit.)] 454. c. As to vascular depletions, however prac- tised, no general rules can be assigned. Each case of insanity presents a distinct subject of study as to this practice ; and a correct judg- INSANITY—Of Remedies advised for. 605 ment can be formed only after taking into con- sideration a number of circumstances connect- ed with the age, previous health, nutrition, and occupations of the patient, with the causes of the malady, and with the states of vascular ac- tion and vital power. Among the more recent writers on insanity, M. Foville, M. Esquirol, and Dr. Prichard have formed the most cor- rect views as to the propriety of vascular de- pletions in this malady. According to my lim- ited experience, however, the first and last of these writers may be considered as somewhat too partial to the practice, while M. Esquirol may be viewed as placing rather too little de- pendance upon it. Estimates formed respect- ing it, from the results obtained in public insti- tutions, cannot always be depended upon, un- less all the circumstances were known con- nected with the great majority of patients ad- mitted into them—with the particular classes of patients that they commonly receive ; for, in some public, or even private asylums, many pa- rents are admitted who have not received ben- efit from vascular depletion, or for whom it has been injudiciously employed; while those for whom it has been properly prescribed, as to quantity or repetition, and who have recover- ed after recourse had been had to it, require not the aid of those institutions. Besides, of the numbers sent to asylums, there are com- paratively few cases which are strictly recent, or in which the period of deriving benefit from vascular depletion is not already passed ; and it should also be recollected, that by far the greatest number of those who are admitted into public institutions for the insane have become deranged from those predisposing and exciting causes which exhaust physical as well as men- tal power, and that they are precisely the class of subjects least able to bear evacuations, or other depressing means of cure. 455. The lesions found in dissections of chronic cases, by MM. Bayle, Calmeil, Fo- ville, and others, show that they are incom- patible with the due exercise of an organ so delicate as the brain, and with the healthy manifestation of the mental powers; and, whether mental exertion or emotion disorder the circulation of this organ, and, consecutive- ly, the material fabric, the integrity of which is necessary to the due performance of the men- tal operations ; or whether the circulation, or the structure of the organ, is the first to be af- fected, and the mind the last to suffer, still such means as reason suggests and experience has shown to be most efficacious for quieting excited and disordered vascular action, gen- erally and locally, without materially depress- ing or exhausting vital power, cannot safely be always, or even generally dispensed with. 456. M. Foville states that, during many years of extensive practice in one of the lar- gest lunatic institutions in France, he has had recourse to evacuations of blood, general or local, abundant or in moderation, rare or fre- quent, according to the strength of the patient, the state of the pulse, the redness of the eyes, the heat of the head, and the agitation and want of sleep, in the greater number of cases of recent insanity which have been placed un- der his care. He has preferred general bleed- ing, where there existed general plethora ; but, in opposite circumstances, he has found leech- es on the neck, the temples, or behind the ears, or cupping upon the same parts, or on the shaved scalp, to produce decided benefit. He considers local bleeding so very serviceable, as to prescribe it in addition to general bleeding, when the symptoms imperiously demand this latter evacuation, yet he never rests exclusive- ly upon the efficacy of vascular depletion, but has recourse to other means. He adds, that he has had many cases of intermittent mad- ness, the attacks of which had lasted three or four months, or even longer, when left to na- ture ; but that there was not a single attack of a month’s duration since they were treated by blood-letting, and by warm baths, with cold ap- plications to the head at the same time ; and that the symptoms were often dissipated in five or six days by these means. The experience and views of Dr. Prichard as to this point en- tirely agree with those of M. Foville. Indeed, the practice was advocated by him {Treat, on Dis. of the Nervous System, ch. i., Lond., 1822) long before the treatise of M. Foville appeared. In estimating, however, the opinions of physi- cians attached to public institutions for the in- sane, as to the propriety or extent of vascular depletions, the sphere of their practice should not be altogether unheeded, and especially the circumstance of the patients having been treat- ed previously to their admission, and the dura- tion even of those which have been called re- cent cases. It is very obvious, that a patient who has been ill only three or four days, but du- ring that time has been very actively treated, will not bear evacuating means on admission into an asylum ; while another case, that would have been benefited by vascular deple- tions in the first few days of the malady, may be injured by them after a week or a fortnight had elapsed ; and this, and even other cases of much longer duration, are usually considered as recent. After all that can be advanced on this point, the propriety of prescribing san- guineous depletions, to whatever extent, must depend upon the pathological knowledge and discrimination of the physician ; and if he pos- sess not these qualifications in a high degree —and unless he study and practise his pro- fession as a whole, and as a profound and comprehensive science, and not as a trade or mechanical art, divisible into a number of sep-- arate parts, he cannot truly possess them—he is quite incapable of rationally and judiciously treating insanity, or any other class of maladies. 457. d. There are numerous circumstances which shoidd be duly considered before san- guineous depletions are prescribed for insanity. The predisposing and exciting causes, and the various-concurring influences, should be ascer- tained and kept in view ; the age, habit of body, constitution, and occupations of the patient must be taken into account ; and the duration of the distemper, and the means which have been al- ready employed, ought to be precisely known. Next, the exact pathological conditions of the patient should be inquired into, and made the principal basis of the indications of the physi- cal and medical treatment. If the patient be young, plethoric, or strong; if the attack has been acute and sudden ; if the carotids and temporal arteries pulsate strongly ; if the sur- face, and especially that of the head, be hot; if the face be red, or the conjunctiva injected, 606 INSANITY—Op Remedies advised for. and the pupil contracted; if intolerance of light or of noise, want of sleep, spectral appearan- ces, disordered sensation, and much agitation be present, the abstraction from the arm of twelve, fifteen, or eighteen ounces of blood will generally be productive of benefit, if it be practised within the first few days of the at- tack. If the good effect be only temporary, cupping upon the nape, or on the occiput, or behind the ears, will generally be requisite, and should be preferred to a repetition of ven- ajsection. 458. The suppression of evacuations and of eruptions indicates, as M. Esquirol insists, the propriety of vascular depletion ; and this is the case generally; but care should be taken in prescribing it, even in such circumstances, if the foregoing indications of its propriety are not present in some degree or number. The suppression is an important reason for having recourse to blood-letting, but it should not be the only reason by which the physician is gui- ded in the matter. The mode or situation of local depletion, in such cases, should have ref- erence to the evacuation which has been sup- pressed. If the catamenia or the hasmorrhoids have disappeared previously to the attack, leeches may be applied to the highest parts of the insides of the thighs, or around the anus. Acute mania most frequently requires vascular depletion ; and next, melancholia. For the lat- ter, venaesection is seldom necessary, cupping behind the ears, or on the occiput, or on the nape, being preferable. The practice is some- times also requisite in some other states of par- tial insanity, particularly after the disappear- ance of an accustomed discharge or eruption. Whenever melancholia or any other form of partial insanity is attended by headache, or by a feeling of oppression or of weight in the head, by a full stato of the blood-vessels, and by con- stipation, blood-letting is necessary. In the more doubtful cases, the application of leeches, or cupping behind the ears, so as to abstract six, eight, or ten ounces of blood, or even a smaller quantity, in persons of a weak consti- tution, is generally beneficial. The earlier in the attack that depletion can be resorted to, the more certain and permanent will be the benefit to be derived from it; and even when an attack is threatened or impending, it should be had recourse to, if the circumstances and symptoms indicating the propriety of it (§ 457) are more or less manifest. ,459- e. The repetition of vascular depletion should be guided by the same indications as point out the propriety of it in the first in- stance ; when these continue or return, local depletion especially may be safely prescribed a second, or even third time, varying, however, the quantity with existing symptoms, and with the effects pioduced by the previous evacua- tion, and with those observed at the time. The absence of redness or flushing of or even pallor of the countenance, may not be a reason against depletion, especially if the oth- er indications of the propriety of it are present. When blood-letting in any mode is indicated, it should be performed in a standing, or sitting, or reclining position ; and on the first sign of an effect having been produced in the pulse by it, or of faintness, the abstraction of blood should cease. 460. /. It is of great importance to attend to all the circumstances and symptoms indicating the impropriety of vascular depiction in the treat- ment of this class of disorders; these are, chiefly, far advanced age, debility, exhaustion of the vital power, and the puerperal states; the operation of those predisposing and exci- ting causes which depress or exhaust the vital energies, the physical functions, and mental faculties; continued addiction to the vice of masturbation, or to the inordinate use of spir- ituous liquors, or to narcotics ; insufficient nu- trition previously to the attack ; all indications of weakness and irritability, without power or tone; and all approximations to the state char- acteristic of delirium tremens, as a pale or col- lapsed countenance ; very quick, tremulous or small, irregular, soft pulse; copious perspira- tions ; a terrified, fearful, and agitated state of mind; insensibility of external impressions, and tremors of the extremities. Wherever the tongue is tremulous, or the voice weak or tremulous, the hands unsteady, the pulse weak, quick, or open, and readily compressed; or when the extremities and skin are cold, damp, or clammy; or the sweats profuse, and the tongue is covered with a dark, brown, mucous coating—however great the maniacal or deliri- ous excitement and agitation may be—san- guineous depletion will then be injurious. A natural temperature, or coolness of the scalp ; weak action of the carotids, and great frequen- cy of the pulse, with swimmings or giddiness on assuming the standing or sitting position, are also strong indications of the impropriety of blood-letting. 461. B. The abstraction of heat from the head, bathing, &c.—The hair should be removed from the head in all acute cases; and where there are great heat of the scalp, and vascular ex- citement, particularly in mania, the head ought to be shaved.—a. For young, robust, and ma- niacal patients, the shower bath, twice or thrice a day, or the affusion of cold water on the head, is of the greatest benefit, and is recommended by Celsus, Rush, Esquirol, Burrows, Foville, Prichard, and many others. When hysterical symptoms are associated with insanity, the af- fusion of cold water on the head is especially beneficial. Both the cold shower bath and the cold affusion are sometimes followed by reac- tion, and consequent excitement and violence, particularly in irritable temperaments. In these cases, a repetition of the treatment, and the continued application of cold to the head, by means of evaporating lotions, or the ice-cap, will generally be necessary. M. Foville pla- ces a cap on the head containing ice, and keeps the body immersed in a warm bath for two or three hours, and repeats this practice twice or thrice in the day, according to the violence of the symptoms. At first he found, when resorting to it only once a day, that re- action, with increased agitation, not infre- quently supervened ; but, on repeating the bath, and keeping the ice constantly applied to the head, the success of the treatment has been much greater. This combination of warm and tepid bathing, with cold applications of various kinds to the head, was, however, long previous- ly advised by Daniel and Folberg. 462. The foregoing modes of abstracting heat from the head, as well as the application INSANITY—Of Remedies advised for. 607 of evaporating lotions, are serviceable chiefly in recent cases, where there are much heat of the scalp and irritability; but they should be discontinued when the temperature is reduced to the natural standard, and repeated as soon as it rises above it. Intense cold applied to the head, in chronic states of insanity, although the patient be noisy and violent, seldom indu- ces sleep or quiescence : it may even become a source of irritation. The temperature of the scalp should be a guide to the practice in all cases. It may be stated as a general rule, that the heads of all insane persons should be kept cool, and the hair closely cut : they should never wear any covering on the head when within doors. The only exceptions to the rule are furnished by some cases of dementia, or partial insanity, where the low temperature of the head, and weak action of the carotids, in- dicate insufficient vascular action and tone in the brain : in these cases, the hair may be worn longer than in others. Insane patients should also sleep with their heads more or less raised. 463. b. The tepid douche, or affusion, tepid shower bath, or even the warm douche, are sev- erally of use in certain states of mental disor- der, especially when there are great restless- ness and want of sleep. In melancholia, I have found the tepid shower bath, commencing with the water at 90°, and gradually lowering the temperature to 80°, and ultimately to 60° or 50°, of great benefit. The warm douche, or af- fusion, is most appropriate to delicate females, or to persons of great susceptibility and irrita- bility, conjoined with weak action and deficient vital power, and particularly when there is pro- longed watchfulness. Warm and tepid bathing are extremely serviceable in most cases of in- sanity, when judiciously managed and con- joined with other appropriate means. If there be great vascular action generally, as well as locally, as in recent maniacal cases, tepid bath- ing will then be appropriate. If the lower extremities are cold, and the general surface is either of the natural temperature, or below it, warm bathing is particularly indicated. If there are chronic eruptions on the skin, a lan- guid circulation, sleeplessness, and irritability, the warm bath continued for a considerable time, and frequently repeated, is especially beneficial. In many cases, increased heat of the scalp exists in connexion with these states of the general surface and extremities ; and for these, the addition of mustard or of salt, or both, to the warm water, while cold, in some form, if applied to the head, will be of great service, particularly in the more recent cases. The association of cold applications to the head, and of the warm semicupium, or pediluvia, either simple or medicated, is also useful, par- ticularly when there are much restlessness and watchfulness. Cold bathing, especially salt-wa- ter bathing, is sometimes of service in chronic mania, and in melancholia; but chiefly during convalescence, and when tonics, change of air, and invigorating regimen are necessary. It has been advised by numerous writers, but it requires a careful consideration of various cir- cumstances connected with each form of in- sanity, and with individual cases, before it should te carried into practice. The bath of surprise, or suddenly plunging the patient into a cold bath, and keeping him immersed in it for some time, or until incipient asphyxia is produced, although recommended by Baglivi and Boerhaave, is not only an empirical, but also a dangerous practice. It has been said to have cured many, that is, many have recov- ered after having had recourse to it; a few, probably, almost immediately ; but others have experienced attacks of apoplexy, or of epilep- sy, or even of palsy, in consequence of it. The cold shower bath is certainly the safest and most generally applicable mode of cold bathing for any form of mental disorder, the tempera- ture, as well as the quantity of water, being va- ried according to the circumstances of the case. 464. C. Emetics have been recommended by many writers in this class of disorders, and es- pecially by Monro, Perfect, Selig, Ranoe, J. Frank, Rush, Cox, Esquirol, and Prichard. They are more particularly indicated in melan- cholia. Dr. Burrows has had recourse to them, chiefly to free the stomach from troublesome ingesta, accumulated phlegm, or morbid bile, and sometimes to give activity to torpid visce- ra. He has found them useful, also, by inter- rupting intense abstractions, hallucinations, and capricious resolutions, and when urine has been retained from obstinacy. They are, however, still more beneficial by emulging the biliary or- gans, by evacuating mucous sordes from the stomach, and by rousing the organic and as- similating functions. Dr. Cox states, that in every species and degree of maniacal disease emetics have proved valuable and efficacious ; and Dr. Prichard adds, that Dr. Wake, physi- cian to the York Lunatic Asylum, has assured him that he has found no remedies so frequent- ly efficacious as emetics. Dr. Haslam, how- ever, although he confirms their utility in cases attended by disorder of the stomach, declares that, after the administration of many thousand emetics to persons who were insane, but oth- erwise in good health, he never saw any bene- fit derived from them. The experience of Es- quirol, Foville, and Prichard respecting them agrees with my own observation ; they are pre- cluded by a plethoric habit and cerebral con- gestion, at least until these are removed. They are most likely to be of service in hypochon- driacal dejection and melancholia, attended by torpor, and when the secreting functions and vital actions require to be stimulated and rous- ed. They are also sometimes useful during states of furious excitement, producing a calm- ness and restoration of sleep. Where there is a morbid addiction to intoxicating liquors, or a ravenous appetite in maniacal cases, tartar emetic, added to these liquors, or to the food, so as to produce either nausea or vomiting, is often of service. When there is much deter- mination of blood to the head, and in other cir- cumstances connected with insanity, vomiting is frequently excited by tartar emetic, or even by other substances, with great difficulty. In these cases, the cold affusion on the head, soon after the emetic has been taken, will often cause its operation, as well as protect the brain from the ill consequences of its operation. A combina- tion of emetics is also of use in these respects. 465. D. Purgatives.—a. The propriety of ex- hibiting cathartics or purgatives in the treat- ment of mental disorders is undoubted ; but there are various circumstances, complications, and states of these disorders which contra-in- 608 dicate their use. There can be no hesitation in prohibiting them when there is any indica- tion of inflammatory action in the digestive mucous surface. This surface is often inordi- nately irritated, or even ulcerated in the more chronic states of insanity, and especially in de- mentia, imbecility, aid fatuity; and where such is the case, purgatives are generally injurious. In other circumstances, purgative medicines, judiciously selected, combined, and managed, are among the most important means which can be prescribed in mental derangement. The chief difficulties are the selection and combina- tion of them appropriately to the circumstances of individual cases ; and in the ability of over- coming these difficulties the science, ability, and success of the physician consist. Dr. Prichard remarks, that “ the mildest cathartics are pref- erable to others in most instances, because their use can be long continued without injury to the structures on which they immediately actand that “ the neutral salts, infusion of senna, rhu- barb, jalap, castor oil, are, in the majority of cases, sufficiently powerful, and may be used daily or frequently, according to circumstan- ces.” More active purgatives than these are, however, often necessary in the early and acute stage of insanity, and especially in melancholia, mania, and some states of partial insanity. In these, particularly, the intestinal and biliary se- cretions are frequently viscid and morbid, and the cells of the colon and caecum are loaded with these and other faecal matters. Hence a continued use of the more attenuating and sol- vent purgatives, and an occasional, or even fre- ]uent, recourse to the more active cathartics, aided by cathartic enemata, are necessary to the obtaining of the effects which these medi- cines are capable of producing on the mental disorder. Montanus was correct when he said that half purges tire and molest the body with- out being of much service : and hence the par- tiality of the ancients for the more drastic pur- gatives, as well as many of the older physi- cians among the moderns, in the more acute forms of insanity. Willis gave a scruple each of calomel and extract of black hellebore, with six grains of extract of jalap, in melancholia ; and, although the quantities may appear great, yet it should be remembered that calomel in this dose will produce a solvent rather than a pur- gative effect, and that much of the virtues of extracts were dissipated by the mode of prep- aration in those days. 466. b. That the virtues ascribed to hellebore by the ancients, in mania and melancholia, were not greatly overrated, may be inferred from the confidence reposed in it down almost to the present time, and still confided in through Ger- many. Celsus gave the black hellebore in mel- ancholia, and the white in mania ; preferred the former, and Mayerne the latter. Both species are employed on the continent, but the black is more frequently used. Be- rends, Greding, Hufei.and, Ploucquet, &c., prefer it to the other purgatives, and Quarin prescribes it in the form of Bacher’s pills (F. 156). Dr. Burrows, however, states that he has tried the extract of both the black and the white species, and found their operation very uncertain, and their effects, both upon the men- tal disorder and upon the excretions, in no way different from other purgatives or emetics. The INSANITY—Of Remedies advised for. extract of the Gratiola officinalis was much praised by Fischer, Lentin, Hufeland, and Schmidtmann, aloes by and many others, and jalap by Rademacher. 467. c. In the acute and early stages of the disease, with manifest congestion or determi- nation of blood to the brain, I have preferred full doses of calomel with extract of colocynth and scammony, or with the compound camboge pill, given late at night, and followed in the morning occasionally by about four, five, or six drachms each of castor oil and spirits of tur- pentine, taken on the surface of milk, or of some aromatic water. If these do not operate copiously, an enema, containing about double the quantity of the oils, should be administered in the course of the day. I have found these oils the most efficacious purgatives, particular- ly as respects their operation on the mental dis- order, in the early stages of mania. In some cases it will be serviceable to trust to the more common purgative pills, with the addition of a little croton oil to sharpen their action. After a time the calomel may be omitted, but during the acute state of disease, purgatives should be continued until the appearance of the tongue and of the evacuations improve. In many cases, especially those attended by much vas- cular excitement, the addition of tartarized an- timony, or of ipecacuanha, to the purgative, will greatly promote its operation and keep down vascular action. When it is desirable to produce both an emetic and a purgative opera- tion, as in several states of mania, a solution of Epsom salts, or of sulphate of soda, to which tartar emetic has been added, may be taken ev- ery hour or half hour until the effect ensues. It may afterward be continued at longer intervals, so as to act freely on the bowels. 468. d. In the more chronic states of insan- ity, and especially when there is much irrita- bility or want of power, or when the tongue continues loaded and furred, but moist, not- withstanding the frequent exhibition of purga- tives, tonics should be conjoined with them, and the constitutional powers ought to be sup- ported by suitable diet and restorative medi- cines. In these circumstances, the compound infusions of gentian and of senna, with sul- phate of potash, or sulphate of magnesia, or with tartrate of potash, and an aromatic tinc- ture (F. 266), or the extract of aloes with sul- phate of quinine and camphor (§ 441), will gen- erally prove not only efficacious in their action on the bowels, but also beneficial as respects the mental disorder. 469. e. In respect of purgatives, as well as of bleeding, it may be observed, that when insan- ity proceeds from moral and depressing causes, they are not generally beneficial unless conjoin- ed with tonics, and that frequent doses of cal- omel in such circumstances are often injurious. Purgatives, howrever, of a stomachic kind, or a combination of them with restorative medicines, are requisite in order to promote the secretions and excretions. [Purgative medicines are too inconsiderately given in cases of insanity, in some of w'hich they are not at all required, or are actually hurtful. It is an error to suppose that obsti- nate costiveness is a common accompaniment of acute mania, and of other forms of insanity. In cases of hysterical insanity, and in melan- INSANITY—Of Remedies advised for. 609 cholia, it is excessive and sometimes incredi- ble ; but in other forms of insanity the bowels are not unfrequently irritable, the patient is readily disordered by particular articles of diet, and much depressed by rough purgatives, with- out mental benefit. If the bowels require at- tention, any of the ordinary purgative medi- cines may be given, and those are the best which the patient has the least objection to take. The nervous irritability occasioned in many constitutions by the frequent use of any mercurial medicines, suggests caution with re- spect to their continued employment ; but in many cases the combination of a small quan- tity of blue pill, or calomel with rhubarb, or colocynth, or aloes, is often less disagreeable to the patient than any other form of medicine. There are many forms of mental disorder in which the pulvis jalapce composites is particu- larly serviceable : forms in which there is a de- termination of blood to the head, or a general tendency to plethora, seem to be especially benefited by this simple medicine, taken in doses of a scruple or half a drachm every morning. In cases in which there is an obsti- nate resistance to medicine, the best plan is to apply one or two drops of croton oil to the tongue by means of a quill, or it may be given in beer.—(Conolly.)] 470. E. Mercury.—Mercurials may be employ- ed for mental disorders with three intentions : 1st, to evacuate biliary and faecal accumula- tions ; 2d, to improve the secretions, particu- larly that of the liver; and, 3d, to produce a co- pious flow of saliva. To fulfil the first of these intentions, calomel is extremely useful, partic- ularly in melancholia and in mania; but it should be conjoined with, or followed by, other purga- tives. To produce the second effect, any of the mercurial preparations maybe employed, either alone or with emetic tartar, digitalis, camphor, narcotics, &c. To accomplish the third end, calomel, blue pill, or the bichloride of mercury, may be given in any of the foregoing combina- tions, or alone. Mercury may also be exhibit- ed in such a manner as to produce both a ton- ic and an alterative effect. With this view, small doses of the bichloride may be given in a tonic tincture or infusion, or small doses of Plummer’s, or the blue pill, may be taken on al- ternate nights. The employment of mercuri- als to an extent likely to produce salivation, or with this intention, is of very doubtful proprie- ty, but was recommended with this view by Willis, Rolfinck, Perfect, Smith, and oth- ers. Mercurial salivation was much praised by Rush. Dr. Prichard remarks that it is by no means a general remedy for maniacal dis- eases, but in cases of torpor, with suppression, or a very scanty state of any of the secretions, it is frequently advantageous. He adds that mer- cury should be used in mild alterative doses, and discontinued as soon as the gums become slightly affected. Dr. Burrows mentions two chronic cases of melancholic insanity in which the occurrence of salivation produced a cure. In mania, this effect is occasioned by mercury with greater difficulty than in melancholia. This writer states that he, subsequently to these cases, made many attempts to cure in- sanity by mercurial salivation, and that, al- though ptyalism was accomplished in several, yet he never succeeded but in one case to re- store the mental functions ; and this also was one of melancholia. Several instances of cure effected by salivation have been recorded by authors; still, I believe that mercury, exhibit- ed to the extent necessary to produce this ef- fect, and especially when it fails of causing it, is quite as likely to be as injurious as beneficial —to cause partial insanity, melancholia, and mania, to lapse into dementia or imbecility, particularly in weak, susceptible, and irritable constitutions. We know, from numerous cases (and several have been observed by me), that the injudicious or excessive use of mercurials will sometimes occasion partial and melanchol- ic insanity, a circumstance which should, in some manner, influence our practice. Unfor- tunately, we know nothing of the symptoms or of the modifications of insanity which indicate a probable advantage from mercurial salivation. The most*likely conditions are mania, or mel- ancholia consequent upon apoplexy, or compli- cated with hepatic disease. Mercurials, and particularly salivation, are most likely to prove injurious in every form of insanity which has been occasioned by depressing moral, or by ex- hausting physical causes, and especially by pro- longed anxiety or by masturbation. The bi- chloride of mercury, however, used in minute doses, as an alterative, in conjunction with tonics, is sometimes of service in several forms of mental disorder, and particularly in scrofu- lous constitutions. 471. F. Soporifics.—a. Sleep, &c.—It has been supposed that it is indispensable to procure sleep, particularly when watchfulness is pro- tracted, and that relief will generally follow it when obtained; but sleep is not always much required, and is not even generally followed by relief, although it frequently is. In the early, or even incipient states of mental disorder, top- ical bleeding, shaving the head, cold applied to the scalp, and purgatives, are the best means of producing repose ; and others, especially narcotics, are then generally injurious; but in more chronic cases, and where there is obvi- ous exhaustion, consequent upon depletion and evacuations; or a state of great susceptibility and irritability, or of vascular inanition gener- ally, or locally as respects the brain, appropriate means of procuring sleep, and the use of nar- cotics in suitable combinations, are most requi- site. Various modes of producing a soporific effect in mental disorders have been advised, and very often with little attention to the path- ological conditions for which they are severally suited. A few of these have been just men- tioned ; and others, especially refrigeration of the scalp, swinging, gyration, diet, certain po- sitions of the patient’s head, narcotics, &c., have been also recommended, with a view to this effect. It is often more beneficial to pro- cure repose by other and more indirect means, than by narcotics ; but several of these may be more dangerous than the latter, if empirically prescribed, as they too frequently have been. 472. Swinging seems to have been used by Celsus and Caelius Aurelianus to procure sleep; and its influence, in a limited form, is shown, by the rocking of a cradle, on children, and by the motion of a boat or vessel at sea, upon both children and adults. It obviously affects the circulation, especially that of the brain, and, indirectly, both the stomach and 610 INSANITY—Of Remedies advised for. the cutaneous circulation. Horizontal gyration W’as advised by Darwin, and both it and swing- ing were practised by Dr. Cox in mental disor- ders. Dr. Hallaran, also, adopted both these means in the Cork Lunatic Asylum, and coin- cided with Dr. Cox as to their utility. They employed two machines, or, rather, modifica- tions of the rotatory machine; one in which the patient was kept in a sitting position ; the other in which he was placed horizontally in a bed or crib. The former, or the erect machine, is described as seldom failing to produce copi- ous evacuations in the most obstinate cases, especially if, on increasing its velocity, the mo- tion. be suddenly reversed every six or eight minutes, pausing occasionally, and stopping its circulation suddenly. The effects are, an in- stant discharge of the contents of the stom- ach, bowels, and bladder in quick succession. Should the stomach only be acted upon, a purge is recommended immediately afterward. The horizontal modification of this machine, or cir- cular bed, is employed for procuring sleep ; the erect, for producing evacuations and moral re- pression. At La Charitd, in Berlin, machines for both horizontal and perpendicular rotation were employed. Von Hirsch recommended swinging in a hammock ; and various other modifications of this method have been advised. 473. Dr. Burrows remarks, respecting these powerful means of treatment, that clear evacu- ation of the bowels should precede the use of either, and that they should not be employed early in the disease until the violence of the attack has subsided, nor in young, plethoric per- sons, nor where there is vascular determina- tion to the head. The motions ought to be commenced gradually, till carried to the degree of velocity desired. When sleep is the object, a slow and continued action of the machine, without affecting the stomach, if possible, is necessary. When its full motion produces great prostration of strength, and lowers re- markably the circulation and animal tempera- ture, advantage has been obtained from it. In the intermitting form of mania, it has some- times checked the approaching paroxysm ; and in the more continued cases, it has broken the catenation of morbid ideas ; and the dread of being again placed upon it has often made the patient more manageable and alive to surround- ing objects. Dr. Prichard states, that Dr. Bompas and Dr. Drake, of the Lunatic Asylum at York, have assured him that they consider the rotatory machine as a resource of great value in the treatment of madness. Although the opinions of these physicians, as well as of Dr. Cox, Dr. Hallaran, and some others, are in favour of the use of this-machine in the treatment of insanity, yet it requires so much caution, and pathological observation and ex- perience, to avoid the most dangerous conse- quences* from it, as to deserve the opinion al- ready expressed respecting it (<) 440). 474. \\ ant of sleep, in some chronic cases of insanity, sometimes arises from inanition, consequent upon too low diet and the abuse of evacuating and lowering remedies. In these, as well as in those cases of recent mania occur- ring in delicate and nervous constitutions, and arising from a deficiency of blood generally, and possibly, also, locally in regard of the brain, a full diet, and malt liquor or wine in modera- tion, will prove the most serviceable soporifics. Tuke, Burrows, and others have remarked, that noisy maniacs, who hardly ever sleep, by a change from a low to a full diet, especially after a full meal before going to bed, with the addition of a moderate quantity of porter, or even with porter alone, have often slept sound- ly, and ultimately recovered. It has been rec ommended to procure sleep by causing the pa tient to sleep with the head low; but this is a dangerous experiment, especially where there is vascular determination to the brain, and in such cases is sure not to succeed. Indeed, sleep in the entirely recumbent position is sel- dom attended by benefit to maniacs. When, therefore, they can be persuaded to sleep in a semi-recumbent position, it is to be preferred. The sitting position is generally better than the entirely horizontal; but, whatever may be the position, sleep will not afford relief if the head be not kept cool by sufficiently refrigerating applications. The hop-pillow is sometimes of service, in the more nervous and irritable ca- ses ; but it is rarely of use when there is active vascular determination to the brain—at least, not until this morbid state is removed. When much disorder of the stomach exists, alkalies and other antacids often assist in procuring re- pose, especially when presented in conjunction with narcotics, and when the circumstances of the case warrant the use of these latter means. Very gentle friction of the head, prolonged combings of the hair, and gentle friction of the general surface, especially after a tepid or warm bath, have been followed by refreshing repose in many of the nervous states of mental disor- der, or in cases unattended by marked vascu- lar excitement in the brain. 475. G. Narcotics.—a. Opium and its prepara- tions have been prescribed in mental disorders by Cox, Odier, Brandreth, Chiaruggi, Doem- ling, Riel, and many others, while a few wri- ters reprobate the practice. There can be no doubt of opiates being of great service when appropriately employed. They are not gener- ally admissible, and they therefore require great discrimination in prescribing them. I have al- ready stated the pathological conditions and the previous treatment warranting a recourse to them in mania ($ 440); and the same remarks apply to the employment of them in melancholia. In this latter affection, however, as well as in the more purely nervous states of mania and mono- mania, or when these are complicated with hys- teria, it is often necessary to conjoin opiates with some restorative or antispasmodic, as camphor, valerian, ammonia, aether, &c. Opi- ates are less frequently useful in any of the forms of dementia than in these. M. Guislain justly remarks, that in cases of high excitement, strong, full pulse, heat of skin, fulness of the vessels of the head, opium is injurious. It is most serviceable in delicate and attenuated per- sons of feeble constitution, and in those with cold, relaxed skin, and frequent, small, weak pulse. If the disease has been of some dura- tion ; if the circulation has been daily losing * Dr. Horn, of Berlin, remarks, that this powerful rem- edy should never be employed without great caution, and by experienced persons. Dr. Burrows adds, that, not- withstanding his caution, a fatal accident occurred to one of his patients from its use, and created so great a popular clamour as to oblige him to retire from La Charite. INSANITY—Of Remedies advised for. 611 its force ; if there are only nervous symptoms to combat, there can be no hesitation in giving opium. I may add, that it is especially indica- ted when restlessness, or prolonged want of sleep, has continued after sufficient evacuations have been procured ; and still more so, if great exhaustion, tremor, cold perspirations, fits of violent delirium, and a very rapid and small pulse supervene. 476. Still, much of the benefit that may be derived from opium will depend upon the selec- tion of the preparation, the dose, and the mode of combining and of exhibiting it. The acetate and muriate of morphia are not so likely to dis- order the head subsequently as pure opium or the simple tincture; and Battley’s solution, or the black drop, may be preferred to the lat- ter. When, however, opium or its tincture is given with aromatics, consequent disorder is more rarely produced by it. Van Swieten, Darwin, Kriebel, Brandreth, Currie, and others record cases in which remarkably large quantities of opium have been given with ad- vantage. But these are extreme cases, which merely show what may occur, but which should not guide our practice. It will generally be preferable, when the indications for the use of opium are conclusive, to prescribe it in a full dose at once, especially if the chief object be to procure sleep. In this case, from one and a half to three grains may be prescribed; or half a grain of the acetate or the muriate of morphia. If this dose fail, it may be repeated after six or eight hours ; or even a somewhat larger dose may be taken. If a third dose pro- duce no good result, it should be laid aside. In some cases, much smaller quantities may be prescribed with advantage, especially when de- bility, exhaustion, or inanition of the vascular system is great; but, in these circumstances, the opiate should be repeated somewhat more frequently, and be combined with aromatics, restoratives, antispasmodics, or tonics, accord- ing to circumstances. Dr. Burrows states, that where an anodyne has been required, he has begun with three grains of opium, and re- peated one every two or three hours, never, in this way, exceeding twelve grains ; and that if sleep has not then followed, he has desisted. [It has been remarked by Dr. Conolly, that in cases where mania comes on with fever, and the patient is excessively feeble, and yet extremely restless and violent at the same time, the tongue being coated and brown, and scarcely any food being taken, all sedatives are useless, or worse than useless; and that, in every case of acute mania, it is important to avoid giving sedatives for a long time, or in frequently-repeated doses, as they either ob- scure the symptoms, or modify, without amend- ing, the patient’s condition. In private prac- tice, he also states, that he has seen patients kept under the influence of acetate of morphia for many months without any good effect; and that opiates, if repeated in increased doses, af- ter disappointing the first trials of the practi- tioner, may be followed by wilder and rapidly- increasing excitement.] 477. The combination of opiates with other remedies thus becomes a matter of no small importance ; and, indeed, much of the benefit opiates afford depends upon this circumstance. Friborg advises them to be prescribed with camphor and nitre; and Perfect, in nearly a similar form. There can be no doubt of the advantage often derivable from this and simi- lar modes of exhibiting them. Where there is much determination of blood to the head, how- ever, the camphor, unless in very small doses, may be injurious. But, if restlessness and watchfulness arise chiefly from exhaustion, in- anition, or morbid nervous susceptibility—if the disorder be chiefly or altogether nervous— be independent of increased vascular action in the brain—this and similar combinations, and especially those with the preparations of vale- rian, of aether, of ammonia, asafcetida, musk, various aromatics, &c., will be most advanta- geous. In more doubtful circumstances, the combination of opium with ipecacuanha, soap, and a little capsicum, has proved beneficial in my practice. When hepatic derangement is present, or when some degree of vascular ex- citement still remains in the brain, opiates, con- joined with calomel and James’s powder, are sometimes of use ; but they should, even in this combination, be prescribed with caution and discrimination. 478. The question as to the employment of opium or morphia in enemata and endermicully is altogether subordinate to that respecting the circumstances in which this medicine is indica- ted. When these circumstances are clearly manifested, the usual mode of exhibition should be tried, at least at first, more especially as it admits of the combination of opiates with oth- er remedies ; but when there is great difficulty in administering them by the mouth, or when they fail of affording the desired benefit, al- though obviously indicated, then the acetate or muriate of morphia may be sprinkled on a blistered surface, from which the cuticle has been removed ; or any of the preparations of opium may be prescribed in enemata. Owing, however, to the occasionally rapid absorption of fluids from the rectum and colon, a much smaller dose of opium should be exhibited in this than in the usual way. From ten to fifteen minims of the tincture may be administered every six hours. I have found the compound tincture of camphor and the sirup of poppies severally of use ; from one to two drachms of the former, and from two to four drachms of the latter being thus employed, but at different times, or in separate cases. When the patient awakens from sleep procured by the use of opi- ates, in a state of increased excitement, their exhibition should be relinquished. 479. b. Hyoscyamus has an advantage over opium, in neither constipating nor stupefying the patient. In order to obtain decided soporific effects from the extract, a dose of from ten to fifteen grains should be given at bedtime, or from a drachm to a drachm and a half of the tincture. It is apt to produce dryness of the mouth and fauces, and heat or irritation in the stomach; but it calms the circulation, and al- lays nervous susceptibility and irritation. It is very serviceable in cases characterized by mor- bid sensibility and irritability, and is much prais- ed by Fothergill, Willis, Stoerck, Selig, Meyer, and Hufeland. Dr. Prichard does not consider it to be a remedy of great impor- tance ; while Dr. Burrows views it in a mjich more favourable light. The opinion of the lat- ter physician accords more with my own expe- 612 INSANITY—Of Remedies advised foe. rience. It is often of great service when pre- scribed with camphor. [Dr. Conolly gives the preference, in acute mania, to the preparations of hyoscyamus, es- pecially the tincture, in doses of 3ij , or of the extract from 8 to 10 grains, and, whatever sed- ative is employed, he states that the dose should be large.] 480. c. Belladonna has been recommended in mania by Theussinck, Vogel, Buchoz, Ludwig, Remer, Schmalz, and Hufeland. J. Frank advises it in mania complicated with epilepsy ; and Muller prefers the powdered root to the extract, and gives it in gradually increased doses until the pupil becomes dilated. It has been chiefly employed in the forms of extract and tincture in this country, and is favourably mentioned by Dr. Seymour and Dr. Burrows. Dr. Millingen states that he has found bella- donna preferable to hyoscyamus or conium; and that the external employment of the ex- tract, according to the endermic method, has been very effectual in reducing excitement, more especially when applied to the epigastric region. In the case of a female to w’hom I was very recently called in consultation, and for whom the indications (§ 440,475) for narcotics and restoratives w’ere very manifest, the fol- lowing pills were prescribed with great benefit: No. 271. R Extracti Belladonnse gr. ij.; Camphor® ras® gr. xij.; Ammonite Carbon, gr. xij.; Pulv. Capsici gr. iij.; Pulv. Acacise et Balsami Peruviani q. s., ut fiant Pilulae viij., quarum capiat duas, sextis horis. 481. d. Stramonium has been employed in mental disorders by Allioni, Maret, Stoerck, Remer, Reil, Greding, and Barton, chiefly in the form of extract and tincture. The vinous tincture of the seeds, made by infusing two ounces of the bruised seeds in eight ounces of Spanish wine, and one of alcohol, according to most of the German pharmacopoeias,, has been recommended by Schneider and Hufeland in doses often to twenty-five drops, twice or thrice daily. Dr. Burrows states that one grain of the extract of stramonium has procured several hours’ sleep in furious mania, when other nar- cotics, in considerable doses, had not succeed- ed ; but the patients were much more violent when they aw’oke. This result too frequently follows the use both of stramonium and of bel- ladonna. The effects of these narcotics, when given in considerable doses, should be carefully w’atched, and distinguished from the more un- favourable symptoms observed in mania. When dryness of the throat, dilatation of the pupils, anxiety, vertigo, convulsive movements of the extremities, &c., appear, as well as when men- tal excitement is increased by them, the em- ployment of them should no longer be persisted in. The extract and tincture of aconite have been prescribed by Durande and others ; but it is a dangerous medicine in most forms of mental disorder. Conium is less useful than hyoscyamus, and hence unnecessary. [The Indian hemp (Cannabis saliva, hachisch, &c.) has lately been employed in France, and to some extent in this country, in the treatment of insanity, and apparently with very beneficial effects.* Dr. Brigham, of the New-York State Lunatic Hospital, states that he has employed the pure extract of it, procured from Calcutta, in doses of from one to six grains, and that he regards it as a very energetic remedy. It had no particular effect in dementia; in melan- cholia it caused an exhilaration of spirits, some- times causing intoxication ; at others, nausea and sickness at the stomach. In some instan- ces it produced headache, and some were ren- dered for a short time apparently insensible and cataleptic. On none had it any lasting effect, either good or bad. It would, however, appear to be a powerful remedy, and is well worthy of farther trials.—(Am.. Jour, of Insanity, vol. xi., No. 3, p. 281). Dr. Conolly has also recently made trials of this article, and thinks it very useful in chronic cases, although its effects are uncertain. He recommends 3jss. to 3ij. of the tincture of the plant grown in a tropical elimate (tropical heat being necessary for the develop- ment of its medicinal properties) in cases of recurrent mania.] 482. H. Sedatives. — a. Digitalis has been praised as a remedy in mental disorders by Darwin, Ferriar, Currie, Fonzaoo, Jones, Muller, Guislain, Uwins, Burrows, Ellis, and others. Dr. Cox ranks it next to emetics, and thinks that its efficacy is attributable as much to the nausea it creates, when given in sufficient doses, as to its power over the circu- lation. Dr. Hallaran considers'that, when it is given after the system is reduced by proper evacuations, and particularly by repeated purges of calomel, it is more to be trusted to than any other remedy. Besides its capability of re- straining the heart’s action, he supposes it to possess remarkable anodyne and soporific qual- ities in maniacal cases. He commences its use in doses of five or ten drops of the saturated tincture, thrice daily, and gradually increases the dose to fifty drops. Dr. Burrows remarks, that the propriety of lowering the system, by depletions and purgatives, before the exhibition of digitalis is begun, is confirmed by his own experience ; and that he perfectly concurs with Dr. Hallaran in considering this medicine as having a very powerful influence in all the sta- ges of insanity accompanied with great vascu- lar excitement and a rapid pulse. Dr. Prich- ard observes, that the cases in which digitalis is most likely to be useful are those attended by great arterial action and high mental excite- ment. M. Foville considers that it is chiefly beneficial in those cases in which the mental affection is complicated with hypertrophy of the heart. I may remark, respecting this substance, that, when the large doses advised by Dr. Hal- laran are given, the well-known effects of it should be carefully watched ; and, as soon as they begin to appear, camphor, ammonia, aether, &c., should be had recourse to, and its use relin- quished. Digitalis is useful, also, in other forms of the malady besides those particularized above—and even in the low’ states of derange- ment—w’hen conjoined W’ith camphor, ammo- nia, and other remedies. In these, as well as in other forms of the disorder, I have given it with great advantage in the following manner, after evacuations had been freely procured : No. 272. R Camphors rass gr. iij.—v.; Pulv. Digitalis gr. ij. ; Extr. Hyoscyami gr. vij.; Mucilag. Acacise q. s. M. Fiant Pilulae iij., hora somni sumendae. No. 273. R Camphors rasas gr. ij. : tere cum Mucilag. Acacia 3j.; Aquae Menthae virid. fj.; Spirit. iEtheris Sulph. Comp. 3j. ; Tinct. Digitalis 1llx.—xx. ; Tinct. Hyoscyami 3ss. M. Fiat Haustus, bis terve in die sumendus.—VeJ * ©u Hachisch et de Alienation Mentale Etudes Psycho- logiques, par J. Moreau (de Tours), Medicine del’ Hospice, de Bicftre, &c., 8vo, p. 431. Paris, 1845. INSANITY—Of Remedies advised for. 613 No. 274. ft Tinct. Digitalis Ttyx.—xx.; Tinct. Hyoscyami 3ss.; Spirit. Ammon. Arom. 3ss. ; Liq. Ammonia; Acetatis 3jj. ; Mist. Camphor® fj.; Sirupi Aurantii 3SS. Fiat Haustus, ter in die sumendus.’ 483. b. Prussic acid and laurel water have been recommended as sedatives in various forms of insanity. The latter was advised by Thilenius ; the former by Dr. Seymour and Dr. Balmanno. Dr. Burrows states, that he made trial of prussic acid, but never derived permanent benefit from it in any one case. 484. c. Tartar emetic, in small and frequently repeated doses, in order to reduce vascular ex- citement in the brain, as well as in the system generally, was recommended by Willich, Mul- ler, Bodel, Frize, Burserius, and Baldinger. A combination of it with tartrate of potass, so as to act also upon the bowels, was advised by Pideret, Fordyce, and Hufeland. Several writers have prescribed it so as to produce more or less continued nausea. Drs. Cox and De Vos, of Berlin, consider it of great service when vascular action is excited, and when the haemor- rhoidal or menstrual discharges have been sup- pressed, or the portal circulation obstructed. These are, indeed, the circumstances especial- ly requiring it, whether existing in mania or monomania, and more especially in the sanguine or bilious temperament. Where there is more obvious vascular inanition or exhaustion, and in nervous and susceptible persons, a continued use of tartar emetic is injurious. The indica- tions for, as well as against this medicine, are nearly the same as those which relate to vas- cular depletions. 485. d. Cold water, drunk in large quantity, has been praised by Lorry, Theden, Hilscher, and Hufeland in melancholia and mania. I have seen it beneficial in melancholia compli- cated with hysteria. Avenbrugger advised it in those cases especially which are attended by a desire to commit suicide. Falret and Guis- lain, however, observed no benefit accrue from it in such circumstances. It is probable that, in the very few cases in which it has proved useful, it has acted chiefly as a sedative of ir- ritation in the digestive mucous surface and collatitious viscera, that has excited or perpet- uated disorder of the cerebral functions. The remarkably large quantities of water taken al- most hourly in most of these cases may like- wise have tended to remove obstructions from some one of the abdominal organs. Cold water acidulated with the vegetable acids, and more especially with vinegar, was recommended by Buchoz, Theden, Locher, Selig, and Bang, as a sedative and refrigerant of the vascular sys- tem ; and, in order farther to promote this in- tention, small doses of camphor, or of camphor- ated vinegar, were advised by Bona, Perfect, and others. Nitre was also similarly employ- ed, either alone, or with small doses of cam- phor, so as to secure the refrigerant and seda- tive effects of the latter. Cold water, medica- ted in either of these modes, and in the latter more particularly, or by the addition of the spir- its of nitric cether, is more likely to be of service than when used simply. Muriate of ammonia, however, is preferable to nitre in most cases, inasmuch as it combines a tonic influence with its refrigerant and sedative properties. Acetate of lead was likewise used by Schrceder as a sedative and refrigerant in mental disorders at- tended by vascular excitement; but no notice has been taken of it in such circumstances by recent writers. In conjunction with vinegar and narcotics, it is as likely to be of service in these disorders as in several others in which it has been lately employed. The biborate oj soda and boracic acid were also formerly em- ployed, in order to allay vascular action in con- nexion with mental excitement. They have long fallen into disuse ; but I have had reason to consider them as still deserving of notice. [The best sedatives in these cases we hold to be exercise in the open air, the shower bath, and flesh-brush ; and especially the removal of all bodily restraints, and the constant manifes- tation of kindness, gentleness, and forbear- ance on the part of the attendants. Religious exercises, also, have often a wonderfully sooth- ing and quieting effect upon the minds of the insane, far more useful than “ poppy, mandra- gora, or all the drowsy sirups of the world.” A glass of beer and a light supper at bedtime are recommended by Dr. Conolly as a very use- ful anodyne in many cases, where opiates would have no effect.] 486. I. Stimulants and Antispasmodics are especially indicated in nervous temperaments and delicate constitutions, or whenever the mental disorder appears in connexion with de- ficient nervous or vital power ; when the head is cool, and the mental affection is independent of vascular fulness or action ; when sanguine- ous depletions and alvine evacuations have been carried sufficiently far ; or when exhaus- tion follows either these or the previous excite- ment. In other circumstances, particularly if the scalp continue warmer than natural, or the carotids pulsate somewhat more strongly, these may still prove of service, if refrigerants be applied to the head; or they may be conjoined, in such circumstances, with sedative and di- aphoretic medicines. Of stimulants and anti- spasmodics, the most frequently useful are, camphor, valerian, ammonia, asafcetida, cether, and the compound spirit of cether. Others have been employed, as the oxides of bismuth and zinc, cas- tor, serpentaria, arnica, electricity, and galvanism. 487. a. Camphor, in the circumstances just specified (§ 486), is a valuable remedy, and as such has been recognised by Wherlhof, Loe- DENSTEIN, KlNNEIR, FlSCHER, ReMER, AvEN- brugger, Perfect, Percivae, and Hufeland. On the other hand, Haslam, Prichard, and Burrows esteem it of little value. Its influ- ence in this, as well as in other diseases, is very different, according to the doses and com- binations in which it is exhibited. Many years since, I entered upon a series of experiments, in order to ascertain its operation in different conditions of the system ; and, in a paper pub- lished some time afterward (Lond. Med. Repos- itory for September, 1825, p. 245), I stated the result of my researches, and of my experience of it in some cases of mania, which I had seen with Mr. Alcgck, Mr. Carroll, and others. Since then I have prescribed it in several cases, both of mania and melancholia, and generally with more or less benefit. Dr. Millingen, in a work just published, forms a juster estima- * [Dr. Conolly states, that he has been entirely disap- pointed in the use of digitalis in mental disorders, and no ionger employs it. Its depressing effects are often distress- ing, without being followed by any manifest benefit.—(Loc. <*■) 3 614 INSANITY—Of Remedies advised for. lion of it than many other recent writers. He states it to be a valuable medicine, but requi- ring much discrimination. It is not advisable, he adds, when there is cerebral excitement, with a hot, dry skin, full pulse, and wild coun- tenance ; but where there is much restless- ness and uneasiness, with a low, weak pulse, or cold and clammy skin, it will be found most beneficial. This is altogether in accordance with what I have stated respecting it in the pa- per just referred to. I have there shown that camphor in very small doses is refrigerant; but in full or large doses it is restorative, exci- ting the brain and nervous system, and consec- utively calming and anodyne. In mental dis- orders, it should not be employed until alvine evacuations and sanguineous depletions, where these are required, have been duly employed. The combinations in which I have most fre- quently prescribed it, are with opium, morphia, or hyoscyamus, or belladonna, or with nitre, or with the solution of the acetate of ammonia, or with digitalis, or with James’s powder, or oth- er antimonials, or with the alkaline carbonates, or with acetic acid, or with any two of these that .may be congruous with the circumstances of the case. Selig, Schoenheider, and Per- fect prescribed camphor with vinegar, and Friborg, with nitre and opium, in maniacal cases. The dose of camphor in mental disor- ders, as well as the combination and mode of exhibiting it, ought to be regulated by the pe- culiarities of the case, and the effects of the previous treatment. M. Esquirol usually di- rects from half a drachm to a drachm to be dis- solved in two ounces of vinegar, or dilute ace- tic acid, and given in an aromatic infusion in the course of the twenty-four hours. I have found this mode -very serviceable in puerperal and hysterical mania, other appropriate means be- ing also employed; but smaller doses are more appropriate in many cases. Cold applications to the head, the shower bath, or tepid bath, &c., may also be resorted to during its use, or when increased heat of the scalp or skin is caused by it. 488. b. The infusion and compound, tincture of valerian have proved, in some cases of mania and of monomania, or melancholia, in which I have employed them, of great service, more es- pecially in the states of these disorders already described ($ 486). When these affections are associated with hysterical symptoms, or when the patient entertains the idea of committing suicide, or has a disposition to indulge or to adopt any dangerous caprice, these prepara- tions are often beneficial, particularly after ap- propriate evacuations, and in combination with the solution of acetate of ammonia, or with the alkaline carbonates, or with digitalis, hyoscya- mus, &c. Musk has been advised, in similar circumstances, by Thilenius, Locher, Selig, Pargeter, and Gmelin ; but it and castor, am- monia, asafcetula, the oxides of bismuth and zinc, and the cethers, are severally inferior to either camphor or valerian ; yet they are often useful, especially as adjuncts to other stimulants and restoratives, or to narcotics or sedatives, or even to tonics, in the more strictly nervous forms of insanity, and in cases of debility and exhaustion. 489. K. Tonics were recommended by Syd- enham, Selig, and Wintringham, and are ob- viously required in most of the circumstances in which stimulants and antispasmodics are in- dicated, and particularly in cases manifesting more or less of vascular inanition.—a. Cincho- na, or the sulphate of quinine—the latter espe- cially—is often preferable to othef tonics, more particularly in the intermittent forms of insan- ity. The infusion of bark with the solution of the acetate of ammonia is most suitable when vascular or nervous excitement is passing into exhaustion, or in cases where the propriety of having recourse to tonics may seem doubtful. In circumstances of obvious exhaustion, or in- anition ; in the more purely nervous states of disorder ; in advanced stages, after evacua- tions have been carried sufficiently far, or when the head is cool, and the pulsations of the ca- rotid are not increased in strength or fulness, the sulphate of quinine, either alone, or with camphor and with the extract of aloes, if the bowels require to be kept freely open, will oft- en be of service. I have given the following pills, varied with circumstances, in several cases of partial and general mental disorder; the first, when the bowels are costive ; the sec- ond, when they are too relaxed. In this latter state, a combination of cinchona and opium was recommended by Ferriar. No. 275. R Quirue Disulphatis 3ss.; Camphor® rasse 3ij.; Extr. Aloes purif. 3ss.—3ij. ; Extr. Hyoscyami 3jss. ; Bal- sanii Peruviani q. s. M. Fiant Pilul® L., quorum capiat tres, bis terve in die.—Vel. No. 276. R Quin® Disulphatis 3j.; Camphor® 3ss., Extr. Humuii 3jss. (vel Pilulie Saponis cum Opio 3j.); Sirupi Simp. q. s. M. Fiant Pilula xxxvj., quarum capiat duas, vel tres, bis in die. 490. h. The arsenical solution has been pre- scribed by Neumann, Winckler, Ackermann, and Seymour ; and in states and circumstances of the disease for which I have advised the sul- phate of quinine, and especially in the inter- mittent forms of insanity, is well calculated to be of service. It requires not only great dis- crimination in entering upon the use of it, but also caution as to the quantity prescribed, and the continuance of a course of it; as excess in either may be followed by inflammatory irrita- tion of the digestive mucous surface, especial- ly in the large intestines, or by endocarditis. 491. c. The nitrate of silver has been recom- mended by Agricola and Kesler ; and, in cir- cumstances truly indicating the propriety of tonics, and when insanity has been occasioned by depressing or exhausting causes, and in purely nervous cases, it may prove of service. It has been considered as more particularly suited to the complications of mental disorders with epilepsy. When, however, this associa- tion is dependant upon vascular or structural disease of the encephalon, little or no benefit can result from it. I prescribed it lately in one case of this kind, but was obliged to discon- tinue it. I have, however, found it of service in two cases of melancholia, with chronic irri- tation of the digestive mucous surface. 492. d. The infusion and tincture of hop have been recommended by Dr. Mayo ; and, in the numerous circumstances and cases of the dis- ease requiring both tonic and anodyne reme- dies, they are appropriate, and likely to prove serviceable. They, moreover, admit of various useful combinations with other remedies in mental disorders. The preparations of iron, and chalybeate mineral waters, have been employ- INSANITY—Of Remedies advised for. 615 ed by Lange and others. They are beneficial in several states of mental disorder, and espe- cially in the more purely nervous cases, and in states of vascular inanition, or when derange- ment has proceeded chiefly from masturbation or exhausting discharges. The sulphate of cop- per has been prescribed by Boerhaave and Cur- rie. It is suitable chiefly in diarrhoea occur- ring in chronic mania, and dementia. Absinth- ium was used by and Paulus JEai- neta, and the muriate of baryta by Hufeland. 493. e. Various other stimulants and tonics have been recommended by writers on men- tal affections; but very few of these require particular notice. Phosphorus is mentioned by Loebel and Kamer. Its powerfully stimulant qualities require great caution in its use. Form- ulae for exhibiting it are to be found in the Appendix (F. 6, 7, 428). The extract of nux vomica is noticed by Murray and others : it also requires great discrimination in employing it (see F. 541, 542). Both these substances are suitable only in the more nervous forms of men- tal disorder, especially in melancholia and de- mentia, proceeding from exhausting and de- pressing causes, and in the circumstances indi- cating the adoption of the more energetic stim- ulants, and of chalybeates. In dementia and chronic mania, complicated with general palsy (§ 167), these medicines may be tried, upon the principle adopted by Celsus, “ Melius est anceps remedium, quam nullum.” The chelidonium was prescribed by Muller, on account of its stimu- lant, laxative, and diuretic properties. As it promotes the secreting and excreting functions, and thereby exerts a deobstruent and alterative influence, it may be tried in mental disorders complicated with obstructions or other diseases of the abdominal viscera, and especially in mel- ancholia. The decoction of hypericum was praised by Meyer and others. It is nervine and stimulant, and is most appropriate in the more purely nervous states of mental affection, and in melancholia, after sufficient alvine evac- uations. Dr. Mayo observes, that the use of re- storatives and tonics in the first stage of insan- ity is valuable in the nervous and serous states, but mischievous in the bilious and sanguine, and that, in the stage of exhaustion, they are re- quired in every temperament. 494. L. External Irritants and Derivatives have been long and generally recommended in the treatment of mental affections. They may be divided into, 1st. Irritants applied to the scalp; and, 2d. Irritants applied to parts more or less re- mote from the head, so as to produce some degree of revulsion or derivation from the seat of mor- bid action.—a. Scarifications of the scalp were ad- vised by Aurelianus, Wal- ther, and Prichard ; but they are admissible only when the scalp and head are more or less congested, or when inflammatory irritation or structural change is inferred to exist in the en- cephalon. In nervous and susceptible persons, and in states of general or local inanition of the vascular system, they may prove injurious. The application of the actual cautery to the oc- ciput, or of moxas in the same situation, as ad- vised by Pascal, Larrey, and Valentine ; and artificial ulceration of, or setons or issues insert- in the scalp, as prescribed by Horn and oth- ers, are indicated and contra-indicated by the pathological conditions just mentioned. Inunc- tion of the tartarized antimonial ointment on the shaved scalp, until a copious eruption of pustules is produced, was advised by Munro, Autenrieth, Jenner, Gumprecht, and others, and has been found of service in some cases of mania, especially when the acute stage is be- ginning to decline, or to pass into the chronic state. The application of blisters to the head was recommended by Thilenius, Durr, and Hufeland. The practice is not without haz- ard, particularly in the more acute states of mental disorder. It is more appropriate in the more chronic and low forms of derangement, and especially in imbecility and dementia. 495. b. The application of irritants so as to produce a derivative or revulsive effect is appro- priate in many of the more acute and early, as well as in the more chronic states of mental disorder; and yet, in very irritable, nervous, and susceptible patients, in the early stage of mania, and in cases where the vascular system is rather deficient than too full of blood, these irritants often increase disorder by exciting the general sensibility. Where, however, the disorder has been consequent upon the suppres- sion of accustomed eruptions, ulcerations, and discharges, and in many cases of melancholia, or of other forms of monomania, derivatives and revulsants are often of much service. In the more acute and recent cases, and especial- ly of mania, they should not be resorted to un- til vascular depletions and other evacuations have been employed. 496. Various modes of producing derivation of disorder from the brain have been recom- mended. Several of these are already noticed, as also falling under other heads, especially purgatives, warm bathing, &c. Blisters on the nape of the neck, or on the legs, &c., are often resorted to ; but they are seldom of service in mania, especially in the early states. They are useful chiefly in the stages of disorder just mentioned. Guislain recommends them to the nape, back, or insides of the thighs or legs, when insanity commences with depression of mind, or melancholia, and in some states of de- mentia ; but he has rarely found them service- able in this latter state. Avenbrugger applies them to the region of the spleen in melancholia ; and, when prescribed either to the epigastrium or to the hypochondria, they are sometimes of service in that affection. More advantage may be expected from issues and setons than from blisters, unless the latter be kept open for a considerable time. Zacutus Lusitanus ad- vised setons or issues to be inserted over the region of the liver or spleen in melancholia. In the majority of cases, however, their inser- tion in the nape of the neck is preferable, espe- cially in the other forms of insanity. Dry cup- ping in this situation is often of service. Dr. Burrows suggests the application of the cups as a derivative to the shaved scalp itself; and, doubtless, this place will often be preferable. I have, in some instances, caused the nurse or attendant to resort to dry cupping on the nape several times in the day, and to employ merely a large glass, tumbler, or any other convenient article for this purpose, and a piece of lighted paper. 497. The production of irritation or artificial eruptions on parts of the body still more distant from the brain, or on the surface generally, has 616 INSANITY—Of Remedies advised for. been advised, in order to remove irritation from this organ. They are commonly produced by the tartarized antvmonial ointment, and by fric- tions with croton oil. Thilenius, Odier, Mu- zell, and Bartholomew recommend inoculation of the itch. Besides these, warm mustard pedi- luvia, mustard poultices applied to distant parts, and particularly to the lower extremities, the hot turpentine embrocation in situations remote from the brain, and irritating or cathartic enema- ta may severally be employed in circumstances which seem to require them, and especially when a tendency to coma or lethargy is ob- served. 498. c. Of the various modes of external irri- tation, Dr. Burrows and Dr. Muller consider pustulation, by means of the tartarized antimo- nial ointment or plaster, the best; and they prefer the application of it to the shaved scalp. Dr. Millingen prescribes it to the back of the neck. The choice of situation should depend upon the form and stage of disorder. In de- mentia, in cases attended by stupor or impair- ed sensibility, and when melancholia or men- tal depression is threatening to pass into ex- citement, the scalp may be preferred, after due evacuations have been procured. In some states of mania or monomania, this ointment, or plaster, may be applied to other parts. M. Guislain states that he has derived little ad- vantage from it in dementia; but that he has sometimes found it of service in melancholia and in mania. Dr. Jenner published several instances of its success, when applied to the epigastric region, nape of the neck, scalp, and other situations. During the eruption thus produced, a restorative treatment is often ne- cessary. 499. The insertion of sctons in the neck is considered by Dr. Prichard to be most advisa- ble in mental disorders of a chronic form; but he also recommends issues made by a long in- cision in the scalp, over the sagittal suture, where there is great intensity of disease, and a state of the brain threatening a fatal increase. In cases of stupor, and of dementia following apoplexy or palsy, or severe fevers, he believes this method more beneficial than any other. He also suggests a recourse to it in the com- plication of insanity with general palsy. M. Esquirol remarks, that dry cuppings, blisters, and irritating applications are most success- ful in cases consequent upon metastasis, in monomania attended by stupor, and in demen- tia uncomplicated with convulsions or paraly- sis. There can be no doubt of counter-irrita- tion being more appropriate in cases character- ized by torpor and insensibility, instead of mor- bid activity or excitement and intensity of feel- ing. Dr. Prichard observes, that in almost every case of paralysis, with a tendency to coma and lethargy, in which he has used this class of remedies, he has witnessed decided ad- vantage from them. The opinions of Dr. N. Hill, M. Guislain, and of Dr. Mayo, are also in favour of these means. [Observation abundantly proves that insani- ty presents as great variety, in relation to causes and circumstances, as any other disease what- ever, and that no general treatment can be laid down applicable to all cases ; in other words, there is no specific remedy against it, as it is uo special disease, but arises from a variety of causes acting upon the mental functions, through their organ, the brain. The treatment naturally resolves itself into moral and medi- cal, the former of which will he hereafter con- sidered. The late Dr. Spurzheim was the first, next to our own Rush (who anticipated many of the recent discoveries in relation to the na- ture and treatment of mental diseases), who enforced the necessity of applying the general principles of pathology to the brain as well as to other parts of the body, and who pointed out the importance of treating its diseases in con- formity with their nature, and with cerebral structure and functions, instead of resorting to a senseless routine, or the incongruous variety of means at the same moment, which were for- merly in vogue. Dr. Rush had long ago re- marked {Med. Inquiries and Observations, vol. ii., p. 22), that “ it is, perhaps, only because the diseases of the moral faculty have not been traced to a connexion with physical causes that medical writers have neglected to give them a place in their systems of nosology, and that so few attempts have been hitherto made to lessen or remove them by physical, as well as rational and moral remedies.” Pinel, on the other hand, attached .but little, if any, im- portance to medical treatment, but depended almost solely on the moral management; the truth, as generally happens, lies between the two extremes. In no country on the globe, it is believed, has the treatment of insanity been crowned with more flattering success than in the United States, as the statistics of our different institu- tions will show ; and this success is doubtless owing to the happy mode of combining moral, medical, and hygienic means, which characteri- zes the management of this class of patients, both in our public and private practice. In this coun- try, treatment is, to a great extent, regulated by those principles of pathology which modern researches have established, and which lead us to regard the proximate cause of insanity as corporeal, and seated in the brain. Dr. Rush led the way, by his truly philosophical work on the “ Diseases of the Mind,” in which he dwelt on the importance of the principle just laid down, and remarked, that “ the successive and alternate changes of the different forms of mad- ness into each other show the necessity of re- nouncing all prescriptions for its names, and of constantly and closely watching the disease.”— {Med. Inquir., &c., p. 237.) In no class of diseases, then, is it more im- portant to regard the causes of the disease, the previous health of the patient, the age and du- ration of the disorder, hereditary predisposi- tion, former treatment, &c., in order to arrive at a knowdedge of the true indications. The treat- ment proper for recent cases would be injuri- ous to those of longer standing; and those which arise from mechanical causes require far different management from those which are oc- casioned by bodily disease, or by moral influ- ences. That acute mania is sometimes caused by a hyperasmic or congested state of the brain, will not admit of a doubt; and here general and local bleeding, with cold applications early in the disease, will be attended with marked success ; but that this condition is rare, and very liable to be mistaken for one of an oppo- site kind, is equally true. “ There is,” as Dr INSANITY—Of Remedies advised for. 617 Conolly has recently remarked (Clinical Lec- tures on the Principal Forms of Insanity, &C., Lond. Lancet, vol. iii., p. 10, Am. ed.), “ such an apparent superabundance of energy in the pa- tient as to betray an inexperienced practitioner into hazardous measures. When the face is flushed, the skin warm, the pulse quick ; when the voice is loud, the gesticulation vehement, it is difficult, at first, to believe that the vital power is not in excess ; and when this state of morbid excitement lasts for weeks or months, it seems scarcely credible that there is all the time a tendency to sudden depression of all the energies of life, and that no violent reme- dies are admissible. Yet, in the most recent state, the condition of the circulation is seldom such as to encourage even one bold depletion ; and, as the case proceeds, emaciation advan- ces, signs of exhaustion are perceptible, and sometimes there is sudden exhaustion and death. I feel myself, therefore, justified in cau- tioning you most strongly against general bleed- ing as a rule in those cases. I am convinced that it is not often admissible, and that it some- times does irreparable mischief, particularly if resorted to freely, or practised repeatedly.” Dr. C. states that some of the worst cases he has seen were those in which the patients had been largely bled before admission, and where the violence had been increased by the loss of blood. Pinel remarks, that the early symptoms of mania were often aggravated by the low diet to which patients were subjected in his day, and that one of his first measures was to supply them with an abundance of sub- stantial and nutritious food ; and he relates ca- ses where, under the influence of such a diet, delirium rapidly subsided, and convalescence was speedily established. It is now, we believe, the general opinion among the physicians of our different lunatic hospitals, that although there may be cases in which bleeding may be useful, yet that they are very rare, and that the copious blood-lettings formerly recommended by Rush and Frank are altogether inadmissi- ble. Dr. Conolly states that, in more than twenty years’ practice, he has seen but two or three cases in which bleeding appeared to be useful; but has generally found it injurious, even in plethoric cases that seemed to war- rant its use ; and that, in six years’ experience ■it Hanwell, he has found no encouragement to esort to it in a single instance. In two cases, he found its effects most unfortunate ; in both, a state of imbecility ensued, and an inability or indisposition to speak, which lasted in each case more than twelve months ; and in neither case was any amendment observed. Dr. C. is disposed to regard the excitement of the brain in mania as not dependant on increased action of the heart and arteries, a pathology which would seem to be supported by the fact that, in nearly all cases, the pulse is feeble, as well as rapid, and that symptoms of prostra- tion of strength early supervene. The same objections, however, do not apply to local as to general blood-letting, which is not only often admissible, but extremely serviceable. Leech- es will generally be found preferable to cupping. The late Dr. Todd, of Hartford, Connecticut, was one of the first to prove the superiority of the tonic, anodyne, and soothing treatment, over the depleting and antiphlogistic in mental dis- eases; the ratio of cures in recent cases un- der his management being as high as 91 per cent. He made great use of conium macula- tum, stramonium, and hyoscyamus, and of the different preparations of iron, together with urine and cinchona, in the treatment of the insane, and found them more efficacious than any oth- er remedies. We subjoin the following remarks on the medical treatment of insanity from the pen of the late Samuel White, M.D., of Hudson, New- York (Address on Insanity, delivered before the N. Y. State Med. Soc., Feb. 5, 1844), as they are believed to represent the views of a major- ity of our physicians who are devoted to the treatment of the insane, and especially as they imbody the experience of a long life of labori- ous toil employed in the management of this class of diseases. “ In the therapeutical treament of insanity,” says Dr. White (Address on Insanity, p. 12), “ every case must be considered and treated as an insulated one. Remedies must be applied to the constitution and peculiar features of each case. While the first indication is to remove or lessen, as far as possible, irritation as the immediate cause, pervading the cerebral and nervous system, and through sympathy the vascular, yet are we to bear in mind the con- dition of other remote organs morbidly excited, and participating in the general disturbance. For instance, the associative powrers of the stomach as a central organ are immensely im- portant, as it regards the phenomena of dis- ease. So also, through arterial agency, de- fective secretion of the gastric juice, and loss of power in the secerning system, we account for local congestion, impaired appetite, and waste in fevers. “ Remedial means, when rightly applied, need be but few. And what is the popular aim, in the cure of diseases, at the present day 1 but to sustain the conservative principle, the strong- est in nature, by the revulsion of excitement to parts less essential to life, and equalizing cir- culation. Hence the importance that our first move, in the treatment of incipient insanity, should be based upon a correct diagnosis ; crit- ically regarding the necessary distinction ever to be maintained between phrenitis and active mania. The one concentrated inflammation, affecting the substance and meninges of the brain ; the other irritation, specifically embra- cing the nerves of sensation and volition, sym- pathetically disturbing every function and fibre of the human system. The first demanding bold depletion as the anchor of safety ; the lat- ter to be approached cautiously, by milder and more comprehensive means, as we shall pro- ceed to enumerate. “ Here, then, permit me to remark that no one is competent to endure this searching or- deal who is not well versed, analytically and pathologically, in every branch of medical sci- ence. “ Copious abstractions of blood should ever be avoided in insanity, as endangering demen- tia. Very few are the cases of insanity, even in its incipient stage, that admit of venesec- tion. In such only as are plethoric and in the vigour of life is it admissible at all, and then only in a cautious degree. The pulse is de- ceptive ; for though there may be increased im- 618 INSANITY—Of Remedies advised for. petus of blood in the carotids, yet they will be found compressible, and the radial artery fee- ble in its action, showing an unequal distribu- tion rather than congestion. In such cases, where symptoms seem urgent, topical blood- letting, by leeching or cupping, may safely be resorted to without danger of collapse. In the treatment of six hundred cases, venaesection has not been resorted to in more than one in a hundred after they entered the institution, and then only moderate in quantity. Many, how- ever, have been brought to the asylum after two or three copious bleedings, undoubtedly with the best intentions ; yet the results have proved a prostration of the vital energies, more difficult to overcome than the original disease.” “ Active emetics are seldom admissible, as tending to a determination to the brain. Where there is great derangement of the digestive or- gans, ipecac and calomel combined, in such quantities as to produce an emetico-cathartic ef- fect, may prove salutary in their operation ; so also the blue mass, with one fourth part of ip- ecac, adds to its efficiency in restoring the functions of the liver. “ Drastic purges are seldom advisable ; lax- atives, to keep up a steady action of the in- testinal tube, are far preferable, and may be aided by injections, due exercise, and a well- regulated diet. No particular formula can here be laid down. The judgment of the physician must decide on the quantity and appropriate- ness of the article, according to the constitu- tion and peculiarities of the patient. “ Narcotics and sedatives are next in order. Opium, camphor, morphia, stramonium, coni- um, belladonna, and aconite are most to be re- lied upon, but require great prudence as to the time and manner of their administration. These are often improved by combination with other remedies ; for instance, opium, ipecac, and soap, equal parts, form a pill much easier given than Dover’s powders. Camphor mixture, with half a grain of tart, antimony, and five drops of laudanum to the ounce, given in half ounce do- ses, is a powerful sedative and adjuvant in al- laying nervous excitement. Morphia with col- chicum, when there is a gouty or rheumatic diathesis, endangering metastasis, is a valua- ble auxiliary in treatment. Stramonium acts specifically on the sensorium, stimulating the absorbents. A saturated tincture of the seeds in camphor mixture is the best mode of admin- istering it. Conium is best combined with the different preparations of iron. Belladonna and aconite are often improved by combination. Extracts of these vegetables can only be relied upon when evaporated by solar heat. “ Counter irritants, revulsive in effects, are valuable auxiliaries, more especially in me- tastasis and suppressed eruptions, and are more cheerfully submitted to when allayed with some of the vegetable narcotics endermically applied. “ Bathing.—One of the most powerful reme- dial agents in equalizing circulation is the warm bath. The patient should be immersed from twenty to thirty minutes, the heat at 96 Fahren- heit, refrigerating the head while in the bath, when the heat of the part should indicate its necessity. Warm bathing will be found par- ticularly beneficial and appropriate in melan- cholia and delirium tremens Fixed alkanne salts added to the water are useful in remo1- ving the sebaceous oil from the surface of the body. The nitro-muriatic bath is a valuable and effective agent in a congestive state of the liver, and should be repeated in connexion with the usual remedies, until we have evidence of a healthy secretion of bile. The value of the shower bath is known to all, yet it is too in- discriminately used. Great prudence and watch- fulness are necessary in its application. Should atony prevent a suitable reaction and warmth over the surface, it may do serious and lasting injury. A pitcher of cold water poured over the back part of the head is often grateful as well as useful to the patient. “ In the second stage of insanity, a more ton- ic treatment becomes necessary, and it is to be regulated according to the age, constitution, and temperament of the patient. The various preparations of iron, nitrate of silver, followed with a solution of iodine to prevent a discolor- ation of the skin, conjoined with suitable mor- al treatment, will often decide the future pros- pects and destiny of the patient.”—(Loc. cit.) “ Insanity is a physical disease,” says Dr. Woodward (9th Annual Report, p. 79), “ and as susceptible of cure, by remedies which make impressions upon the system, as any other dis- ease of equal severity. Like other diseased organs, the brain often suffers by sympathy with other parts diseased, and the cure of the primary affection relieves the secondary in the usual way. “ The influence of Dr. Rush’s notion of the utility of liberal bleeding in insanity still clings to the physicians in the country generally, and we rarely have a patient committed to our care who has not been copiously bled. The physi- cians in the charge of the institutions, both in this country and in Europe, have long since abandoned this practice as rarely beneficial, and often hazardous. It is a frequent remark, that it is often more difficult to cure the evil that arises from the loss of too much blood than to remove the insanity in violent cases of recent attack. “ The condition in which the patient is found in violent mania, when the physician visits him, is not always duly considered. The great ex- citement of the pulse, the distention of the blood-vessels, the heat and redness of the skin, and the amazing muscular power which they sometimes exert, only show what he has done, rather than the condition in which he is ; they are the effects of his amazing excitement, and not the symptoms of his disease. A little cold water or ice applied to his head will afford him greater and more immediate relief than the loss of a pound of blood.” “ In a case of genuine mania, there is usu- ally no inflammation of the brain or its appen- dages ; the excitement is much more frequent- ly of a nervous character, and will yield more readily under a mild and safer treatment. Lo- cal bleeding, cupping, ice to the head, mild cathartics and narcotics succeed far better, and are less hazardous. Many cases yield like a charm to narcotics, if the system is prepared for their use, and they are prescribed in a prop- er manner and with discrimination. Bark and iron, combined with narcotics, dc well when excitement has abated and the strength re- quires to be restored. INSANITY—Moral Treatment of. 619 “In chronic cases of insanity, tonics, nar- cotics, baths, laxatives, and remedies that tend to remove local disease, if it exists, are often found beneficial. In certain torpid cases, the cold bath, with stimulants and acrids, is a val- uable auxiliary in the cure.” “ One thing is well established, that the in- sane cannot be as well treated at home as with strangers, nor as well in a private fami- ly as in an institution. Few physicians can give to them the attention which they require, or persevere a sufficient time with such rem- edies as they need, or with sufficient regu- larity. “ The insane man is the only one who dis- cards the kind offices of his friends at the time when he most needs their aid and solace, and throws himself upon strangers. “ In chronic cases, much benefit arises from a perseverance with remedies for a much long- er period than most physicians would prescribe them, or most patients pursue them.”] 500. iii. Moral Treatment. — Recourse to moral management has either been too much neglected, or too exclusively adopted. It is but seldom that the truly philosophic physician is satisfied, even in the present day, that phys- ical treatment is duly associated with moral management; or that either, or both, are ap- propriately directed to the removal of existing pathological conditions, and of the associated mental disturbance. Yet both physical and mor- al means should be judiciously conjoined and directed to the peculiar circumstances of each case. It is impossible, especially in my con- fined limits, to describe the impressions which should be produced, and feelings excited, in or- der to combat the various states of mental dis- order that come before the physician. These means, to be appropriate and beneficial, must necessarily vary in each instance, and be so en- tirely based upon the ever-varying phases of disorder, as not to admit of description. Yet much useful information on this subject, and even the principles of moral management, will be found in the writings of Sir H. Halford, Dr. Mayo, Dr. Prichard, Dr. Burrows, MM. Guislain and Esquirol. 501. a. It is chiefly at the commencement of mental disorder, and when the stage of ex- citement is about to lapse into comparative calm, that moral treatment is most beneficial. Still, it should not be neglected at any period, as long as the patient retains any power of com- prehension. Dr. Mayo observes, that, supposing the morbid state to be commencing, every ef- fort must be made to strengthen the influence of the will. The patient, at this period, grad- ually surrenders himself—though not without a struggle—to some prevailing idea, fear, or delusion : he supposes his friends to be con- spiring against him, or insulting, or watching him; or he believes calamities of various kinds impending over him. Meanwhile, he is strug- gling against the morbid impression. His ef- forts, therefore, whether manifest or not, must be aided when right, and his mind tranquillized. His fears should be shown to be unfounded, and his hopes excited and encouraged. To ad- minister this aid is generally a matter of diffi- culty. The danger of mischief to himself or others, as well as the occasional necessity of repression, dictates surveillance (which is al- ways irksome and distasteful), when it is most requisite to conciliate regard. 502. In this state of commencing or impend- ing insanity, the morbid sensations or percep- tions, and the unreal ideas or assertions of the patient, should not be rudely contradicted, and imputed to imagination. They are real to him; and to controvert them is the readiest way to irritate the mind, to destroy all his confidence in the judgment and friendship of his adviser, and to strengthen and confirm the disease. His mind requires to be soothed, diverted, and ab- stracted from the fears and anxieties by which it is absorbed, depressed, and exhausted. He should be told that his feelings and perceptions will soon change, as his health improves; he should be comforted by admitting the justness of his complaints, and cheered by attributing them to a temporary disorder of his general health, which will be removed by suitable rem- edies ; and these remedies ought always to be resorted to, in order, both that s.uch disorder, which is never absent, may be cured, and that his confidence may be gained. At the same time that such admissions are made, and that the ut- most kindness and encouragement are evinced, the greatest firmness must be exercised : noth- ing should be yielded that ought not to be con- ceded. He will thus be brought to look for sup- port, and to trust to it, against his own insta- bility and weakness of purpose, as well as for aid in his struggles against morbid impulses and desires. In this incipient stage of mental disorder, much consequent mischief may be prevented by judicious moral management— by moral and religious consolations, mental ab- straction, and diversion ; by firmness, kindness, and moral control; by change of occupation, of scene, and of air ; by travelling or voy- aging ; and by the amusements and intellectu- al agremens of society. Foreign travel is gen- erally preferred in these cases, as affording greater novelty; and visiting watering places and mineral springs, in connexion with travel- ling, presents several advantages. These con- spire, with other circumstances, to excite, or to preserve hope, at the same time that they may be beneficially directed to the removal of physical disorder. At this period, nervous pow- er is depressed by the continued operation of debilitating fears and sensations, while the as- similating, secreting, and excreting functions are impaired; and hence, recourse to chalyb- eate, sulphureous, or saline waters, or to vari- ous combinations of these, in conjunction with moral influences, is frequently of the greatest benefit, especially in the hypochondriacal and melancholic states of disorder. In addition to these, regular exercise in the open air, particular- ly walking and riding, and, still more, exercise and occupations which interest the thoughts, and engage the feelings in an agreeable man- ner, as tennis, cricket, fishing, shooting, hunt- ing, gardening, farming, &c., should be en- joyed, with due precautions against injurious physical agents. The patient should almost al- together live in the open air; but the air should be dry and temperate, and the situation eleva- ted. In unfavourable weather, in-door exer- cise and occupations should not be neglected. Amusements, also, may be often permitted, es- pecially billiards, chess, backgammon, &c. 503. b. Even in the more violent mental ex- 620 INSANITY—Moral Treatment of. plosions observed in mania, or when intense re- action follows upon depression or melancholia, moral restraint and discipline are often of great service. The union of firmness with kindness, even in such circumstances, is not to be laid aside. As M. Pinel observes, the physician sustains, in these cases, the sentiment of his dignity, and the principles of a pure and en- lightened philanthropy. He allows the maniacs all the liberty compatible with the safety of themselves and of others; conceals from them the means of constraint which he is obliged to employ; and treating them with indulgence, leads them to suppose that they are only sub- mitting to the laws of necessity. M. Georget remarks, that active and incessant inspection must be exercised, particularly in an asylum, over both patients and attendants. Lunatics evincing a disposition to suicide should never be a moment out of sight. It is often necessa- ry to confine violent patients, and those who are addicted to indecent practices, wfith the strait-waistcoat. The only measures of pun- ishment, he adds, that should be practised, are the strait-waistcoat, seclusion in a cell, the shower bath, and some occasional privations. Dr. Prichard justly observes, that all means of punishment and intimidation should be used •as sparingly as possible, and be of the most harmless kind. Solitary confinement and the strait-waistcoat are sufficient in ordinary cases. M. Foville has recourse to the cold shower bath, and to cold affusion on the head; the violent maniac being seized by a number of attendants, and subjected to the affusion until he becomes subdued. The circular swing has been used with a similar intention; and after it has been once used, a threat of its repetition is frequently sufficient; but the cold affusion is a safer remedy. When obstinate lunatics refuse to take food or medicine, persuasion should be first tried, and if it fail, threats and harmless punishments may be adopted. The stomach- pump may be had recourse to in these cases; the use of it on one occasion will generally pre- vent the necessity of again employing it. 504. M. Guislain justly remarks, that the physician ought, as much as possible, to ab- stain from saying or doing anything before a lunatic calculated to inspire fear or dread, or by which he might become an object of aver- sion, or lose the confidence of the patient. Some other person should appear to be the agent in all restraints or punishments that may be required; and the physician should be re- garded as the protector of his patients, and the dispenser of kindnesses and indulgences. 505. c. When the acute stage, or the period of excitement, has passed, a calm usually fol- lows ; and in this state of comparative com- posure, the morbid delusions adhere to the mind less pertinaciously. The patient himself often begins to doubt their reality, and his es- tranged affections seem disposed to return. The observations of Sir Henry Halford on the moral treatment of this period are particu- larly deserving of attention. “If, at this au- spicious moment,” observes this able physician and classical writer, “ the intercourse of a dis- creet friend be permitted, it will cheer the pa- tient’s heart; while, by kindness and attention, the physician will easily get possession of his returning confidence, and so induce him to un- bosom himself of the distempered notions which still continue to haunt him. These, although they be founded in palpable error, the physician will not combat, although he will take proper opportunities of hinting his doubts of their re- ality. He will never deceive his patient, but take pains to prevail upon him, whenever they recur, to refer them to his unbiased and more practised judgment; and to be guided by that rather than by his own, in estimating the cor- rectness of such opinions. He will act, as it were, upon a system of education, and will aim thereby at confirming the spirits and strength- ening the mind of the convalescent; and as the discipline employed in youth encourages and enforces the predominance of reason over the passions, so will discreet converse assist in restoring reason to her seat, and in giving her back again her proper sway over wild impulses. He will engage the mind agreeably, by present- ing to it new objects, and by recalling former pursuits to their wonted acceptance.” “ Had the patient, before he was ill,” Sir H. Halford continues, “ any favourite amusement of a harmless nature 1 Was he fond of music, for instance 1 Music, without exercising the atten- tion severely, has the power, however, to fix it; therefore, with this ‘ sola voluptas solamen- que mali,’ the only gratification, perhaps, of which he is capable at this period of his men- tal darkness, he may be indulged immediate- ly.” “Or, had the patient, before he became insane, a predilection for any particular stud- ies 1 Would he take the counsel of Lord Ba- con, and entertain such as fill the mind with splendid and illustrious objects, as histories, fables, and contemplations of nature ! Or, did he prefer mathematics! and can he now be prevailed upon to enter upon a course of such reading! Plato has called mathematical dem- onstrations the purgatives of the soul, as being the most proper means to cleanse it from er- rors, and give it a relish for truth. Certainly, nothing more entirely bars the intrusion of thick-coming fancies, by occupying the whole mind, than mathematical studies.” Sir H. Hal- ford states, that Dr. A became deranged, while practising physic in the country, and, after a separation from his family for some months, was advised to resume the study of Euclid, having dropped hints of his partiality to it. He did resume it with the happiest ef- fect, and recovered at length so entirely as to commence business in London, and to practice until his death. 506. Experience has shown that monoma- niacs are injured by directing their attention, or by adverting in any way to their illusions. It is, on the contrary, requisite to engage their minds, as much as possible, with very different subjects, and with external objects. Still, au- thors have adduced instances of persons having been cured of their delusion by some deception. Thus, M. Esquirol states, that a lunatic would not pass his urine, because he supposed that, by doing so, the world would be subjected to a second deluge. He was at last prevailed upon by being told that the town was on fire, and that he could save it from the flames. But any advantage obtained in this manner is generally only temporary. During convalescence, pow- erful impressions on the mind, even in connex- ion with the patient’s delusion, may rouse the INSANITY—Moral Treatment of. 621 patient, as if from a dream, and thus dispel the unreal impression. A female patient had taken the mast violent dislike to her family; the ti- dings of the death of a son in a foreign coun- try excited in her a desire to see her surviving children, and recalled all her parental affection, instantly sweeping from her mind her insane an- tipathies, and restoring her to right feeling and reason.—(Rep. of Glasg. Asyl., &c., for 1839.) 507. On this subject Dr. Burrows remarks, that to reason with a lunatic is folly ; to oppose or to deny his hallucinations is worse, because it is sure to exasperate : an impression on him can be made only by talking at, not to him. He will often notice what is said to others, and ap- ply much of it to his own situation or delusion. To endeavour to convince him, or to break the catenation of his morbid ideas by trick, fraud, surprise, or terror, is always attended by haz- ard. The chances are very many that it will not succeed ; and if it fail, the case is thereby rendered more intractable. “ The confidence of his patients,” Dr. Burroughs adds, “ is the sure basis of the physician’s success. A cheer- ful, encouraging, and friendly address; kind, but firm manners; to be patient to bear, but cau- tiously prudent in answering ; never making a promise that cannot safely be performed, and, when made, never to break it; to be vigilant and decided ; prompt to control when necessa- ry, and willing, but cautious, in removing it when once imposed ; these will always acquire the good will and respect of lunatics, and a com- mand over them that will accomplish what force can never attain.” 508. Moral management must necessarily vary with the states of the disease. In the more violent state, restraint and medical disci- pline should be applied until violence subsides. In the more passive states, restraint is never necessary, unless there be a propensity to sui- cide, or to a solitary vice which is so frequent- ly a cause of, as well as often an attendant upon the mental disorder. To prevent this latter propensity is extremely difficult; but va- rious means may be had recourse to with ad- vantage, and these will readily suggest them- selves.* Vigilance is necessary in all cases ; for the passive may change in a moment to the active or violent state, and mischief may thus be done before it can be prevented. [The results of experiments that have been made of late years, especially by Dr. Conolly, of Hanwell, justify us in the conclusion that restraint in violent cases is inexpedient, unne- cessary, and always hurtful. The following re- marks of Dr. Earle, of the Bloomingdale Asy- lum, on this subject, express, it is believed, the views that generally prevail among those who have charge of insane institutions in this coun- try : “ The means of bodily restraint, ‘ tranquil* lizing chairs,’ straps, muffs, wristbands, mittens, and other appliances for the confinement of the body and limbs, have been considered as neces- sary evils, or, perhaps, by some as necessary promoters of good, in establishments devoted to the accommodation of the insane. Hence they have been employed, even in very recent time, to a much greater extent than was neces- sary. “ In our individual experience, we have found that, in proportion as we have become acquaint- ed with the insane—with their tempers, dispo sitions, habits, powers of self-control, and ca- pabilities of appreciating the ordinary motives which influence the conduct of mankind—has our opinion of the degree to which these means are necessary been diminished. Our practice has corresponded with this change of opinion, and the results have been eminently satisfac- tory. At the present time there is no patient in the asylum upon whose body or limbs there is any apparatus of restraint. In the men’s department, no such means has in any instance been resorted to during the last six weeks, and in but a single instance during the last three months. In the case alluded to, a patient whose ordinary conduct is unexceptionable, but who is subject to sudden and uncontrolla- ble impulses to destructiveness, acting under the influence of one of his paroxysms, broke a chair and some windows, and his hands were confined by wristbands two days. “ The so-called 1 tranquillizing chairs,’ which had for many years been among the means of restraint, were taken from the halls in April last, and neither of them has since been used. “ It has heretofore been customary to keep a supply of the other kinds of restraining appara- tus in each hall throughout the establishment. About the 20th of November, everything of the kind was removed from the men’s department, and deposited in the physician’s office, where it has since remained undisturbed. And yet, during the period that we have been connected with the asylum, there has been no equal ex- tent of time in which there was so general a prevalence of quiet, order, good feeling, con- tentment, and reasonable conduct as during the last six weeks; and, in support of this state- ment, an appeal may with confidence be made to the other officers and the attendants of the in- stitution, as well as to those gentlemen of the committee who have visited the several depart- ments of the establishment during that time. It is not asserted, for it is not our opinion, that restraints upon the limbs are never neces- sary. On the contrary, we believe there are cases in which the application of them is the most judicious course that can be pursued. We once heard a patient beg most earnestly to have her hands confined, lest she might injure herself. There is a female now in the asylum who is subject to frequent and very violent spasmodic paroxysms, or ‘fits,’ in which there is an uncontrollable propensity to bite herself. If her hands be unconfined, she immediately plunges her teeth into the flesh of the fore fin- ger, the upper portion of the thumb, or the arm. We have no hesitation in regard to the propri- ety of confining the hands in a case like this. One of the means of restraint, among the most simple, effectual, and least offensive to the pa- * Sir W. Ellis recommends a pair of wide canvass sleeves, connected by a broad shoulder-strap, so as to rest easily on the shoulders. They ought to come up well on the shoul- ders, and to extend about an inch beyond the points of the fingers; the part covering the handling made of stiff leather, to prevent the hand grasping anything. They keep the arms hanging easily by the sides of the body. They are fastened at the back by two straps, one going from one sleeve a little above the elbow, across the loins to a similar position in the other sleeve; a second lower down; and by three similar straps in the front, the latter being secured by buckles. This mode of restraint is less heating, and pro- duces less pressure on the chest, than the common strait- waistcoat. 622 INSANITY—Moral Treatment of. tient, is the Camisole, the only distinguishing peculiarity of which is, that the sleeves are of about twice the length of those of ordinary gar- ments. This being on, the patient’s arms are folded, in the manner frequently adopted by per- sons in health, and the two sleeves are tied to- gether behind. Thus there is no pressure upon the body or limbs, no liability to abrasion of the skin, as with the wristbands and muffs, and the limbs are in a position as easy and agreeable as any in which they can be placed.” (Eari.e, 24th An. Rep. Bloomingdale Asyl., 1844, p. 34.) “ Whenever they have been brought to the asylum in chains,” says the late Dr. White, “ I have made it a point to remove them with my own hands, as I am sure, by so doing, to gain permanently the confidence of the patient. “ I once took by the hand a furious son of the Emerald Isle, and held an exciting dialogue respecting the heavy chain cast round his an- kle and bolted to the floor. Though warned of my danger, as I approached him with a pleasant salutation, he as cordially responded, and re- ceived me as his friend. We at once made a binding contract: I was to knock offhis chains, when he should be placed under my care, and he was to become my body-guard, and be obe- dient to all the rules of my house. A few days after, the bargain was consummated, and he remained faithful to his trust.” “ No other restraint is put upon our refracto- ry patients, under sudden impulses, than seclu- sion for the shortest possible period of time, and the use of a belt cast round the waist, with wristbands or a muff attached, to prevent them from tearing their clothes, and committing oth- er mischievous acts while at large.” (White on Insanity, p. 15-16.) In the New-York Lunatic Hospital, we are informed that, besides seclusion, “leather and cloth mittehs, and leather muffs and wrist- bands” are the only means of restraint; that strait-jackets and restraining chairs have nev- er been in the institution; and that the vio- lent and excited are more easily calmed by the warm bath, by cold showering to the head, and sometimes narcotics and opiates. “ No better evidence,” says Dr. Brigham (First Annual Re- port, p. 52), “ need be given of the general dis- position of the insane to be quiet and orderly, when properly treated, than the fact that here have been, for several months, from thirty to forty men associated together, in each of our halls, not one of them under the least bodily restraint, and yet no accident of any importance has occurred, nor injury to any individual.”] 509. d. During convalescence especially, moral treatment requires the greatest judgment and discrimination in all its relations. In this pe- riod, the dawnings of reason should be carefully observed and assisted, and every aid afforded to the struggling efforts of nature. The bodily disease is now loosening its hold over the men- tal powers ; and these powers may be now aid- ed in emancipating themselves from the morbid bondage. The suggestions, and, occasionally, the reasoning of the physician, advanced with kindness and sincerity, and in the soothing lan- guage of friendship, in this stage, often assist in removing weakened and decaying delusions. When convalescence approaches with a revi- val of the affections, the consolations of the physician are often requisite to calm the feel- ings which thus burst forth, and to guide them in right directions ; or his encouragements are necessary to elicit them, and to give them per- manency. Dr. Burrows justly remarks, that if, in reasoning with the patient on any remain- ing delusion, a painful recollection is revived, the subject should be changed, and resumed at another time. If any domestic event have oc curred, during the loss of the patient’s reason, likely to excite a strong feeling of joy or of grief, it should be withheld until the mind has acquired strength to bear it; and, even then, caution in communicating it is requisite. One of the most important and delicate tasks, in communicating with a convalescent as to the past and present, is, to preserve a due medium between gratifying and checking his eager im- portunities for information. Too great a flood of reminiscences, called up by much informa- tion, may endanger the mind enfeebled by dis- ease. The recollections of the past affect dif- ferent minds very differently. With some, the retrospect is a perfect blank ; others remember the past as a dream ; others recollect all its re- alities. Some refer to the past with indiffer- ence ; others advert to it with gratitude to those who contributed to their recovery; oth- ers recall it with pain and abhorrence, and avoid all reference to person, place, or circumstance connected with it. Whatever may be the im- pression on the mind of the patient, it should be carefully noted, and the conversation with him should conform to it. 510. e. Religious consolation is frequently of the greatest benefit in the partial and chronic forms of insanity, wThen judiciously resorted to. It has been, however, supposed by some to be injurious, or of doubtful advantage, because re- ligion is sometimes a cause of the malady; but, as I have shown ($ 293), it is only mista- ken, unsettled, and fanatical views of Christian doctrines that occasion, in some instances, men- tal disorder; and, even in these cases, as well as in many others, the truths and consolations which true religion affords may be made most efficacious means of cure, when judiciously pla- ced before the mind of the patient, at a proper season, by the well-educated and sober-minded clergyman, and when the physician finds no circumstance contra-indicating the propriety of having recourse to them. Mr. Tuke very judiciously remarks, that the mild but powerful influence of the precepts of our holy religion, where these have been strongly imbued in early life, become little less than principles of our na- ture ; and their restraining power is frequently felt, even under the delirious excitement of in- sanity. Before, however, religious consolation or instruction should be attempted, some infor- mation should be acquired of every patient’s former and present opinions and state of mind ; and then religion will often be most advanta- geously brought in aid of physical and moral treatment; and will tend not only to the resto- ration of the mental powers, but also to the preservation of them subsequently. The min- ister of religion, in order to be useful, should have free intercourse with the patient; and ad- minister consolation, or remove doubts, rather by private communication than by more public instruction or preaching. When the latter is attempted in an asylum, a judicious selection l ought to be made of the patients, and the dis- course should be suited to their states—to in* spire hope and confidence—carefully avoiding whatever may perplex the mind, or cause fear or alarm. 511. In a recent report of the Glasgow Asy- lum for Lunatics, it is stated that, in many in- stances, the personal and private, as well as public ministrations of the chaplain, have car- ried consolation and comfort to the minds of the patients, particularly those troubled with distressing apprehensions on religious subjects. The sermons delivered in the chapel are de- scribed as being adapted, as much as possible, to the peculiar circumstances of the audience, and as being the means of withdrawing their attention, for a time, from their prevailing illu- sions. Everything that is conceived to have a tendency to agitate the mind is carefully avoided, and pains taken to present the most soothing and practical views of divine truth. Two very important advantages are derived'to the patients from the institution of public wor- ship—that of alleviating the malady under which they labour, and that of gratifying and strength- ening those pious feelings from which they de- rive the greatest consolation. 512. /. Employments and Amusements.— Ex- ercise, by equalizing the circulation, by deter- mining it to muscular structures and to the ex- tremities, and by promoting the exhalations and secretions, is of great service in the partial and chronic states of insanity. But it must be varied according to circumstances, and to the previous habits, conditions, and occupations of the patients. Walking and riding in the open air, or long walks in fields and woods, in com- pany with a suitable guardian, during as great a portion of the day as the strength of the pa- tient will permit, are often of great service. All establishments for the insane ought to be provided with the means of affording to their inmates regular exercise and employment in the open air. They should also be constructed with galleries and covered courts, freely admit- ting the air, where the patients may take exer- cise in wet weather. Gardening and various agricultural occupations should engage a con- siderable portion of time at stated periods of the day. In manufacturing districts many lu- natics may be made to follow, as a means of distracting their minds from their delusions, their several callings. In the Salpetri'ere, the women are permitted to sell a part of the prod- uce of their industry, and to apply it to the re- lief of their necessitous families. Females and men of sedentary habits should be engaged, as much as possible, in some regular occupation. In many asylums, especially abroad, the fe- males are occupied in embroidery, in spinning, knitting, sewing, and various fancy works. Most lunatics are disinclined to work; but kind entreaties, or the prospect of procuring the means of extra comforts, will often tempt them to do something. Even in the early stages of dementia, it is not impossible to induce such patients to work at some merely mechanical occupation. Employments, suited to the pre- vious habits and stations of the patients, miti- gate the disease, and tend much to promote the recovery of curable cases. Where the taste and previous occupation of the patient leads to study or sedentary pursuits, these should not be indulged for too long a period INSANITY—."Moral Treatment of. without relaxation, or to the neglect of proper exercise in the open air. The greatest diffi- culty is to find employment or amusement for the higher classes of lunatics. They soon tire of the same pursuit. Reading, chess, cards, bagatelle, billiards, and other games, should be diversified with bowls, tennis, gardening, walk- ing, cricket, and various athletic exercises. [In many, if not all American institutions for the insane, reading-rooms are provided for the patients, which are furnished with books, news- papers, and periodicals, and which are read with much interest by many of the inmates. Writing-books, arithmetics, and slates are also placed in the hands of some, which contribute essentially to their entertainment and instruc- tion. At the Bloomingdale Asylum, Dr. Earle has made trial of the effect of delivering a se- ries of lectures on miscellaneous subjects, il- lustrated by diagrams and pictures, handsomely painted on canvass, which a large number of the patients regularly attend, and with very happy results. At this institution, as well as at the State Hospital at Utica, &c., a regular school is carried on, which is attended by many of the inmates, and thus far the effects have been highly beneficial. As some of the faculties usually remain sound in mental derangement, we deem it very essential to recovery that these should be diligently cultivated. Where there is a taste for drawing, music, or mechan- ical contrivances, as turning, whittling, &c., that faculty should be employed; and the pa- tient should be tempted to make the best exer- tion he can with his intellect, which not only contributes to his happiness and comfort, but powerfully tends to substitute sound for un- sound ideas ; or sanity for insanity. The mor- al faculties must also be attended to, and the feelings brought into a healthy channel, which can never be done if restraint and harsh meas- ures are employed, the object of which will al- ways be mistaken by the patient. If the mind can be brought into a pleasurable state of ex- citement, and kept in that condition, while the mental faculties are agreeably occupied, if there is no organic disease present, a speedy recov- ery may be confidently anticipated. To ensure this, however, mental occupation and bodily exercise should go together.] 513. Music has been considered useful by several writers, as a means of abstracting the attention of lunatics from disordered trains of thought. M. Guislain observes, that music is useful with reference, first, to those who play upon some instrument; and, secondly, to those who listen to it. It should also be viewed both as a means of beneficially exercising the mind, and as a mere amusement. Persons who can use a musical instrument, and those who are fond of music, will sometimes derive advantage from it; but it is doubtful whether or not it will afford any benefit to others. Dr. Prichard states, that Dr. Cox considered that some ad- vantage was derived from it as an amusement; but that it is of little importance in the treat- ment of insanity, is proved by the circumstance of Dr. Bompas, the successor of Dr. Cox in the asylum conducted by him, having discontinued it. M. Esquirol remarks, that he has very rarely obtained any advantage from music. It sometimes calms the spirits, but it exerts no curative influence ; it may even render maniacs 623 624 more furious. He, however, admits its bene- ficial influence during convalescence, particu- larly of those who have cultivated music or who are fond of it. In the more lethargic or dull states of madness, in melancholia, and in other forms of partial insanity, it is often of service, while it may prove injurious in some cases of mania, more especially those charac- terized by a tendency to violent excitement. When the patient has been a performer, play- ing on his instrument is allowable, as innocent- ly employing both mind and body. 514. g. Visits of Friends, and Restoration to So- ciety.—Convalescence is often checked, and the disorder reproduced, by the patient’s impatience to be freed from all restraint; and the same effect is too often caused by the impatience and distrust of friends. During convalescence the physician has not only, as Dr. Burrows ob- serves, to encourage every dawning sign of re- turning reason, to employ the soothing lan- guage of friendship, and to calm the agony which reminiscence often generates, but also to repress impatience, and to contend with and remove the suspicion and want of confidence, which his cautious course usually produces in relations and friends, and which, if not steadily resisted, endanger the approaching recovery of his patient. The chief risks to which con- valescence is exposed, are the premature visits of friends, and removal from the proper sphere of treatment to an intercourse with relations and society, and with business and its various contingent annoyances and distractions, before the action of the brain and the manifestations of mind have been sufficiently restored or the restoration adequately confirmed. The diffi- culty of determining when friends should be admitted and when the patient should be re- stored to society is generally great, and the evils resulting from a too long seclusion are sometimes not much less than those which might accrue from premature intercourse. The experience and good sense of the physician will enable him to arrive at a just conclusion with reference to particular cases, for no gen- eral rule on this subject can be laid down. When convinced that either measure will be detrimental, resistance should be carried to the utmost, or until importunity on the part of those who have authority assumes the form of com- mand. “ In yielding contrary to his judgment, the physician should distinctly throw all re- sponsibility on the applicant; otherwise, the consequence, if injurious, will certainly be cast on him.” (Burrows.) I would add, that the commands of the friends, in such circumstan- ces, should be required to be made in writing ; as they will be much more cautious than other- wise in thus making them, and as evasions of responsibility will often be attempted, in this as well as in many other matters, when there is no written document to prove its existence. 515. Before permitting the visit of any per- son, the state of the patient’s feelings and views to that person should be ascertained. It will be also preferable to select for the first inter- view some one who the least interests the pa- tient’s affections ; and, if this communication is borne without any ill effect, a nearer friend or relative may be selected, leaving the object of warmest attachment to the last. Proceeding in this cautious way, Dr. Burrows remarks, INSANITY—Moral Treatment of. the too sensitive or feeble mind is gradually brought to bear a renewal of intercourse with- out being too much moved. But the physician might be deceived by the dissimulation of the patient, who will often assume an appearance of amendment merely to obtain an interview, with a friend, his only object in seeking it be- ing to request his release, or to complain of his treatment. 516. Cunning being a characteristic of mad- ness, the physician should always be upon his guard against being imposed upon. Many are fully aware that, if they can conceal their de- lusions, they may be considered well; and, when only one delusion is entertained, it is often difficult to detect it. Dr. Burrows had a patient whose specific delusion gave rise to outrageous conduct requiring her confinement; and yet this delusion was successfully conceal- ed for nine months, at the end of which time it was manifested in an alarming manner. In this and similar cases, a recovery might have been prematurely or improperly pronounced. On the other hand, it is possible for an impres- sion, made previously to complete mental de- rangement, to be so firmly retained after recov- ery as to have the semblance of a delusion, and yet be none ; especially when no recollec- tion is retained of what has occurred between the accession of disorder and recovery, and when the patient reasons and acts upon this conviction, and reckons a circumstance long passed as having recently taken place. Much discrimination and experience are necessary to determine when seclusion may be terminated, and the patient restored to society. If the dis- order have been caused by intemperance, a longer confinement after convalescence is re- quired than in other circumstances; for the longer it is protracted, the greater is the chance of the patient being induced to relinquish a re- currence to the cause. 517. h. After the patient is restored to society, moral and hygienic management ought to be continued for a considerable period. Due care should be taken not to excite, or inordinately indulge the passions and desires. Irritations of mind and body should be avoided, and all emo- tions which depress, equally with those which unduly stimulate the mind, ought to be evaded. Mental exertion is also injurious. The intel- lectual as well as the moral powers should not have too much imposed upon them. They ought, at first, to be only agreeably and gently exercised; and, as they re-acquire strength, more may be exacted from them. Travelling, agreeable society, change of scene and of air, regular and early hours of sleeping and dining, pleasant occupations, and exercise in the open air, are all of the most essential service after recovery. Of no less importance are regular and abstemious modes of living, and strict at- tention to the states of the digestive and ex- cretive functions. In a word, the predisposing and exciting causes ought to be carefully avoided. 518. iv. Classification of Patients, and Arrangement of Institutions, &c.—A. The classification of the insane, in both public and private asylums, is too frequently dependant upon their extent, and upon subordinate cir- cumstances and arrangements, instead of these being made subservient to a classification which may contribute to the safety and speedy INSANITY, CONNATE. 625 recovery of the patients. It is difficult, and even not very requisite, were it easy, to state the classifications and arrangements which may be adopted in various circumstances. In these matters, as well as in the organization and man- agement of these institutions, medical knowledge, and an acquaintance with mental disorders, under the guidance of common sense, will generally enable the physician to arrive at judicious conclusions. But in all arrangements and modes of organization, a due separation of the different classes of cases, and of convales- cents, should be secured ; and no asylum, pub- lic or private, should be allowed or licensed that is not placed under the constant superin- tendence of a regularly educated and qualified medical practitioner, who should reside in it, and be in constant communication with its in- mates. On this particular topic, much infor- mation will be obtained in many of the recent publications referred to in the Bibliography at- tached to this article. I can furnish only a brief abstract of what has been stated regard- ing it by Pinel, Esquirol, and Georget. 519. a. The classification of lunatics is requi- site, not merely for the purpose of separating such as are liable to injure themselves or oth- ers, but also with the view of permitting those to associate together who may contribute to each other’s cure. A lunatic asylum should be composed of several parts, more or less insu- lated. There ought to be a quarter for each sex; a division for the violent; a second for those who are tranquil; a third for those la- bouring under accidental disorders or compli- cations ; and a fourth for convalescents. It is, above all, necessary to separate the sexes, the convalescents, and those who have depra- ved habits and indecent manners. Divisions should also be allotted for those of melancholy feelings; for those in a state of imbecility or dementia ; for the noisy and furious; and for those who are untameable, or are confined by way of punishment. It would be preferable for each division to have a court planted with trees, and a garden for the patients to walk in. 520. b. It is farther requisite, for the con- venience and safety of the patients, and to fa- cilitate vigilant superintendence and protection, that an asylum should be built on level or slightly elevated ground ; that the cells for vio- lent patients should be spacious, with a door and window opposite each other, and opening from without; that they should be boarded, and not paved; furnished with a bed firmly fixed in the wall; that all the cells should communi- cate with covered galleries or corridors, in which the patients may walk in bad weather, and by means of which the inspectors and ser- vants may easily pass to different parts of the building ; that all the rooms should be warmed by pipes containing hot water in preference to hot air ; that water should be abundantly sup- plied ; that the privies should be arranged so as to occasion no inconvenience to the patients ; and that there should be places appointed for a general work-room, for a common dining-room, for baths, shower baths, and douches. There should be suitable dormitories for convales- cents, melancholic patients, idiots, and those who are debilitated. For others, little cells with one bed are preferable; the patients go- ing out of them in the daytime, and associa- ting with one another, no companions being allowed in the night. 521. B. The selection of the inspectors and at- tendants in lunatic institutions is of great impor- tance. Insane persons look upon the attend- ants as accomplices in the power which has deprived them of liberty, and as inhuman jailers, view them with suspicion and hatred, and even abuse and strike them. It is often difficult to make servants understand the states of those committed to their care, so as to enable them to preserve their temper, and to act with kind- ness and firmness in all circumstances ; and it is not easy to convince them that the insane have the use of.some of their faculties, and are often quick, observant, and cunning. Those attendants who have been themselves insane are generally the most careful, forbearing, and kind to those over whom they are placed. M. Esquirol has a favourable opinion of conva- lescents as keepers : they are compassionate to the infirmities which they have themselves so recently suffered; they aid the physician more efficiently; and their examples are en- couraging to others. The attendants ought al- ways to be sufficiently numerous—one attend- ant to from eight to twelve male patients, and one to from ten to fifteen females, according to circumstances. Old military men are among the best keepers ; for, as Dr. Conolly remarks, they keep up their own authority, and are obe- dient to superior orders. Therphysician of a lunatic asylum ought to be careful to instruct those who are to have the management of the patients. It is absolutely requisite that a judi- cious arrangement of authority and subordina- tion be established in all asylums, and that the power of the physician should be superior to all, in respect of everything that concerns the patients. IX. Insanity, Connate ; and Puerile Imbe- cility.—Syn. Idiotcy, Natural Idiotism, Con- genital Privation of Intellect, Puerile Imbecility, Weakness of Mind, Silliness, Stupidity, Con- nate Fatuity, Primary Fatuity, Idiotism, Men- tal Deficiency, Original Deficiency of Under- standing ; Stupiditas, Vecordia, Amentia, Imbc- cillitas Ingenii; Fatuitas ; Amentia Congenita, Sauvages, Sagar, Vogel; Dtmcnce innee, Fo- dere; Idiotisme, Pinel; Die Spracheigenheit, Bl'ndsinn, Germ. ; Idiotismo, Ital. 522. Defin.—Deficiency or entire privation of intellect, appearing during infancy and childhood, depending either upon an original defect, or upon an arrest of the development of the mental facul- ties. 523. Puerile imbecility and idiotcy may be con- sidered as representing two grades of primary mental deficiency. The former is that state or degree in which there is an original impairment, but not an entire want of intellect. The latter is a more complete grade of deficiency, some- times amounting to an absence not only of the moral and intellectual manifestations, but also of the instincts necessary to self-preservation. Between, however, this, the highest degree of idiotcy, and the slightest state of intellectual deficiency, there is every intermediate grade. Original defect of intellect should not be con- founded with the imbecility, or incoherency, o- fatuity consequent upon other forms of insani- ty, or upon cerebral diseases—the Amentia ac- quisita of authors ; nor with senile fatuity, im- 626 INSANITY, IDIOTIC—Grades of. becility, or dotage—the Amentia senilis. The distinctidn has been very properly made byEs- quirol and Prichard ; and most succinctly and correctly stated by Dr. Klein Grant, under the article Amentia, in his edition of Hooper’s Med- ical Dictionary. Original deficiency and entire want of intellect may appear unconnected with any bodily disease ; may be simple and uncom- plicated ; or they may be associated with other maladies, or complicated. Complete idiotcy, es- pecially, may be farther associated with con- genital deficiency of some organ or part, or connected with malformation, or arrest of de- velopment of some portion of the brain, or or- gan of sense. 524. i. Deficiency of Intellect appears in every grade and form until it amounts to com- plete idiotcy. The slighter degrees of deficiency are manifested chiefly by weakness of charac- ter and capacity, or by stupidity or deficiency of the powers of perception, or of the understand- ing. These grades of defect are generally not sufficient to render an individual incompetent to the management of his affairs, or to conduct himself with propriety, and are hence not con- sidered sufficient to constitute unsoundness of mind, in its legal acceptation. But as the origi- nal defect may present every grade, from the slightest of those just mentioned to complete id- iotcy, it is difficult to draw any line of demarca- tion between what maybe considered soundness or unsoundness of mind. This line must still remain unfixed, or at best be only conventional', for no standard or criterion can possibly be es- tablished. As in consecutive impairment or disorder of mind, so in original deficiency of intellect, there are every shade and degree of mental manifestation, descending from the high- est state of perfection of the human understand- ing down to the lowest state of privation of intellect and of instinct; there being no break in the scale, or in the continuity of declension. 525. Deficiency of intellect begins to appear from the first to the eighth or ninth year of age. When it is congenital, it may manifest itself even somewhat earlier than the former period. When it arises from an arrest of the develop- ment of the mental faculties, owing to injury or physical disease, it may not be evinced until a later period than that assigned. In this lat- ter case, the deficiency is seldom so great as when it occurs at earlier stages, or depends upon changes that have taken place in the en- cephalon either previous to or soon after birth. 526. From what has been already stated, it is obvious that all the grades and forms of ori- ginal imbecility cannot be described within mod- erate limits. Nor is minute description at all requisite : the works of Georget and Esquirol will furnish it, and numerous illustrations of it. I may, however, briefly observe, that imbecile persons have a limited capacity for certain ac- tions or employments, and acquire some de- gree of facility in performing them. These they generally execute in a tolerable manner, while they are quite incapable of any other modes of exertion or occupation. Habit has a great influence on all their proceedings, and gives to many of them an appearance of regu- larity which may be mistaken for the result"of steadiness and of higher powers. All are, how- ever, deficient in the powers of attention and thought. They are generally timorous, often docile, weak and inconstant in purpose, and frequently irascible. The senses of some give rise to feeble and dull impressions; of others, to more lively perceptions. Memory is strong in some; while in others it is weak, confined in its range to the most ordinary objects and frequently repeated ideas, or it hardly exists. They display some indications of mind, of in- tellectual faculties, and of feelings and affec- tions ; and they have the use of speech and of language generally in a degree proportionate to the grade of perfection of their several senses and mental powers. They show the same va- rieties of character, inclination, and moral pro- pensity, as persons of stronger understanding. Left to themselves, they are careless, lazy, and filthy. At the age of puberty, they evince the animal instincts by the most offensive gestures, habits, and solitary vices. Some become sub- ject to paroxysms of capricious violence, to hysteria, to nymphomania, or satyriasis. Many are prone to lying, pilfering, and stealing. Sev- eral lapse into melancholia, or sink in a grad- ual decay of physical health—frequently owing to an uncontrollable addiction to masturbation. In oth«r circumstances, they eat and digest well, and females have the catamenia regularly. Some imbecile persons evince signs of talent in particular pursuits, particularly in music and the ruder of the imitative arts. Others have retentive memories, learn languages, and are capable of other acquirements, while, in all other respects, they are deficient in any talent, and generally in mental power. They com- monly present much of the character, in man- ner and in the development of mind, of infants or children. They are deficient in affection, in application to any pursuit, in the powers of comprehension, of pursuing a train of ideas, and of entering into a rational or sustained conversation. They are without energy and steadiness, and are fearful and cowardly. They are incapable of reflecting, of contriving any- thing, or of accomplishing anything. 527. ii. Idiotcy.—More or less complete priva- tion of the mental faculties.—This is the highest grade of original deficiency of intellect. In this state, the moral, the reflecting, and the in- tellectual manifestations are altogether want- ing ; and sometimes the instinctive emotions of mind are also partially or totally undevelop- ed. Indeed, the different states of idiotcy de- pend chiefly upon the extent of deficiency of this class of the mental powers. Those in- stinctive feelings and desires which are the most generally bestowed on the animal creation, and which especially subserve the preservation of the individual and of the species (see Classif. in note to 6 66), are chiefly present—frequently in an inordinate degree—and are deficient only in the most extreme cases. Infants that be- come idiots have large or ill-formed heads, im- perfect features, take the breast with difficulty, are long before their eyes follow the light, and often squint. They are puny, lean, of bad com- plexion, have a feeble physical development and vital endowment, are incapable of instruc- tion, cannot learn to walk until they are six or eight years of age, or sometimes till they attain the age of puberty. They articulate imperfect- ly, or learn but a few words, or are altogether incapable of articulate sounds, although they may possess the sense of hearing. When the INSANITY, IDIOTIC—Causes of. head is very small or very large, or flattened in any direction, or much deformed, death gener- ally takes place early—generally long before pu- berty, or at any age between this epoch and the first months of existence. 528. Idiots, both children and adults, present not only these deformities, but all those descri- bed in the article Cranium. Their features are irregular and repulsive ; their eyes are blink- ing, and deeply set; their lips are large, thick, flaccid, and relaxed ; their mouths are gaping, and admit of a drivelling of the saliva ; their organs of sense are imperfect—they* see and hear imperfectly, or are entirely deaf and dumb. Their taste and smell are also deficient, and they eat without selection of food. If speech exist at all, it is extremely limited, and drawl- ing or lisping, and capable of expressing only the most urgent physical wants. Their chests are narrow or contracted; their limbs ill-form- ed ; and their gait, as well as all their move- ments and attempts at muscular exertion, un- steady and awkward. They are sometimes club-footed, and the muscles of the arms or legs contracted. They are commonly rachitic, or scrofulous—often partially or generally para- lytic, or subject to epileptic fits. Not only are they without the reflecting and intellectual fac- ulties, but even their sensibility is deficient; and sensation, when excited, is scarcely follow- ed by perception of objects or ideas. They are incapable of directing their attention to any- thing. Owing to the defective state of their instinctive feelings, they appear far below the brutes in the scale of animal existence; and, as M. Esquirol remarks, are monsters or im- perfect beings, who are destined to a speedy extinction, if the tenderness of parents, or the compassion of others, did not prolong their ex- istence. Yet idiots have the bodily appetites and sexual desires—sometimes in an inordinate degree and repulsive manner. They often ex- hibit signs of premature puberty, and are gen- erally addicted to masturbation. They are often, also, subject to anger and rage. Some display faint glimmerings of intelligence, when their notice is excited by strong impressions on their senses. They then appear to look at certain things with a vague expression of pleas- ure, or of curiosity ; they seem to desire some objects, particularly articles of food ; they occa- sionally indicate, by gestures or cries, objects of desire or aversion, or the pleasure or pain which they feel; they come to know the per- sons who habitually take care of them ; but they are incapable of dressing or undressing themselves, or of the common acts of cleanli- ness. Others are debased to the lowest state of being—are sometimes even unconscious of their evacuations, and incapable of command- ing or restraining them ; and enjoy only a vege- tative existence, devoid of sensation and sen- sibility. Idiots of a higher grade of develop- ment are capable of moving from place to place; but are, like machines, made to repeat the same movements ; they move their arms, as if to fa- cilitate progression ; laugh mechanically ; ut- ter inarticulate sounds, as if to amuse them- selves ; occasionally catch a few notes of a simple tune, which they constantly repeat; and become attached to particular places and po- sitions. 529. iii. The Complications of imbecility and icliotcy are chiefly those already noticed (§ 523, 528), more particularly rickets, scrofula, gener- al or partial palsy, epilepsy, contractions and malformations of the extremities, deficiencies of the organs of sense, goitre, and, still more particularly, Cretinism, which, in its fully de- veloped states, is always associated with more or less absolute want of the mental powers. (See art. Cretinism.) 530. iv. The Causes of imbecility and idiotcy are of importance, both in a medical and in a social point of view.—A. The remote causes are, 1st. Those which are referable to the parents, and which operate previously to birth ; 2dly. Those which more especially belong to the pa- tient, and which affect him subsequently to birth.—a. The causes which operate previously to birth are, whatever exhausts or debilitates the parents, or renders the reproductive acts im- perfect ;* as habitual debauchery, solitary vices, and drunkenness ; sexual debility, or states ap- proaching to impotency ; the insalubrity of cer- tain localities, particularly those observed to produce cretinism 6); the scrofulous and rickety diathesis ; and the advanced age or de- bility of one or both parents. Esquirol states that idiotcy is more common in the country— especially in mountainous districts—than in towns. He, as well as numerous other writers, insists upon the influence of violent mental emotions, and moral shopks during the early or middle months of utero-gestation. Several modern writers have affected to doubt this cause ; and, as they cannot dispute the frequent occurrence of arrest of development of the ner- vous system, and congenital deficiency of men- tal manifestations in the children whose moth- ers had been thus affected during the period of their fcetal existence, yet consider the phenom- ena in no way connected, as coincidences merely, and as holding no relation of cause and effect. The vulgar opinion, however, of this matter is nearer the truth; and the evi- dence of the arrest of development having been produced by the mental, and the consequent physical shock of the mother during gestation, is much more conclusive than most of the evi- dence usually furnished us in physiological and practical researches, or than that upon which we are constantly acting in the discharge of our professional duties. It by no means follows that the phenomena which we cannot satisfac- torily explain should therefore not exist, or that relations of which we cannot trace the con- nexion conclusively are on this account alto- gether wanting. Yet, even here, however diffi- cult may be the explanation, or apparently loose the connexion, both the one and the other may be furnished conformably with views stated in this and other articles. It is not improbable, even, that the means sometimes used to con- ceal pregnancy, or to procure abortion, may so affect the development of the foetus as to pro- duce idiotcy. The same causes which occasion 627 * A physician was consulted by a gentleman who was anxious to marry, to secure a fortune in his family, but had been some time deterred from marriage by a consciousness of weakened sexual powers, consequent upon masturbation in early life. As he was young, and his constitution had apparently not suffered seriously, he was advised to marry, under the conviction that a moderate exercise of the sexual functions would assist in restoring their energies. The advice was adopted; but the first child that was born was an idiot. The later children were sound : he had gradually recovered his powers. 628 INSANITY, PUERPERAL—Description of. congenital and chronic Dropsy of the Brain (§ 283, et seq.) will sometimes cause more or less complete deficiency of the mental faculties. Inflammation, or tubercular disease of the brain or of its membranes during fcetal existence, will disturb or arrest the subsequent develop- ment of these parts, and of their respective manifestations. Injuries of the head of the foetus, sustained during parturition, have also produced this effect. 531. h. The causes which operate after birth are, chiefly, injuries of the head ; diseases of the brain—particularly acute and chronic hy- drocephalus ; inflammations of the brain or of its membranes ; convulsions ; dentition ; ex- anthematous fevers—especially when attended by cerebral affections ; tubercular disease, with or without inflammation of the encephalon; remarkable precocity in connexion with a sus- ceptible and irritable state of the constitution ; and very early addiction to the vice of mastur- bation. This last cause is frequently produc- tive of those states of imbecility, or slighter forms of mental deficiency, observed at ad- vanced stages of childhood, or near the ap- proach of puberty. To these causes may be added the use of improper coverings on the heads of infants and children, as ably illustrated by M. Foville {Deformat, du Crane result, de la Meth. de couvricr la Tete des Enfans. Paris, 1834.). 532. B. The pathological causes are chiefly imperfect, deficient, or interrupted development of the encephalon, and affecting it either par- tially or generally ; sometimes associated with changes of the consistence and form of the brain, and not infrequently with some of the usual consequences of old or previous inflam- mation of the membranes—particularly the arachnoid, and of the cerebral structure. Mor- gagni and others found the brain harder than natural. Meckel says that it is often drier, lighter, and more friable than usual. Mala- carne states, that the convolutions of the brain are numerous in proportion to the intelligence, and that in idiots they are always few. They are very generally smaller, less prominent, and less numerous in these persons than in others. M. Esquirol has observed the lateral ventricles uniformly very small in idiots. In some, one hemisphere is much less developed than the other; and, occasionally, one lobe is more de- ficient than the rest. In these cases, one or more limbs have been paralyzed. These defi- ciencies have been more frequently observed in the anterior than in the other lobes. The cerebral substance is sometimes softened in one part, and hardened in another. For farther de- tails, see the articles Brain, Cranium, and Epilepsy.* 533. v. The Treatment of imbecility and id- iotcy is rather preventive than curative. Preven- tion depends entirely upon the avoidance of the remote causes, and upon the employment of those means which tend to strengthen the physical powers of the parents, and of the off- spring after birth. That much is owing to the constitutional powers of the parents, is shown by numerous facts, and by the circum- stance of several idiots or imbecile persons be- ing often met with in one family. Attention to the general health of the infant, good nur- sing, daily cold ablutions, frictions of the sur- face, a dry and temperate atmosphere, frequent changes of air, and due promotion of the sev- eral secretions and excretions, are the chief means by which a healthy development of the offspring of debilitated persons can be secured In every case, a strong, healthy, and young wet- nurse should be procured immediately for the infants of such parents. As dentition and child- hood approach and advance, the means and the cares advised in the articles Age and Denti- tion are especially required. The curative means are limited to physical and moral educa- tion, which may be of use in the slightest forms of imbecility, but which are of no avail in the more manifest states, and in idiotcy. X. Insanity, Puerperal.—Syn. Insania Puer- perarum, Mania Puerperalis; Puerperal Ma- nia. 534. Defin.—Disorder or aberration of mindr of either a partial or general form, occurring in any period of the puerperal states. 535. i. Description.—Puerperal insanity may appear in a slight or partial, or in a severe and general form. It most frequently, however, as- sumes the form of mania and melancholia. In a few cases it presents a mixed character, or that of melancholia alternating with mania. In- sanity may occur, 1st. At any time from con- ception to parturition—the insanity of pregnan- cy—Insania gravidarum; 2dly. From parturition to about three weeks or a month subsequently —the insanity of parturition—Insania post par- turn; 3dly. At any period during lactation, or soon after weaning—the insanity of lactation— Insania lactantium. In the first of these peri- ods, it is usually slight or partial, chiefly affect- ing either the moral manifestations or the un- derstanding. In the second, it most frequently assumes the form of acute mania, sometimes passing into a chronic state, but rarely assu- ming the character of dementia or fatuity. In the third, melancholia, slighter forms of mania, and partial insanity are the most common. Any of these states of disorder, occurring in any of the periods now specified, may be simple or com- plicated, in respect of succession, or co-exist- ence with some other malady, particularly hys- teric affections, epilepsy, convulsions, catalepsy and cataleptic ecstasy, uterine hcemorrhage, disease of the uterus or ovaria. 536. A. Insanity during Pregnancy—Insania Gravidarum.— Pregnancy generally occasions more or less excitement of the nervous and vascular systems ; and sometimes gives rise to various morbid impulses or aberrations of mind, especially in females hereditarily predisposed to insanity. The mental disorder may appear im- mediately upon conception, and disappear on quickening ; or it may occur at any period of utero-gestation, continue through, and cease * [The phenomena of idiotcy, at least, would seem to prove that the mind is not independent of the brain, as maintained above, as a very small brain is invariably a cause of idiotcy ; and there is no instance on record where the mind has been manifested vigorously by a very small brain. But idiotcy arise? not only from deficiency of size, but also from disease of the brain, or injuries, as already stated. Partial idiotcy is also not unfrequently met with where an individual man- ifests one or several powers of the mind with an ordinary degree oT energy, but is deprived, to a greater or less ex- tent, of the power of manifesting all the others. Our coun- tryman, Dr. Rush, has particularly called attention to this partial development of certain mental powers in idiots, and the partial possession of the moral faculties, a phenomenon which, it would seem, can scarcely be reconciled with the doctrine of a single organ of mind.] INSANITY, PUERPERAL—Description or, 629 upon delivery, or it may persist through all the circumstances consequent upon parturition. In this latter case, however, it seldom retains the same form or character, but passes into one more general or severe ; melancholia, or any other partial disorder, being aggravated into mania. In some cases, the mental affection commences as hysteria, or in some one or oth- er of its numerous states ; and in two cases in which I was consulted, it was preceded by cat- alepsy and cataleptic ecstasy—affections inti- mately allied to hysteria. 537. The most frequent states of mental dis- order observed in this period are melancholia, and the moral disorders described above (§ 69, et seq.). The singular feelings and desires, the whims and caprices frequently attending this state, cannot be considered as amounting to in- sanity, inasmuch as they seldom engross the mind, or withdraw it from all other thoughts and pursuits, or overwhelm the natural feelings, or influence the conduct. As soon, however, as any singular desire exercises such a sway as this—when it engages the mind and influ- ences the conduct, uncontrolled by natural sen- timents and requisite occupations — it then amounts to moral insanity, and requires both moral and physical treatment. In some fe- males, pregnancy occasions not only irrepress- ible fears and melancholia, but also various dis- ordered impulses, productive of crime or vari- ous unlawful acts, either before the control of reason can be exercised, or in opposition to the feeble efforts of the understanding (§ 92). In unmarried females, the melancholic feelings, the irrepressible fears, and the morbid impulses of the mind are often heightened by shame, re- morse, the abandonment of the seducer, the consciousness of poverty, or the fears of ill treatment. Under such affliction, the mind may be so disordered as to perpetrate various crimes, or even suicide. In this state, consciousness may be lost for a time, and acts be committed, before it be restored, of the most flagrant na- ture, and the most repulsive to the natural dis- position and feelings. This is the more likely to occur if the mental distress be attended by fits of leipothymia, or of fainting, or by convulsions. In some cases, recovery from these attacks, or the restoration of consciousness, is attended by a short period of maniacal excitement, or a state of momentary delirium, during which su- icide, murder, or incendiarism has been per- petrated. In most cases of mental disorder oc- curring during pregnancy, and in all that I have seen, there was either an hereditary predispo- sition to it, or the patient had been previously subject to obstinate hysterical affections, and had experienced overwhelming or intense emo- tions of the mind. 538. B. Insanity after Delivery—Insania post Partum—Paraphrosyne Puerperarum, Sauvages. —a. Insanity consequent upon parturition is often preceded, during pregnancy, by harassing fears and unfavourable presentiments. In some cases, various hysterical affections, preternat- ural susceptibility, great exuberance or depres- sion of spirits, suspicions, irritability, a state of stupor or sopor, and slight or short attacks of mental aberration, have occurred during gesta- tion. Generally the disease appears from the second or third day to the sixteenth or seven- teenth ; but it may occur almost immediately after parturition, or be delayed to the third or fourth week. Some writers assign the third and fourth, and the thirteenth, fourteenth, and fifteenth days, as the most frequent periods of its appearance. The chance of an attack, how- ever, progressively diminishes after the third or fourth day. The disorder may commence with want of sleep, inquietude, sadness, anxie- ty, or ill-grounded fears respecting some mat- ter ; the phenomena of mania, or profound mel- ancholia, supervening upon these symptoms. Sometimes an explosion of mania takes place more or less suddenly; but more frequently the patient’s manner becomes quick, the temper ir- ritable, and the nights restless, for two or three days before the attack. The form of the men- tal disorder varies remarkably ; but the mani- acal states are the most common. Next to these are melancholia, and diversified forms of monomania. During either of these disorders, and in melancholia especially, suicide jnay be attempted or committed. Mania may alternate with melancholia, and this last with other va- rieties of partial insanity. At first, and partic- ularly in cases occurring soon after delivery, the disorder is maniacal. Sometimes the pa- tient evinces a childish disposition for harmless mischief; is gay and joyous ; laughs, sings, and talks loud and long, occasionally obscenely, and is careless of the infant and of everything about her. She is often, also, suspicious ; imagines everything poisoned; and is busy with some idea, illusion, or some fancied object. In oth- er cases, the maniacal excitement is much more intense; and the conversation and conduct more violent. These states may pass into mel- ancholia, but very rarely into dementia or fa- tuity. 539. b. The physical symptoms are referrible chiefly to the digestive organs, and to the ner- vous system. The bowels are torpid, the secre- tions and excretions impaired and morbid ; the stools are unhealthy, and generally very dark and offensive ; and, from inattention or obsti- nacy, sometimes passed without regard to the natural calls. The tongue is moist, white, furred, or loaded ; and as the disease proceeds, it sometimes becomes brownish, mucous sordes accumulating on the teeth and lips. There is little or no appetite, and rarely much thirst. The pulse is frequent, small, weak, compressi- ble ; and sometimes it is but little, or not at all, accelerated, or it becomes less frequent as the disease proceeds. The skin is relaxed and moist, particularly about the neck, and gener- ally cool, especially on the extremities. The head is often hot, or is warmer than usual, but the heat is not always permanent; it frequent- ly occurs at intervals, and is sometimes great- est when the rest of the body is cool. Occa- sionally the scalp is cool throughout. The gen- eral heat of the body is rarely increased, unless when the disease is coincident with the first secretion of milk, or with inflammation of the breasts, or unless when caused by the violent exertions of the patient. Pain, sense of press- ure, or tightness of the head, is often felt, with uneasiness of the scalp, noises in the ears, and sometimes throbbings of the temporal arteries. There is little or no sleep. The face is gener- ally pale, unless when the maniacal excitement is great, and then it is often flushed or turgid The eyes are vivid or slightly red; but both 630 INSANITY, PUERPERAL—Diagnosis. they and the face are occasionally pale, although the patient is most violent. The abdomen is usually soft, cool, and free from pain on press- ure, unless sometimes in the hypogastric and iliac regions. The breasts are generally flaccid, and the secretion of milk either impaired or ar- rested ; but the milk, in some instances, is not materially diminished, although it is generally deficient in its healthy and nutritive properties. The lochia are often deficient, but they are sometimes abundant or offensive. 540. c. The insanity of females recently de- livered commonly assumes the form now de- scribed ; but its character varies remarkably : in some cases, it nearly resembles sub-acute phrenitis, delirium supervening, as in the form of the disorder described by Dr. J. Burns, in which the symptoms of morbid vascular action in the encephalon precede the mental disorder. In other instances, the insanity verges in its character towards low nervous fever; it is then generally preceded by watchfulness, fever, the supine posture, heat of scalp, and injection of the conjunctiva. Images or illusions super- vene, the ideas become rapid, and the delirium, passing into a muttering delirium, is soon con- firmed. The pulse is quick, and the milk and lochia are usually suspended. Enough has been stated to show that, as regards puerperal in- sanity, as well as many other maladies, the marked lines of demarcation attempted to be drawn by authors and nosologists do not exist in nature ; but that there is a gradual approxi- mation of character observed in this, to other diseases of the nervous system—that the tran- sition from puerperal insanity to phrenitis on the one hand, and nervous fever on the other, is often manifest; cases occurring in practice of an intermediate nature, and referable to one malady as much as to another. 541. C. Insanity during or after Lactation— Insania Lactantium—Mania Lactea, Sauvages— is generally gradual in its approach ; or it is preceded by symptoms premonitory of its oc- currence. Wrhen, however, violent impressions are made upon the mind, or the secretion of the milk is suddenly disturbed, the disorder may burst forth unexpectedly. Generally, howev- er, a change of temper or disposition is remark- ed for some time previously. The manner be- comes hurried, sleep disturbed, the temper irri- table, the countenance suspicious or distrust- ful, and the patient voluble and negligent of her infant. At length, sleeplessness, incoherence, or violence of language and conduct, and delu- sions, supervene. Occasionally, various hys- terical and cataleptic symptoms are associated with these ; and sometimes acts of violence, or attempts at suicide, are perpetrated, even before the nature of the malady is suspected by her friends. 4 he disease may occur at any pe- riod of lactation ; but it is more frequent on weaning, or very soon afterward, than at any other time. The melancholic and monomani- acal forms of insanity are oftener observed du- ring this period, than violent mania : and when the latter occurs, it is apt to pass into melan- cholia, or to alternate with it. Insanity during this and the preceding periods may present some one or other of the complications noticed above (§ 166, et scq.). 542. ii. Diagnosis.—The diagnosis of puer- peral insanity is sometimes difficult, especially after delivery. Some modern writers have en deavoured to point out differences, rather than to describe the relations really subsisting be- tween it and other diseases, especially phrenitis and low nervous fever. But, as I have already stated, the transition of the one into the other is not infrequent, or the pathological condition of these maladies are very nearly the same in many cases. The absence of fever has been considered as particularly characteristic of pu- erperal insanity ; but fever accompanies a con- siderable proportion of cases, especially those commencing about the fourth or fifth day, when the secretion of milk excites some degree of febrile commotion in the system, and, at a later period, when the lochia disappear. Still, it is a rapidity of pulse, and an irregular determina- tion of blood, with increase of heat about the head, rather than fever, that are more com- monly observed. 543. a. In phrenitis, the patient has headache, vertigo, throbbing in the temples, a beating noise in the ears, flushing of the face, injection of the conjunctiva, intolerance of light and of noise, heat of the scalp, rapid pulse, dry skin, suppression or sudden diminution of the milk and of the lochia, constipated bowels, and scanty and high-coloured urine, before deli- rium appears ; and very frequently these symp- toms are ushered in with chills or rigours. In proportion as these phenomena are manifested before the mental disorder appears, the disease may be viewed as possessing an inflammatory character. Puerperal phrenitis, moreover, soon passes into stupor, coma, subsultus of the ten- dons, catchings in the limbs, and unconscious evacuations, and often terminates unfavourably as early as the third, fourth, or fifth day, and rarely passes the eighth ; whereas puerperal mania, even in the most febrile and unfavour- able cases, generally is prolonged beyond this period, unless very injudiciously treated. In the former, the physical disease is manifest and developed before the delirium appears, and is evidently the cause of it; in the latter, the men- tal disorder is coetaneous with, or even pre- vious to the physical disturbance. 544. b. When low nervous fever occurs after delivery, or during lactation, it will hardly be confounded with this disorder, as the febrile commotion precedes mental disturbance for several days; muscular power is prostrated, the patient preserving the supine posture, or being incapable of continuing any other the pupils are but little sensible to light; the tongue is tremulous ; the patient is sleepless, and com- plains of confusion and giddiness, rather than of pain of head ; and when delirium supervenes it is of an incoherent and muttering kind, and very rarely violent or attended by muscular ex- ertion. The pulse is very quick and small; the bowels are readily moved ; and the lochia or milk is suppressed. As the malady pro- ceeds, coma, startings of the tendons, pickings of the bedclothes, unconscious evacuations, and the usual phenomena of nervous exhaustion, terminate life. 545. These maladies the discriminating phy- sician will never confound with true puerperal mania, and he will carefully distinguish such cases as present an intermediate form between either of them and the latter disorder. He will, moreover, keep in recollection the circumstance INSANITY, PUERPERAL—Causes 631 of these diseases frequently leaving, as the physical disorder subsides, more or less of men- tal disturbance behind them, which may as- sume the form of chronic mania, or melancho- lia ; and the risk of this result will be great in proportion to the evidence of a hereditary pre- disposition to insanity, and to the nervous or melancholic temperament of the patient. 546. c. The relation of puerperal insanity to de- lirium tremens has not been adverted to by wri- ters, although the connexion is obvious in many instances, and of practical importance. I have been called to several cases which, in their re- mote causes and essential features, were in- stances rather of delirium tremens occurring in the puerperal state than true puerperal insani- ty. In some cases, the tremor is hardly to be observed, or is present only for a short time ; and yet the affection presents the other char- acters of that disorder, and has arisen chiefly from the abuse of intoxicating liquors. Puer- peral insanity, attended by tremor, usually ap- pears soon after delivery, and is to be imputed chiefly to the effect produced on the system, already injured by excesses, by the shock of parturition, by the consequent evacuations, and by the abstraction of accustomed stimuli. 547. iii. Prognosis.—Opinions of the result of puerperal insanity were either stated in too favourable terms, or imperfectly ascertained previously to the appearance of the works of Esquirol, Haslam, Burrows, and Gooch. M. Esquirol states, that of 92 cases, 53 recovered and 6 died, leaving 31, or 1 in 3, as incurable. Of 85 cases, admitted at Bethlem, Dr. Haslam observed 50 recover, and 35 incurable. Dr. Burrows mentions 57 cases, of which 37 re- covered, 28 within the first six months ; 10 died, 1 committed suicide, and 11 remained uncured. Dr. Gooch observes, that these statements pre- sent a prospect unnecessarily gloomy and dis- couraging ; for, of the many patients about whom he had been consulted, he knows only two who are now, after many years, disorder- ed in mind, and of them, one had already been so before her marriage. It should, however, be recollected that only the more obstinate and severe cases are sent to asylums, and not un- til medical treatment bad been already employ- ed ; hence the more unfavourable results fur- nished by Esquirol, Haslam, and Burrows Of those not sent to such institutions, a much greater proportion than that assigned by these writers recover under judicious management, particularly of the non-febrile form of the mal- ady, which is, fortunately, the most common. Cases attended by much febrile action, more especially those approaching either to the char- acter of phrenitis on the one hand, or to that of nervous fever on the other, are attended by more danger, and frequently either terminate fatally, or in permanent insanity, particularly if a hereditary predisposition to insanity exists. Of the 10 cases which ended in death, out of 57, recorded by Dr. Burrows, 7 occurred within twelve days, 2 within seven wreeks, and 1 after four months. Two had active uterine disease, and 2 others died in consequence of relapses. 548. The causes have a considerable influence on the result. Of the cases which I have seen in the Queen’s Lying-in Hospital, and to which I have been called in private practice, a much larger proportion of incurable and fatal cases has existed among the unmarried than in the married. Previous distress of mind is suffi- cient to account for these results. Of the cases of married females that have occurred in the above institution since I became consulting physician to it (1822), two were represented to me by the matrons as having been caused by remorse consequent upon incestuous inter- course, and both these terminated fatally. It may be inferred, from the results observed by several practitioners, that about four patients in five recover their intellects ; and that about one in eight die, generally within the first month of the disease, the greater number within a fort- night. The proportion, however, of unfavour- able cases is manifestly greater than this in unmarried females. The chief danger in this disease, especially in the more pure, or non-feb- rile form of it, arises from debility and ex- haustion of nervous power. And this is the more to be dreaded when the disorder follows haemorrhage, or improper bleeding, when the pulse is very rapid, weak, or small, or flutter- ing ; and when there are great restlessness and long-continued want of sleep. Recovery is generally more likely to take place, the more remote the attack from tire period of parturi- tion, or when the disorder occurs during lacta- tion. The appearance of the disease during pregnancy should lead the physician to antici- pate a severe form of it after delivery. Moral causes, also, give rise to more severe and dan- gerous attacks than physical causes; and the maniacal form terminates favourably more fre- quently, and in a shorter time, than the melan- cholic, in as far as the recovery of reason is concerned ; but deaths are more likely to oc- cur in it, at least after a short period from the attack. Of 55 recoveries, M. Esquirol states that 38 took place within the first six months. Of 35 recoveries, recorded by Dr. Burrows, 28 occurred within the same period. When the delirium is of a gay character, and the patient sings, laughs, talks wildly, and is a little mis- chievous, it rarely lasts long; but when it is attended by great suspicion, apprehension of poison, and sullenness, or when suicide , Convulsions, Disease, Epilepsy, and Irri- tation, at the sections just referred to.' IRRITABILITY—Conditions necessary to. 695 the operation of these agents, which either ex- haust or directly depress the nervous power. Galvanism, electricity, mechanical irritation, &c., exhaust this property, and narcotics de- stroy it, or, at least, greatly impair it. These effects are produced upon both voluntary and involuntary muscles, and whether the agents be applied to the muscular tissue directly, or to the nerves distributed to them. In the former case they affect chiefly the organic corpuscles or vital nerves actuating the muscular struc- ture ; in the latter, they produce a nearly sim- ilar effect through the medium of the voluntary nerves terminating in it. Many of the exciting causes of disease, and the majority of our me- dicinal agents, produce these effects in a sim- ilar manner; the several manifestations of con- tractility being thereby impaired, exalted, or exhausted, or specifically modified, according to the natures or properties of such causes and agents. From what has been stated, as well as from obvious phenomena coming under the cognizance of every observer, it may be infer- red that the several grades of irritability of this property, viewed in the sense entertained by Glisson, are the most general and important of the several endowments of life, and the most requisite to the continuance of life. I have also stated, and more fully attempted to show many years since, that this property results from a peculiar organization—from the distri- bution of the organic or vital nervous fibrils and corpuscles to the tissues displaying this property; and that the apparent dependance of it, in voluntary muscles, upon the cerebro- spinal nervous system is owing to the termi- nation of motor nerves in these muscles, in order to bring them under the influence of vo- lition ; the high grade of irritability which they possess being, however, derived from the or- ganic or vital nervous system; and probably, also, re-enforced by the influence proceeding from the spinal chord.* 19. It follows from the foregoing, that while the several manifestations of irritability are all directly dependant upon the organic or vital nervous system—are expressions oflife through the medium of this system—one form only of this property, namely, voluntary motion, is un- equivocally influenced by the cerebro-spinal nervous system; this form, however, being chiefly derived from the former source, although excited and directed by the latter. Moreover, it may be inferred that these manifestations being dependant upon this source, the several changes to which they are subject chiefly pro- ceed from changes in the condition of the or- ganic or vital nervous energy ; and that altera- tions of that form of this property, which is more intimately connected with volition, equally with other forms, also proceed from the same source; a healthy state of the cerebro-spinal nervous system, and of its ramifications, being requisite to the due excitement, direction, and determi- nation of this particular manifestation of irrita- bility. These influences, indeed, are daily il- lustrated by the phenomena of disease, more particularly of those diseases which implicate the vital endowments manifested through the medium of the ganglial or vital nervous sys- tem, or which affect the integrity of the cerebro- spinal system. In the former class of these diseases, the irritability of vital organs is af- fected co-ordinately with the disorder experi- enced by the ganglial system ; and that of vol- untary organs is also either imperfectly mani- fested, or incapable of being determined or di- rected. In the latter class, on the other hand, the organic nervous system is entirely unaffect- ed, its functions being quite healthy, and irrita- bility also perfect throughout the frame ; yet, owing to lesion in some part of the cerebro- spinal system, the contractions of voluntary muscles are either not excited, or not directed, or uncontrolled, although the power derived from the ganglial system still continues to be possessed by them. 20. B. The influence of the Hood upon the irri- tability of parts is demonstrable. Stenson, Ar- nemann, Bichat, Emmert, Segalas, and others, have proved this influence, and shown that the presence of blood in irritable textures is neces- sary to the continuance, even for a short time, of the property of contraction; and that the power of volition over voluntary muscles is lost when blood is no longer sent to them. It is also fully proved that arterial blood is requi- site to the due performance of the several grades of contractility, and that, while the con- tinued action of this blood on irritable parts is necessary to their functions, this blood loses something by this action, or undergoes changes in the course of it, that give this fluid the ve- nous character. That venous blood is incapable of supporting irritability in its healthy and more persistent states, is shown by the blue disease, and by the several modes of producing asphyxia. The state of the blood in respect, also, of the presence in it of either stimulating, depressing, narcotic, or specifically alterative materials, has also a most important effect upon the several forms of irritability. Many of the causes of dis- ease, many remedies, and many poisons, act upon the frame by passing into the circulation, and affecting, by their presence in the blood, the different grades of this property, their influence being exerted in this way, either upon the organic and cerebro-spinal nervous systems, and through them upon the irritable structures, or upon these structures directly, or even upon these systems and structures conjointly and coetane- ously. The changes, also, which take place in the blood, in the course of diseases, particular- ly contaminating maladies and fevers, owing either to the absorption of morbid matters into the circulation, or to interrupted elimination of effete and injurious materials from it, affect the several forms of irritability, and even the vital cohesion of the tissues, in the manner now ex- plained ; the absorption or accumulation, how- ever, of these excrementitious matters gener- ally having a similar effect to that produced on the frame by animal poisons. Contractility is affected by the various stimuli or irritants which may act either directly on irritable or contractile parts, or on nerves supplying them, * “ It appears, from the effects of agents upon voluntary or other muscular parts, when directly applied to the gan- glial or vital nerves—from the intimate organization of con- tractile parts—from the distribution of these nerves to the vascular system, to the extreme capillaries, and to volunta- ry as well as to involuntary muscles—that the ganglial or vital nervous system gives rise, in both these kinds of mus- cles, to the phenomenon called irritability; the different manifestations of this property, as it is displayed in volun- tary and involuntary muscles, resulting from the accessary supply of the spinal nerves which the former muscles re- ceive.—{Notes, &c., 1824.) 696 IRRITATION—Preliminary Remarks or on the central nervous organs ; but remarks on this part of the subject, as well as on the varying susceptibility of irritation in different persons and diseases, will find a more appro- priate place in the article Irritation. Bibi.iog. and Refer.— Glisson, De Ventriculoet Intes- tinis, 1678, p. 239.—Baglivi, I)e Fibra Motrice, &c., Opera, an. 1703, p. 261.—De Garter, Medicinae Compendium, i731. — Winter, De Certitudine in Med. Pract., 1746. — Haller, Deux MOmoires sur les Parties Sensibles et Irritables. Lausanne, 1756 ; et Elementa Physiol., 1. iv. et 1. xi.—Zim- merman, De Irritabilitate, &c., 1751.—Bordeu, Recherches Anat,. sur les Glandes, &c. Paris, 1751. — Sense, De la Structure de Coeur, &c. Paris, 1749. — Whytt, Physiol. Essays. Edin., 1755 ; Works, :3sive in any important organ or tissue, may readily be admitted. The usual effects of irrita- tion upon the vascular system, especially in pro- ducing a febrile state, and in thereby impeding the functions of digestion, assimilation, and ex- cretion, must necessarily, more or less, change the blood from its healthy constitution. Even in cases where local irritation does not pro- duce marked febrile excitement, or merely a remittent or intermittent form of it, the quan- tity, as well as the healthy condition of the blood, may be affected nevertheless. When irritation of a particular tissue or viscus takes place in plethoric persons, febrile excitement or reaction may be very fully manifested, and a consequent change in its constitution may take place with a rapidity co-ordinate with the grade of excitement; but, when the blood is deficient in quantity, or in the proportion of hasmatosine, the febrile excitement may be of either a low, remittent, or obscure form, or be identical with hectic, and the blood may expe- rience still farther changes in its quantity and constitution. But, in all cases, much of the effect produced by irritation on the blood will depend upon the temperament and circumstan- ces of the individual, as will be shown here- after. 29. While, however, this condition thus af- fects the blood, the states of the blood, in their turn, exert an equally marked effect upon the local consequences or products of morbid se- cretion and nutrition depending as much upon the conditions of this fluid as upon the irrita- tion which, existing in a particular viscus, has determined these changes to take place in it. Indeed, the materials furnished by the blood often constitute and characterize these chan- ges, the local irritation causing either a dis- charge of a portion of these materials in the secretions of the part, or their deposition in its structure, thereby giving rise to various organ- ic lesions, more fully described in the article Disease (§ 93, et seq.), and in the various arti- cles more particularly devoted to each of these lesions. 30. iv. Of the Propagation, Reflection, Reaction, and other Consecutive and Sym- pathetic Phenomena of Irritation.—Irrita- tion may act in various modes, or may have its effects limited or extended, in various grades, in different persons, in diversified circumstan- ces, and according to the kind, nature, or degree of the irritating cause. It may thus be, 1st. Sim- pie or direct, its effects being either local, ex- tended, or propagated ; 2d. Reflected, or con- veyed to some portion of the nervous centre or axis, and thence reflected upon distant parts ; and, 3d. Consecutive, sympathetic, or reactive, and constitutional. As to each of these modes, it requires a more particular consideration. 31. A. Simple and direct irritation is (a) at first local; and, in this state, it may continue for some considerable time, or for a period so short as hardly to admit of appreciation ; and (b) it may extend or propagate itself, or its effects, to more distant parts. The extension of the morbid action, condition, or impression, ofwhich irritation consists, varies, 1st. With the nature and intensity of the cause producing it ; 2d. With the state of organic nervous or vital pow- er ; and, 3d. With the conditions of the blood and of the excreting or depurating functions. When the cause is intense in its operation, and at the same time contaminating, vitally de- pressing, or poisonous, relatively to the state of vital power or resistance, the irritation or local effect produced by such cause is rapidly extended, by means chiefly of the organic ner- vous and vascular systems, to adjoining parts, and even to the whole frame. On the other hand, when the cause is merely mechanical, or simply irritating, without being depressing or contaminating, the constitutional energies con- tinuing unimpaired and the blood uncontami- nated, the irritation may be long in producing more extended effects, or materially injuring the frame. It is chiefly when the organic ner- vous influence is weak, the secreting and ex- creting functions are already impaired, and the blood more or less .morbid, that irritation is rapidly followed by severe local and constitu- tional disorder. When the blood is supera- bundant as to quantity, and especially as to the quantity of haematosine, or fibrin and albumen, relatively to that of serum; when the blood is thus rich and inflammatory, and the tempera- ment and diathesis are sanguine and phlogistic, then the irritation, unless its cause be poison- ous or contaminating as well as irritating, soon assumes an inflammatory character, and is quickly followed by all the local and constitu- tional effects of inflammation. 32. When the irritation is slight or mod- erate, the blood being neither superabundant nor rich, or even somewhat deficient or thin, and the temperament being phlegmatic or lym- phatic, then it may not produce great change, either locally or constitutionally, until it has continued long, or affected the secretions of the part; but when these states of the vascu- lar system are coexistent with the nervous or irritable temperament, the local, and especially the remote and constitutional effects of irrita- tion will be quickly and severely manifested, particularly on the nervous system, and on muscular or contractile parts. Illustrations of these facts occur frequently in practice, and are met with in many of the affections char- acterized by extreme pain and spasm. Irrita- tion is influenced, as to grade and consequen- ces, not only by the temperament, diathesis, and states of the blood and of the secretions, as just stated, but also by organic nervous power, and by whatever tends to depress or vitiate this power, or to contaminate the blood 33. In depressed states of vital power, irri- 704 IRRITATION—Pathological Relations op. tation more rapidly develops its effects, other circumstances being equal, than when this power is unimpaired, the resistance exerted by the constitution to the morbid impression or irritation being weaker, and consequently the less capable of overcoming this primary affec- tion, which increases and extends itself with a rapidity co-ordinate with the vital or the or- ganic nervous depression or exhaustion. Mor- bid conditions of the blood, arising from the passage of contaminating matters into it, or from the accumulation of effeete materials in it, owing to deficient or interrupted action of eliminating organs, exert an equal, if not a still more remarkable influence, in favouring and in accelerating the extension and consequences of local irritations. Punctures, external abra- sions, local injuries, the acrid, contaminating, and animal poisons, and numerous other caus- es acting locally, or even on the minutest point of the organism, produce effects of the most severe and deleterious character in these cir- cumstances of organic nervous power, and of the circulating fluids ; and, although these caus- es are often deleterious in the most healthy conditions of the frame, yet are they very much more so in the circumstances just now stated, occasioning the worst forms of erysipelas, dif- fusive inflammations of the integuments and subjacent cellular tissue, the most violent con- stitutional disturbance, contamination of the blood and soft solids of the body, with effusion into shut cavities and other lesions, and, ulti- mately, death. 34. B. Reflected irritation may be of three kinds; namely, (a) The irritation may occur in a surface or part of a viscus supplied either chiefly or solely with organic or ganglial nerves, and be transmitted to the ganglion by the ner- vous fibres first affected, and thence reflected upon these fibres themselves, or upon others supplying different structures, or communica- ting with other parts of this system, or with the cerebro-spinal axis.—(b) The irritation may commence as in the preceding variety, and extend to either the roots of the spinal nerves, or the chord itself, and thence be reflected, in the form of pain or spasm, to superficial parts, or to the extremities.—(c) The irritation may commence in, or affect the nerves of sensation in these last situations, be transmitted to the spinal chord, or to the roots or ganglia of the spinal nerves, and be reflected thence by sen- sitive and motory nerves, occasioning altered sensation, morbid sensibility, or convulsive or irregular movements. These several modes of reflected irritation occur most frequently in nervous and irritable temperaments, and in persons neither plethoric nor robust. 35. a. The first of these often attends visceral disease, both functional and organic, hysteria, the several forms of colic, constipation, gastro- intestinal disorders, visceral neuralgia, or pain- ful affections of the abdominal organs, and dis- eases of the sexual and urinary organs, but generally in irregularly or imperfectly mani- fested states. Irritation of the nerves of the uterus or ovaria, or exaltation of their sensi- bility, may be extended to the ganglia, from which these nerves depart, and be reflected thence, not only upon these organs themselves, but also upon the intestinal canal, giving rise either to irregular movements of its muscular coats and to borborygmi, or to altered sensibili- ty, or to abdominal pains, such as I have de- scribed in the article Hysteria, or to both spasm and pain, as in hysterical colic. The irritation of calculi in the pelvis of the kidney may be extended to the renal ganglion, and be thence reflected upon the digestive tube in the form either of colic, or of nausea or vom- iting. The irritation of calculi in the bile-ducts may, in a similar manner, be reflected upon the duodenum, stomach, or other abdominal organs. 36. b. The second variety of reflected irrita- tion, or that extending to the cerebro-spinal nerves, and from thence expressed upon super- ficial or distant parts, may exist either alone or in conjunction with the foregoing variety, as in the several forms of hysteria, especially the more irregular forms of it, in chorea, in ver- minous complaints, in ‘symptomatic epilepsy, cholera, &c. In these affections, as shown in the articles devoted to them, irritation affects a certain portion of the organic nervous circle, and extends to corresponding ganglia, and is thence reflected upon the fibrils of gray nerves supplying other viscera, or upon those commu- nicating with the roots of the cerebro-spinal nerves, occasioning either altered sensibility or extreme pain in the extremities of the nerves of sensation, or spasmodic or uncontrolled movements of the voluntary muscles, through the medium of the nerves of motion. The con- vulsive affections of infants and children are frequently thus produced without any disease of the brain, although the circulation in this quarter generally is affected in the course of the convulsion, owing to the disorder of the re- spiratory processes attending it, and to the im- peded passage of blood through the lungs and heart. The irritation of worms in the intesti- nal mucous surface gives rise not only to vari- ous painful and spasmodic states of the canal, and to palpitations of the heart or of the ab- dominal aorta, but also to convulsions and spasm of voluntary muscles in the manner just ex- plained, and as I have stated in the article Cho- rea (t) 16,17). In 1820 I treated at a dispensa- ry a case characterized by constant clonic spasm or convulsive movements of the abdominal mus- cles. The cause was instantly recognised: spirits of turpentine was prescribed, and im- mense accumulations of faecal matters and many hundreds of lumbrici were evacuated ; and then the convulsions of the voluntary mus- cles ceased. This case was published (see Lond. Med. Repos., vol. xvii., p. 242) soon after its occurrence, and was explained as above. Other illustrations of this form of reflected ir- ritation might here be adduced, but they are unnecessary ; others will be noticed hereafter 37. c. In the third variety, or when the irrita- tion implicates, or is seated in, the cerebro- spinal or sensitive nerves, and is transmitted either to the plexuses of nerves, or to their roots, or through these to the spinal chord, and even to the brain itself, and is reflected thence so as to manifest its effects in the form either of spasm or convulsion, or of pain or altered sensibility of some superficial or distant part or limb, then consciousness is frequently af- fected, in some way or other, in the course of the process; and, consequently, the functions of the brain are co-ordinately implicated. Still IRRITATION—Pathological Relations of. 705 the brain may be no farther affected than in being cognizant of either the primary affection, or of its sympathetic effects, or of both. In this case, only one of the functions of the brain is acted upon, and all the other functions are unimpaired and unaffected. But in other in- stances, the irritation, owing either to its inten- sity and extension to the cerebro-spinal axis itself, and more especially to the brain, or to the latter organ being implicated in the course which it takes in developing its effects, may so affect the brain as completely to overpower its functions; yet this result rarely takes place without being attended by convulsions. 38. On a careful examination of disorders characterized by convulsions, spasms, or irreg- ular muscular actions, we shall find that they may be divided into, 1st. Those which are at- tended by consciousness; and, 2d. Those in which consciousness is suspended. The one, however, may pass into the other, but in com- paratively rare instances. In the former of these, the brain retains the power of sensation, and is not incapable of exerting its functions during the paroxysm ; in the latter, conscious sensation is for a time altogether overwhelmed, and is restored, more or less rapidly, after the attack has ceased. It may reasonably be in- ferred that, in the one, the primary irritation is propagated to the roots of the spinal nerves only, or to the spinal chord, and reflected thence, by the motor nerves, upon the voluntary mus- cles, the brain being still capable of discharging all its functions, excepting that of controlling the muscular movements ; in the other, the ir- ritation extends to the brain, or affects it or its circulation, in such a manner as to suspend or to extinguish consciousness and all its modifi- cations for a time. In many, if not all the lat- ter class of cases, the medulla oblongata seems to be the part more immediately implicated; as soon as the affection extends to it, con- sciousness and the other subordinate manifest- ations of mind being suspended for a time. (See article Convulsions, t) 42, et seq.) 39. h. Severe or neuralgic pains are often caus- ed by irritation, the source of which may be in the trunk of the nerve whose terminations are thus affected, or in the spinal chord, or in vis- ceral or ganglial nerves passing to the roots of the spinal nerves, or to the spinal chord itself. In this latter case, the primary irritation mani- fests its effects in distant parts by a reflex sym- pathy, as already described, and as long since insisted upon in the works already referred to. In all instances of pain from irritation, whether the irritating cause be seated in the nerve itself, or in the chord, or in other or distant nerves, the effect being reflected by means of either the chord or of ganglia, it is expressed chiefly m the ultimate ramifications or smaller branch- es of nerves. When the pain is seated in the trunk of a nerve, it will generally be found that the sheath or neurilema of such nerve is infla- med, either in the seat of pain or near it. In a case recorded by Dr. Denmark, where ex- treme pain was felt in the points of the fingers and thumb, the limb was amputated, and a small portion of a ball, which had been detached from it when it struck against the bone, was found imbedded in the fibres of the median nerve. In several cases which have occurred in my practice, as well as in others recorded by au- thors, irritation and chronic inflammation of the spinal chord or of its membranes have been attended by pain in nerves, chiefly of their ex- tremities, given off from the parts of the chord chiefly affected. Numerous illustrations of this are given in the article Neuralgic Affections. In nearly all cases where the pain is caused by irritation merely, it is intermittent or periodic, or returns only after distant intervals. But when it is produced by inflammation, or by ir- ritation of an intense and permanent kind, it is either continued or remittent only. When it proceeds from the former cause, it is sudden in its accession, intense in grade, often brief in du- ration, and it generally ceases suddenly. When it arises from the latter cause, it is more grad- ual in its increase and subsidence, and more permanent than in other circumstances. 40. The cases of pain from irritation, ex- pressed in distant parts by reflected sympathy, furnish some very singular phenomena, which fall more particularly under consideration in other articles. These are characterized chiefly by their seat, intermittency or remittency, and by the non-febrile and non-plethoric states of the vascular system, in the very great majority of instances. Thus, irritation of the stomach or bowels, by accumulated matters, or by acid- ity, or by flatulence, or by morbid secretions, often causes severe pain in distant and super- ficial parts, or even in less remote organs. A gentleman was seized suddenly with a violent pain in the heart. I was called to him, and, while I wrote a prescription, I directed him to swallow two or three small pods of Cayenne pepper, which were at hand in»a bottle of pick- les. He instantly afterward eructated much fla- tus, and the pain as instantly ceased. Pains of short duration, but of great severity, are oft- en experienced during disorders of the digest- ive organs, in various parts of the body far re- moved from the seat of irritation. Thus, pain at the vertex, or in the temple, or in a limb, or in other parts, is sometimes felt; but it in- stantly ceases upon the escape of accumulated flatus, or upon the neutralization of acid in the prima via, or after the operation of an emetic or of a brisk cathartic. (See article Neuralgic Affections.) 41. C. Reactive, Consecutive, and Sympathetic Irritation. — In certain circumstances of the oeconomy, especially those which will be noticed hereafter, irritation gives rise to general vas- cular reaction, or to various consecutive anu sympathetic effects, having a more or less ob- vious relation to the state and grade of the pri- mary affection. In most instances, the first ef- fect of irritation is displayed in the vessels of the part, in one or other of the modes described above—in either inflammatory action or hajm- orrhage; but in some cases, the irritating cause, owing to its nature, or to the part irritated, or to the constitution and diathesis of the individ- ual, gives rise to very severe febrile commo- tion, or to various consecutive phenomena of either a painful, or a spasmodic or convulsive kind, without the local vascular disturbance being remarkable ; and these effects may be general as respects the (Economy, or more or less limited in extent, or may change their seats and character. Chemical irritants, and vari- ous vegetable and animal poisons, produce these effects, which usually present a very marked. 706 IRRITATION—Pathological Relations of. speciality, their characters varying with the cause which produced them, and with the cir- cumstances in which they are developed. Thus, the irritation of the digestive mucous surface, or of some part of it, by worms, by acidity, by flatulence, by noxious ingesta, or by accumula- ted sordes, frequently is followed by spasmodic movements of the voluntary muscles, by pain- ful affections of the joints, by neuralgic or rheu- matic pains, by gout, and by various visceral affections of a painful of of a functional kind. 42. The presence, also, of morbid elements in the blood, or the accumulation of those ma- terials in it which require to be eliminated, will not only occasion irritation of some portion of the organic nervous system, but more especial- ly of that portion which is supplied to or actu- ates the organs destined to the elimination of these materials, but will, at the same time, fa- vour the rapid development of the reactive and sympathetic effects of the more local affection. Gout, erysipelas, and several other diseases, illustrate this principle; indeed, most of the disorders which are seated principally in the excreting organs furnish proofs of the truth of this view. From the foregoing, it may be safe- ly stated that the sympathetic effects of local irritation are to be traced by means, 1st, of the nervous system of organic and animal life ; 2d, of the vascular system and blood ; and, 3d, of the excreting viscera as influenced by the or- ganic, nervous, and vascular systems. But the consideration of these, if farther pushed, leads to the following part of the subject, which is very intimately connected with the foregoing general views. « 43. v. Constitutional Effects of Irrita- tion.—The principal and most serious effects of irritation are ascribable, 1st, to the nature of the irritating cause; 2d, to the state of or- ganic, nervous, or vital power, especially as manifested by the irritability of contractile parts ; 3d, to the state of the circulating fluids, particularly as respects the accumulation of ex- crementitial or noxious materials in the blood; and, 4th, to the functions of eliminating and depurating organs.—a. Of the influence of the causes in determining the evolution, as well as the kind of constitutional commotion produced by irritation, sufficient notice will be taken here- after ; and I have already shown ($ 31) that the effects of irritation are, caeteris paribus, more extensively, more rapidly, and more severely propagated throughout the frame, the more the organic nervous or vital power is depressed at the time when the irritating cause is in opera- tion. 44. b. When the circulating fluids are loaded with noxious elements or materials, in conse- quence either of interrupted excretion or of the absorption of injurious matters, not only is the vascular system the more readily excited there- by to increased action, but the vital power is also greatly impaired at the same time ; and henee, although vascular action is augmented, power is diminished, and the sooner altogether exhausted. The impeded or interrupted action of depurating or excreting organs, in first caus- ing a morbid state of the blood, exerts, accord- ing to the extent of this primary effect, a simi- lar influence in developing, accelerating, and •aggravating the constitutional operation of lo- cal irritants; and hence the necessity of bring- ing our means of cure to act upon these organs in all cases of local as well as of constitutional irritation. The influence apparently arising, in connexion with irritation, from a superabun- dance or deficiency of blood, and from a too rich or a too poor or watery state of this fluid, has been already noticed, particularly with ref- erence to the supervention of inflammations, haemorrhages, and various spasmodic and ner- vous affections; but these conditions of the vascular system seldom give rise to so rapidly developed, so severe, or so dangerous commo- tions of the whole ceconomy, as when the blood is loaded with excrementitious materials, and when important emunctories are interrupted or impeded in their functions. It may be, there- fore, inferred, as a pathological axiom, that, other circumstances being the same, the con- stitutional effects of local irritants will vary with, and be proportionate to, especially in the rapidity of their development and in the sever- ity and acuteness of their characters, the grades of vital power and of vascular purity, and the states of the several emunctories. In propor- tion as power is reduced, and the blood is im- pure or changed from its healthy state, so the brain becomes oppressed, the soft solids con- taminated, the vital cohesion of the tissues weakened, and the depurating organs impeded ; effusions of serum, sero-sanguineous exuda- tions, hajmorrhages, and various structural changes ultimately supervening, with more or less rapidity. Erysipelas, local irritants giving rise to diffusive inflammation of the cellular tissue, wounds or injuries, and punctures fol- lowed by severe disturbance, and many acute affections consequent upon irritating and mor- bid poisons, furnish sufficient illustration of these inferences. 45. vi. Op the Continuity, Periodicity, Duration, and Terminations of the Effects of Irritation.—A. The effects of irritation are seldom continued, or of equal severity through- out, unless they be aggravated by morbid con- ditions of the blood, or by impeded action of the emunctories. In such cases they may be pro- gressively acute or severe, until they terminate fatally, without any appreciable intermission or even remission. The blood may also be more or less contaminated, particularly by the absorp- tion into it of morbid secretions, and yet the effects will still assume a periodic or remittent form, as in cases of hectic fever; but very gen- erally the constitutional effects of irritation are continued when the blood is much contamina- ted either by absorbed matters or by unelimi- nated elements, as shown by most of the forms of erysipelas, by the consequences of punctured, poisoned, or contaminated wounds, and by nu- merous irritating causes acting locally in these states of the vascular system. 46. B. The effects of irritation, whether they be spasmodic,, or neuralgic, or painful, or con- stitutional, are most commonly periodic, or re- cur after intervals, or become aggravated by paroxysms, if they do not cease altogether for a time. The recurrence or aggravation of these effects generally observes no regular periods, unless intermittent and remittent fevers be con- sidered as constitutional manifestations of irri- tation of the organic or ganglial nervous sys- tem, in which point of view, indeed, I have chiefly contemplated them in their more sim- IRRITATION—In Relation to its Causes. 707 pie states. As long as irritation extends no farther than the nervous systems, and while the excreting organs and vascular system and blood are not greatly disturbed, it generally thus man- ifests itself more remarkably at one time than another. In many cases, the irritation seems to proceed or to exist in a latent form, or the irritating cause seems to have ceased to pro- duce any results after its more immediate ac- tion, until some adventitious circumstance oc- curs, or some change takes place in the states of organic nervous or vital power, or of the ex- creting viscera, favourable to the development of its effects ; and these effects may either in- crease progressively or recur more frequently, or they may soon cease altogether, owing either to exhaustion or to the subsidence of the pri- mary morbid condition. 47. In cases of neuralgic pains, the effects of irritation manifested in distant parts, as above shown, by either a direct or reflex sympa- thy, as wrell as in cases of spasmodic or con- vulsive movements similarly produced, we ob- serve certain phenomena or circumstances of an important and practical kind: 1st. That these attacks are immediate, severe, and con- tinued, in proportion to the intensity of the irri- tating cause relatively to the grade of constitu- tional or vital power; 2d. That they are favour- ed and aggravated by whatever lowers the or- ganic nervous energy and vital resistance, the intervals between them becoming shorter or less marked, and the seizures longer or more frequent the more this power is reduced; 3d. That these attacks are similarly affected by im- paired excretion and evacuation, and by impure or morbid states of the blood; and, 4th. That they are influenced in the same way by mental depression, and by directing the mind either frequently or for a lengthened period to them. 48. C. As to the cause of the periodicity, or of the recurrence of the effects of irritation, no farther or more satisfactory information can be given than by assigning this character to a law of the animal ceconomy, which is observed as long as these effects do not extend much be- yond the nervous systems, or implicate the more important emunctories and the blood and vascular system. If wre attempt to proceed farther in our research, we can infer only that all causes exciting or irritating the source of irritability and the sentient system, produce their effects on sensibility and on muscular movements in a more or less remittent or par- oxysmal manner, the intermissions being com- plete and prolonged in proportion to the slight- ness of the cause relatively to the susceptibility of the nervous system and state of vital power. Even the most violent of painful and spasmodic diseases, as neuralgia and tetanus, are charac- terized by exacerbations during the attack ; and these exacerbations exhaust, for a time, the sensibility and irritability, which, however, are quickly restored under the influence of the causes which continue to excite them ; or, in other words, irritation being once excited in any part of the source of irritability or of the sentient system, explodes itself in fits or shocks on those parts most immediately connected anatomically and physiologically with these sources ; and when the cause of irritation con- tinues in action, or when the irritation is in- tense, although the cause which excited it may have been removed, the effects may continue until the vital energies are exhausted, or may even increase with the vital exhaustion, until life is extinguished, unless some powerful agent be employed capable of fortifying the nervous power and vital resistance, and thereby ena- bling them to overcome the morbid impression which has been produced, or to resist the oper- ation of the causes which are present, until the parts become accustomed to their influence. 49. D. The duration of irritation depends chiefly upon the same circumstances as have just been shown to influence the character or type of its effects (§ 45): these circumstances, however, tend more especially to render the disease more acute, and of shorter duration than it would otherwise prove. In general, irritation is prolonged in proportion to its slight- ness relatively to the degree of vital or consti- tutional power ; and it may continue or recur for an indefinite period, as long as vascular ac- tion and the states of the blood, and of the emunctories, are not very materially affected by it. As these become deranged or remarka- bly diseased, so the duration of the resulting malady is equally short; and this is especially the case when muscular contractility is either inordinately excited or very greatly impaired. Tetanus, rabies, poisoned wounds, &c., are il- lustrations of the short duration of the effects of irritation when its action is energetic, and when its consequences are extensive in respect of the nervous, vascular, and muscular systems. 50. E. The terminations of irritation have been partly noticed (<) 23) when remarking the effects or consequences of it upon the vascular and muscular systems, and upon the secretions and nutrition. The effects of it on these parts of the ceconomy are often intermediate between an advanced stage of its development and its termination ; but still, irritation may arise and subside, or terminate in health, without any of its more palpable consequences or strictly struc- tural lesions having been produced, sensibility and contractility having been only temporarily disturbed. It may terminate in death in a very short time, owing to the intensity of its action, or to its violence, as expressed chiefly on the sensibility or on the muscular and vascular sys- tems, and previously to any very marked effect upon the organization, although generally the secreting and excreting functions, and the chan- ges in the blood requisite to the continuance of life, are either impaired or arrested before death is occasioned. Irritation may also produce va- rious lesions, already alluded to (<) 27-29), these lesions either superseding, extinguishing, or merely masking the original mischief; or then greatly increasing both it and its effects. Most frequently when irritation terminates fatally, this result is owing more to the changes, often numerous and consecutive, produced by it, than to the violence of this state, as expressed merely on the sensibility and irritability of the frame, although the changes in these latter properties may either altogether, or only partly, produce this last result. 51. III. Of the Influence of the Agents ok Causes on the States and Characters of Irritation.—i. Of predisposition to irritation.— An increased susceptibility of irritation may arise from a great variety of circumstances. The influence, however, of several of these is 708 IRRITATION—In Rklation to its Causes. not satisfactorily established, or, rather, hardly admits of proof. It appears very probable that the usual causes of irritation act more readily, and with greater intensity, (a) On the irrita- ble, nervous, and sanguineous, than on the phlegmatic, bilious, melancholic, and lymphatic temperaments; (b) On the scrofulous and gouty diathesis, and the delicate and enfeebled consti- tution, than on the sound and robust; (c) On the young than on the old, and more particular- ly on infants and children; (d) On the female than on the male sex. Besides these causes of predisposition, others may be enumerated, as hereditary or original constitution; unwhole- some diet and insufficient food; modes of liv- ing calculated to weaken and to impede the di- gestive, assimilative, and depurating functions ; confinement in-doors, insufficient exercise, sed- entary occupations, and deficient ventilation. All the depressing passions and emotions ; soli- tary confinement, suppressed feelings, and pri- vation of light, sunshine, and fresh air ; debility and pre-existing disorder, more particularly tor- por of the bowels, and of the excreting organs generally; the superabundance of excrementi- tial matters in the blood, or the absorption into it of morbid secretions; and either too great ful- ness or extreme deficiency of the blood, or vital depression and vascular plethora, or inanition, or contamination, either individually or vari- ously conjoined, favour the operation of the more immediate causes or agents of irritation on the frame. 52. ii. The Exciting Causes.—The operation and nature of these, conjointly with the state of predisposition, influence and determine the form and character of irritation.—A. The nature and amount of external injury, especially in con- nexion with the shock sustained by the (econo- my on the infliction of it, often produce irrita- tion of a serious kind, both locally and consti- tutionally ; and the particular nature and rela- tions of this effect are often misunderstood and unsatisfactorily treated. Among these injuries, surgical operations may be classed. The na- ture and character of the irritation also vary much with the nature of the tissue or part pri- marily affected or injured. Thus, a puncture or laceration of a tendon, or of an aponeurotic ex- pansion, will more readily induce tonic spasm or tetanus than neuralgia ; and the spasm will more readily be produced in a person predispo- sed by a combination of circumstances ; by an irritable or nervous temperament; by depres- sion of organic nervous and vital power; by accumulations of morbid secretions in the bow- els ; and by the depressing passions, than in a healthy individual. An irritating body, lodged either between the fibrils of a nerve, or upon' its sheath, may so alter the sensibility of its sensitive fibrils as to occasion acute pain in their ramifications and terminations, even with- out affecting the motor nerves, or affecting them only slightly and occasionally. In many external injuries the cerebro-spinal nerves may entirely escape, and yet the extent of mischief and the shock to the system may be great. In such cases, the other structures may be serious- ly injured, and especially the organic nerves: these latter affect the circulation in the vessels of the injured part, and consecutively the vas- cular system generally ; and thus extreme suf- fering, shock to the constitution, and vascular reaction—unless the vital powers a.e entirety overwhelmed by the amount of injury and the attendant shock, so as to prevent reaction— are successively produced. In perusing the numerous instances of surgical operations de- tailed in various works, the physiological pa- thologist will readily recognise, in many of the phenomena attending these cases, the effects of irritation caused by the operation. A man is operated upon for axillary or subclavian an- eurism, and the ligature placed upon the sub- clavian artery necessarily produces not only * shock to the constitution, but also irritation as the shock subsides, owing chiefly to the cir cumstance of the organic nerves surrounding the vessel in a closely reticulated plexus being enclosed, strangulated, or irritated by the liga- ture. Hence the oppressed breathing, general coldness, and sinking of the vital powers, fol- lowed by febril commotion and various painful spasmodic and sympathetic affections, accord- ing to the peculiar circumstances of the case, so frequently consequent upon such operations. 53. B. Numerous mechanical and chemical ir- ritants produce not only great local, but also, consecutively, much constitutional irritation. These, however, are generally no farther inju- rious than by disordering or inflaming the parts to which they are applied, unless they are so energetic as to disorganize the structure, as concentrated acids, alkalies, &c. Much of the local and constitutional irritation produced by these, unless they are thus energetic, or are brought in contact with an extensive surface, is owing to the states of the system, and espe- cially of the organic functions—deficient vital power, impure states of the circulating fluids, and impaired secretion and excretion, particu- larly favouring the effects of these agents. 54. C. Many substances combine, with much local irritation, a narcotic or alterative effect upon the nervous and vital properties.—a. These acro-narcotics exert a decidedly poison- ous effect, characterized not merely by local and general irritation, but also by a specific condition of the vital functions. There are both a local irritation or inflammation produced by them, and a change in the states of sensibil- ity, of irritability, and of secretion and excre- tion, having a special reference to the agent or cause. Most of these substances are derived from the mineral and vegetable kingdoms, and constitute, owing to their peculiar modes of action, the principal part of our means of curing disease, when judiciously employed. 55. b. Numerous animal substances occasion either local or general irritation, or both, or combine with this a contaminating or poison- ous effect. In some instances, their operation locally and constitutionally, is chiefly of a sep- tic nature, dissolving the vital cohesion of the tissues, and contaminating the circulating flu- ids ; in others, their action is more strictly irri- tant, in respect either of the organic or of the cerebro-spinal nervous system, or of both, but generally of the former especially ; and again, in others their influence is both septic, as re- gards the tissues and fluids, and depressing, as respects the vital endowment. Thus, putrid animal matter acts principally in the first of these modes, yet partly, also, as a local, and, through the medium of the blood and vascular system, as a constitutional irritant. The virus of rabies affects chiefly the nervous systems, irritating, first, the part inoculated with it, and, consecutively, the organic nervous functions, and, lastly, the cerebro-spinal actions. The venom of serpents and insects both dissolves the vital cohesion of the tissues to which it is applied, contaminates them and the fluids, and remarkably depresses the vital manifestations. 56. c. Acid or excrementitious matters passed into, or accumulated in the blood, are more fre- quent causes of constitutional commotion or irritative fever than is generally supposed. Va- rious secretions and excretions, when accumu- lated or retained, are partially absorbed, and render the blood impure (see art. Absorption, (j 15); others, when interrupted or suppressed, are followed by a redundancy in the blood of the materials forming them, which materials are the causes of irritative fever, of excessive action and greatly depressed vital power. Uri- nous fever, or the constitutional commotion oc- casioned by suppressed or interrupted secretion and excretion of urine, is one of the forms of irritative fever caused by the accumulation of excrementitious or morbid matters in the blood. 57. d. The passage, also, of morbid secretions into the circulation is often productive of the worst forms of constitutional irritation. If these substances pass gradually, so that their elimination from the blood is as rapid as their introduction into it, the consequent irritative fever is comparatively slight, and generally as- sumes a hectic or remittent form ; but when it passes more abundantly and rapidly, as in cases of phlebitis and of diffusive inflammation of the cellular tissue, the constitutional disturbance is very much more serious and acute, and very closely resembles the worst forms of putro- adynamic fever. In lying-in hospitals, where the vital powers are reduced, first, by the shock attending parturition, and, secondly, by the im- pure air of the ward, and when, in conse- quence of these circumstances, the uterus con- tracts imperfectly, or allows a considerable quantity of the bloody sanies escaping from the vessels on its inner surface to accumulate in it, a portion of this sanies is absorbed or im- bibed by the veins into the circulation, and irri- tative fever or constitutional irritation of the worst and most rapidly fatal form is soon de- veloped. In many of these cases, as I have proved by repeated observation and post-mor- tem research, the imbibition or absorption of the matter from the cavity of the uterus, and the consequent contamination of the blood, takes place without producing uterine phlebitis, or, at least, without occasioning that form of phlebitis which is attended by the production of coagulable lymph in the veins (see Veins, Inflam, of); while in others the uterine and spermatic veins are inflamed, either primarily or coetaneously, owing to the irritation of the matters retained in the uterus at the mouths of the veins or sinuses left exposed by the sep- aration of the placenta, or as they pass along the veins, during the process of imbibition. The most adynamic and rapidly fatal cases are of the former description, the more inflamma- tory and prolonged instances are of the latter ; but this important subject is fully discussed in the article on Puerperal Diseases and Fevers, where the results of long and extensive expe- jience are given. The rapid absorption of fluid IRRITATION—In Relation to its Causes effused into the cellular tissue, as in •phlegmasia dolens, (edematous erysipelas, diffusive inflamma- tion of the cellular tissue, and in cases of non- encysted abscesses, is generally followed by con- stitutional irritation of a most remarkable kind, vascular action being excessive, but devoid of power or tone, and all the vital and nervous functions being remarkably depressed. In a case of phlegmasia dolens of both thighs, under my care in 1832, the swellings very rapidly sub- sided, but were soon followed by all the symp- toms of adynamic or typhoid fever, requiring the free use of restoratives and antiseptics, which produced a most beneficial effect and rapid recovery. 58. e. All the animal poisons, and all the ema- nations produced from dead and living organized bodies, seem to act first as local, and more or less rapidly as constitutional irritants. The most remarkable of these is the virus or fluid sometimes inoculated when examining recent- ly-dead bodies. This poison produces excess- ive irritation of the nervous systems, locally and constitutionally, with extreme prostration, weakness, and rapidity of the heart’s action, &c., soon followed by fatal exhaustion. But, while these animal or morbid poisons irritate more or less the organic nervous and vascular systems, they likewise depress their vital man- ifestations and contaminate the blood and se- cretions. They act as a kind of leaven which infects the whole ceconomy, and imparts to it the power of developing a poison, like itself in all respects, capable of producing the same ef- fects, and thereby perpetuating itself. (See arts. Infection; Poisons, Animal, &c.) 59. /. Numerous substances irritate the sys- tem when received into the stomach or bowels, or passed into the circulation, each producing an effect having a strict reference to its nature or peculiar properties, and to the quantity of it taken or introduced into the blood. Indeed, the operation of a large proportion of medicines depends upon this specific influence, modified, however, by a variety of circumstances, duly considered and taken advantage of by the ob- servant and experienced physician. In cases of irritation from these causes, the local and constitutional effects vary with the tissue or viscus upon which they individually act, with their absorption or non-absorption into the cir- culation, with the quantity of the substance employed, and with their specific influences on the different emunctories. Substances which are absorbed, or which otherwise pass into the blood, exert, according to their nature or pecu- liar properties, more or less of irritation of the vascular system, and of the organs by which they are excreted from the blood, modifying, at the same time, the functions of the mucous and cutaneous surfaces, and the states of nervous influence. Owing to these circumstances, these agents produce more or less constitutional com- motion, or irritative fever, unless their influ- ence is slight or is limited to some excretory organ or surface. 60. g. The sensations, when acutely excited, are often causes of irritation, more especially of those parts of the cerebro-spinal nervous system with which they are in the most inti- mate correspondence. Thus, inordinate excite- ment or irritation of the organs of sense is oft- ten followed by inflammatory excitement of the 709 710 IRRITATION—Treatment of. brain, or of its membranes ; and of the nerves of sensation in the extremities, or in the gen- eral surface, by convulsions. Morbid sensation occasionally exerts a similar influence, or re- acts upon and augments the primary irritation producing it. Acutely excited sensation may occasion, by either a direct or reflex sympathy, morbid sensations in distant parts, or spasmodic or convulsive movements, or, by exciting the vascular system or impairing the excreting functions, constitutional disturbance of a more or less severe nature. Indeed, this cause, par- ticularly in connexion with the excitement of a pleasurable feeling, as in sexual irritation, is a much more common source of the diseases of irritation, or, at least, of those which are thus characterized at their commencement, than is generally supposed; and it is almost equally prevalent and mischievous in both sexes. Its consequences are manifested both by direct and reflex sympathy, giving rise to disordered func- tion, morbid sensation, disordered or uncontrol- lable muscular movements, and ultimately to constitutional disease. If we trace the progress of the mischief, we shall detect the effects, first, in the weakness of the various digestive func- tions, through the medium of the organic ner- vous system; next, in the cerebro-spinal ner- vous system, as evinced by morbid sensibility of the spinal nerves and weakness of the men- tal faculties, or by affections of the voluntary and involuntary muscles, or by convulsions; and, lastly, in the augmented disorder of all these, in disease of the vascular system, in de- ficiency and poverty of the blood, and in various nervous, cachectic, and even structural chan- ges, terminating in some instances in death. 61. h. Various moral emotions and intellectual powers, when inordinately excited or exerted, and especially the malevolent passions, anxiety, and some of the depressing feelings, excite more or less of irritation, disturb the circula- tion in the brain, and disorder the actions of the heart. In addition to their more strictly local effects, particularly in respect of the ner- vous system, they may also produce violent constitutional commotion, and derange all the secreting, assimilating, and excreting functions, this latter effect increasing still farther the vas- cular or febril disturbance. The mental emo- tion may even irritate particular organs, accord- ing to its nature, as the heart, the urinary, and genital organs ; and the physical effect may in its turn be a source of irritation to other parts. The mental emotion, also, may be of so violent a nature as to give rise to convulsions, or alter- ed sensibility of remote parts, previously to vascular or other disorder of a general kind having been produced. 62. In estimating the influence of moral or physical causes in exciting local or general irri- tation, too great importance should never be attached to one, or even two causes only, with- out endeavouring to detect others, or compri- sing the various predisposing circumstances in our pathological estimate. Every influence or occasion ought to be recognised and duly weigh- ed ; for, upon the evidence we obtain of each, must a principal part of our indications of cur,e be founded. 63. IV. Treatment op Irritation.—The*n- dications, as well as the means of cure, or of alleviation, of both local and general irritation, must entirely depend upon the knowledge that is obtained of the causes, of their individual and conjoint influence in producing the existing effect, and of the extent of functional or struc- tural disease which has already resulted. It is manifest, from these and other considerations, that the indications and means of cure of irri- tation must, in order to be appropriate and ben- eficial, have strict reference to the several pre- disposing and exciting causes, and to the exist- ing morbid conditions of each case. However closely observant, however experienced the writer may be, he cannot state these so as to apply to all the circumstances of such cases as they are daily occurring in practice. He can only assign those which are the most important and the most applicable to the more usual oc- currences, leaving the reader to modify them, or even to add to them, according to the emer- gencies or the variations presented by particu- lar instances. 64. There is no class of diseases in which the fundamental principle in therapeutics, of avoiding or removing, subduing or counteracting the causes, is so necessary to be observed, or so difficult to be practised, as in this very im- portant and numerous class ; and none which requires greater physiological knowledge, or a more sagacious recognition of healthy and mor- bid sympathies than this does. Thus impressed, I have been led into a fuller exposition of the pathological relations and causes of irritation than may appear necessary to many. It seems, however, that this procedure was not the less necessary that it was difficult, and either avoided by nearly all preceding writers, or treated of in a most empirical manner, or, at least, with a less strict reference to the early, the intimate, and the consecutive changes characterizing the dis- eased condition in question—with a less regard to the actual procession of morbid phenomena than the existing state of physiological knowl- edge warranted. In entering, therefore, upon the treatment of a case of local or constitu- tional irritation, it is necessary not only to as- tertain fully, and to estimate justly, the predis- posing and exciting causes, with the view of removing or counteracting them, but also to trace the origin, the various relations, and the obvious and probable effects of this condition, and to consider them in connexion with the states of vascular action and purity, and of vital power or resistance, and with the sympathies ex- isting between distinct organs and distant parts. 65. i. Treatment of Irritation with reference to removing, subduing, and counteracting the Caus- es.—Many of the causes admit of removal, oth- ers can be counteracted merely; and where the former cannot be accomplished, the latter must be attempted. In many cases, certain only of the causes may be removed, and the others may be either counteracted or subdued—a circum- stance which should not be overlooked in fra- ming our plan of cure. The first part of this in- dication requires no remark, but the latter de- mands farther notice. In order to subdue or to counteract irritation, the means should be applied with strict reference to the nature of the causes, to the state of the (economy, and to the seat and state of irritation. The means which are to be thus employed may be divided into two classes. 1st. Those which are strictly local, or topical; and, 2d Those which act more or less constitutionally, or upon one or more of the gen- eral systems of the frame. 66. A. Of the means applicable to the seal of Irritation.—These consist chiefly of emollients, anodynes, or sedatives, and narcotics; in some instances of refrigerants, of stimulants or irri- tants, and of evacuants. The former of these admit of being variously combined. It is in comparatively few cases of irritation that these means can be applied to the part primarily af- fected ; but where this may be done, it should never be neglected.—a. Under the head emoll- ients may be comprised all the modes of em- ploying moist heat, or of conjoining moderate warmth with humidity ; as the use of fomenta- tions, warm vapour, and poultices.—b. Ano- dynes and narcotics are indicated chiefly in con- nexion with the former, the particular agent be- ing suggested by the nature of the cause and the seat of affection. This combination exerts a more sedative influence on the local disorder than either would if employed singly. Thus, warm water, vapour, fomentations, or poultices, with henbane, conium, belladonna, poppies, camphor, &c., are more efficacious than those emollients used simply. It should not be over- looked, that protection from the action of the air aids many of these in their beneficial opera- tion.—c. Refrigerants are much less efficacious than the foregoing in removing local irritation, although they act, like them, chiefly upon the sensibility of the part; and, in order to be useful, they should be constantly applied. Refriger- ants are most beneficial when irritation is about to excite either haemorrhage or inflam- mation, and they may then especially be con- joined with various astringents and sedatives, as the preparations of lead, of zinc, of opium, &c. 67. d. Stimulants, or even irritants, are some- times useful in subduing local irritation, but it is often difficult to determine the particular cir- cumstances in which they should be resorted to. When the irritating cause is of a poison- ous, septic, infectious, or contaminating or spe- cific nature, then stimulants, or even the more powerful irritants, are generally beneficial. Thus, camphor, ammonia, the turpentines, the chlorides, the nitrate of silver, and numerous other vegetable and mineral substances, are often of service when applied to a part irrita- ted by any of these causes. In such cases, the artificial irritant, if sufficiently energetic, supersedes the action of the morbid one, espe- cially if it be employed before the organization of the part and the vital powers have suffered, or before morbid sympathies have been devel- oped ; and even in these circumstances they may greatly aid the constitutional means of cure. The stimulus, even of dry heat, may be useful in relieving irritation when judiciously employed, or conjoined with other agents. When heat is indicated purely as a stimulant, or even as an antispasmodic and sedative, these will often be most useful when applied in a dry form. The combination of stimulants with narcotics is sometimes of use, even locally, in many cases of irritation, attended by pain or spasm, and it will be seen in the sequel that this combination is still more beneficial when pre- scribed internally, or constitutionally. In most cases of irritation manifested chiefly in the nervous systems, this combination is especially indicated, and is often not less efficacious IRRITATION—Treatment of. 711 when topically than when constitutionally em- ployed. 68. e. Evacuation of the vessels of the part affected, or of fluid effused in the areolae of the tissue, is often of great service in an advanced period of irritation. In such cases, distention of the capillaries and of the tissues by the ef- fused fluid, consequent upon the action of the irritant, perpetuates the morbid state, or even increases it; and in every instance it heightens the constitutional and sympathetic effects of the local affection. This is more particularly remarkable where joints, fibrous or sero-fibrous structures, or deep-seated parts, or tissues bound down by aponeuroses, are so irritated as to give rise to capillary distention or serous effusion. In cases of this description especial- ly, the use of emollients, anodynes, and narcot- ics, will often beneficially follow the judicious local evacuation of the distended vessels, or of the effused serum. 69. B. The constitutional or more general treat- ment of irritation consists chiefly of the use, 1st, of agents calculated to lower or subdue, not only the local affection, but also its sympathetic and constitutional effects, by their direct or spe- cific operation; 2d, of such means as will ex- cite irritation in a particular part or viscus, and thereby supersede or reduce the primary affec- tion ; 3d, of those medicines which stimulate or impart tone to the nervous and vascular sys- tems, and thereby either subdue the local mor- bid condition, or enable the constitutional pow- ers to resist it until it subsides, either naturally, or from the disappearance of its causes, or from the influence of local treatment; and, 4th, of remedies which remove injurious materials from the system, which promote the excre- tions, and preserve the circulating fluids in a state of purity. It is obvious that, in the more severe and intense states of irritation especial- ly, these several means require to be variously conjoined, and to be aided by the topical meas- ures already advised. 70. a. The means most useful in reducing local or sympathetic and constitutional irritation are the usual antiphlogistic remedies ; as low diet, ab- stinence, vascular depletions, refrigerants, sed- atives, and physical and moral quietude. These are more particularly indicated when irritation affects the sanguine, the plethoric, and the ro- bust, or when it has superinduced a state of sub-inflammation, or of active congestion, or of active haemorrhage, or of simple sanguine- ous determination to an important viscus. In opposite circumstances, especially in the debili- tated ; in the nervous, melancholic, lymphatic, and irritable temperaments ; in persons with a poor, or deficient, or morbid state of the blood ; and for those who have long suffered, or who are suffering from depressing influences, the lowering measures now enumerated generally increase the local irritation, and even hasten and augment its sympathetic and constitutional effects. By lowering the constitutional pow- ers, resistance to the extension of the disorder is equally weakened. In cases of this kind, the more restorative measures about to be noticed (i) 76) are required. Where the remedies com- prised under this head are indicated, the choice of them must altogether depend upon the causes and nature of the case ; but generally they should be cautiously prescribed, and they should 712 IRRITATION—Treatment of. be neither repeated nor persisted in, even when indicated, without being combined with narcot- ics, or with antispasmodics, according as mor- bid sensibility or spasm may be the consequence of irritation. In cases where want of sleep or mental irritation attends this affection, the state of circulation in the head should receive atten- tion ; and if these symptoms are clearly not ref- erable to increased vascular action in this quar- ter, then narcotics or anodynes, sometimes con- joined with alkalies, are of great service, and reduce both the local irritation and the nervous affections consequent upon it. In cases of spasm, as well as of morbid sensation, anodynes and narcotics are nearly equally serviceable; but, in the former especially, a combination of them with those stimulants commonly called antispasmodics is productive of great benefit. When these symptoms are violent, without vas- cular determination to the brain, antiphlogistic and lowering means are generally prejudicial, the opposite measures about to be noticed being the more appropriate. In the circumstances just noticed, a recourse to alkalies or their sub- carbonates, with anodynes, is often of service, particularly when the urine is thick, deposites a sediment, is acid, and when the stools are of- fensive, and the skin foul. 71. b. Irritation artificially produced in an or- gan or part remote from the primary seat of mor- bid irritation sometimes supersedes this latter state. The principle of counter-irritation, of vascular derivation, of artificial irritation, &c., has been long recognised in medical practice, has been variously denominated, and various means have been used in carrying the principle into effect. It is, when judiciously prescribed, more serviceable in disorders of irritation than in any other class. The agents employed with this intention may be divided into, 1st. Those which irritate internal organs, and are servicea- ble in consequence, chiefly, of this mode of ac- tion ; 2d. Those that are applied externally with this intention.—a. Of the former, (a) drastic pur- gatives are the most commonly used, and some- times most beneficial. They not only give rise to an amount of irritation occasionally suffi- cient to supersede the original affection, but they evacuate accumulated morbid secretions or faecal matters which either predisposed to or otherwise contributed to cause the disorder. Their good effects may partly, also, be imputed to the vascular determination to the digestive canal, and consequent derivation from the seat of irritation produced by them. It is princi- pally, however, when disorder is seated in parts intimately sympathizing with the intestinal ca- nal that they are the most useful. If it is seat- ed in the nervous centres, or if it affects sensa- tion or muscular motion, cathartics energeti- cally employed afford great relief, as shown in the articles on Neuralgic Affections, Teta- nus, &c.—(b) Emetics are, upon the whole, less serviceable than cathartics ; yet they are of much use for irritation of the respiratory or- gans, especially for hooping-cough, asthma, croup, and for all spasmodic affections of the larynx and bronchi consequent upon irritation of the nerves of these parts. Of cathartics and emetics it may be remarked, that a cautious recourse to them—in some cases a frequent repetition of them—is often necessary to the removal of the irritation produced by morbid secretions accumulated in the gall-ducts and bladder, or even in the cells of the colon, or in the caecum.—(c) The more irritating diuretics, as turpentine, cantharides, &c., are sometimes decidedly beneficial in many of irrita- tion ; and, according to my experience, they are most so when the irritation gives rise to spasmodic or convulsive actions, as in trismus, convulsions, hooping-cough, &c.; but, in order to be thus useful, they should be given so as to produce a marked operation on the urinary passages. I have frequently seen a very man- ifest improvement of states of these diseases as soon as the urinary organs became irritated. —(d) Salivation may be considered as one of the modes of internal irritation and derivation, especially when maintained for a considerable period. Mercurial salivation is, however, more appropriate to inflammatory diseases than to disorders depending upon irritation, unless, in- deed, the latter tend to the former character, and affect the states of vascular action either generally or locally. Irritation, also, when pro- ductive of haemorrhage, is often most success- fully combated by mercurial salivation of a slight form, when it may be readily produced, and without having recourse to a too free ex- hibition of this mineral. In the slightest forms of irritation, especially those affecting parts about the face, mouth, &c., artificial excite- ment of the salivary glands by pyrethrum or other sialogogues may be of use. 72. H. External derivation or irritation has al- ways been prescribed for disease ; but in recent times it has been resorted to by empirics and impostors, who have employed it injudicious- ly, and often injuriously. It is appropriate in most cases of irritation, in some form and mode or other; yet much discrimination is necessary to a beneficial recourse to it, in the choice both of the irritant and of the situation to which it should be applied. The stage of the disorder in which it is most likely to be serviceable, and the other means of cure which should be pre- scribed in aid of it, also deserve consideration. In the more acute and continued cases of dis- order, and when it is desirable to produce an immediate effect, then the external irritants which are most energetic, as hot turpentine epithems and embrocations, mustard poultices, blisters, moxas, stinging by nettles, mustard pediluvia, &c., are also the most useful; but, in the more chronic, remittent, or intermittent states, it will be necessary either to repeat these applications oftener than once, or to have recourse to others which, although slower in their operation, are more permanent in their influence on the complaint, as setons, issues, and artificial eruptions, produced by croton oil, by tartar emetic ointment, or by other means. Some of these modes of producing external ir- ritation require a few remarks. 73. a. Epithems of warm flannels, soaked in spirits of turpentine, produce an almost imme- diate redness and a burning sensation of the part on which they are applied, and are espe- cially beneficial in irritation of internal organs, in painful or spasmodic affections, and particu- larly when there is risk of inflammatory action or haemorrhage being induced. They may be frequently repeated in some cases, and they then usually slightly vesicate or excoriate the surface of the part, the external inflammation IRRITATION—Treatment of. 713 thus produced soon subsiding, and they often procure a copious perspiration. Stinging by nettles was formerly much used, and is an im- mediate and often very efficacious mode of ex- ternal derivation, and is applicable to the cases for which mustard poultices are prescribed. Mustard pediluvia, or mustard manuluvia, the water being as warm as it may be endured, and mustard poultices, are of service chiefly in cases of slight irritation, and before vascular excite- ment has been produced, or after it has been in great measure subdued. These means are seldom of much service when vascular excite- ment is considerable. 74. b. The external irritants which are slow in their action are beneficial in consequence rather of their permanent influence, and the discharge they occasion, than of the amount of irritation or inflammatory action produced by them. This is especially the case with se- tons and issues, in all the various forms in which they are made or kept in action. One of the best modes of forming an issue is by applying the decorticated bark of mezereon, previously moistened, over the part selected, and by re- newing the application daily, or by placing the common issue-pease under the plaster covering the denuded or ulcerated part. When it is de- sirable to produce a free discharge and much artificial irritation at the same time, then open blisters, large issues, or the antimonial ointment may be prescribed. Croton oil, employed so as to occasion free pustulation, and other appli- cations calculated to excoriate the surface and to give rise to a free discharge from it, as vari- ous combinations of concentrated acetic acid and oil of turpentine, or preparations of ammo- nia, are severally of use when judiciously pre- scribed and applied, and when aided by appro- priate internal means. 75. c. Most of these modes of producing ex- ternal irritation and derivation from the primary seat of disorder are indicated, either before vas- cular action has been excited by the primary affection, or after it has been subdued, or in a great measure subdued by suitable treatment. As long as inflammatory action exists, or as long as the primary irritation may be greater than the amount of external irritation that can be prudently excited, but little benefit will re- sult from the practice, unless the discharge procured by its means assist its influence, or compensate for the deficiency in the amount of irritation. In such instances the artificial irritation is seldom productive of that amount of vascular afflux or determination capable of being decidedly beneficial. When, however, a copious discharge is produced and maintained, the internal affection will often be removed, if it does not amount to disorganization or serious structural change ; but when these changes have taken place, the amount of discharge will often only hasten the unfavourable progress of the malady, and sink the patient. In all such cases it is important to watch carefully the ef- fects of this mode of treatment. When morbid irritation has given rise to increased vascular excitement, external irritation and derivation are seldom successfully procured. In these cases they only augment the morbid vascular action, and are prejudicial, or, at least, ineffica- cious, in proportion to the degree in which the vascular system is excited. 76. C. The remedies which stimulate the ner- vous energy and impart tone to the vascular sys- tem—a, are generally of service in diseases of irritation when the vascular system is not ma- terially disturbed, or when it is excited to in- creased action, with a diminution of power, and with evidence of a morbid state of the blood. When irritation has been followed by great frequency of the heart’s action, irritability and muscular power being much impaired, and the pulse soft and open, or expansive, then the more energetic stimulants or tonics, selected with reference to the circumstances of individ- ual cases, and conjoined with means which may promote the action of the emunctories, and counteract morbid changes in the circula- ting fluids, are generally of the greatest service. They increase the vital resistance to the exten- sion of the sympathetic effects of irritation, and enable the vital energies to overcome the primary morbid condition, or to resist its inju- rious influence until it subsides under the local tfr other means of cure, or from other influ- ences. The several preparations of cinchona, or of other tonic barks, quinine, camphor, am- monia, the chlorate of potash, the chlorides, the alkaline carbonates, the hydro-chloric acid and ether, wine, opium, alcoholic preparations, the turpentines, Cayenne pepper, cajeput oil, &c., and the numerous remedies more particu- larly mentioned in the Treatment of Typhoid Fevers (§ 530), and of Diffusive Inflamma- tions (§ 236), are more especially indicated in this state of disease. 77. b. When irritation gives rise to extreme pain, to the more violent forms of neuralgia, or to convulsive or spasmodic actions, the most energetic and permanent tonics, variously com- bined, according to the states of the excreting viscera, are also then more beneficial than a lowering treatment; but these remedies should be aided by the most active narcotics, and by suitable local means. In such cases, brisk •cathartics, followed by quinine, or the prepara- tions of iron, or of arsenic, camphor, the alka- lies, or alkaline carbonates in large doses, am- monia, &c. ; and these, aided by opium, mor- phia, henbane, colchicum, aconite, &c., pre- scribed either internally or externally, or en- dermically, according to circumstances, are the most efficacious remedies, particularly when judiciously combined with one another, or with other medicines. Whenever pain or convul- sion is violent, inflammation is not present; but the irritating cause evidently acts most en- ergetically upon the nervous system ; and the means employed to overcome or remove it should be equally energetic, and so selected and combined as to act upon the source and seat of irritation, and to remove the morbid impression made by the cause of it. In some cases, particularly those of extreme pain, al- ways affecting the same nerve, treatment is not permanently efficacious, although it is gen- erally of temporary service, because the affec- tion depends upon mechanical or irremoveable irritation, near the origin, or in the course of the nerve. In severer cases of spasm, or of convulsion, it is, upon the whole, not much more successful; and is even almost equally hope- less when the complaint depends upon similar causes, or upon structural changes in the head, or spinal column. In all such cases, the means 714 IRRITATION—Treatment of. of cure should not be too weakening, and san- guineous evacuation should be cautiously prac- tised, even although local plethora, or vascular determination to the nervous centres may ex- ist. Local depletions, or small bleedings, coun- ter-irritation and derivation, both internal and external, tonics, anti-spasmodics, narcotics, &c., are more beneficial than other measures. Some years since, a gentleman was sent to me from the country by his medical adviser on ac- count of neuralgia of the occipital nerves ; I considered it, from the history of the case, to be dependant on a permanent cause of irrita- tion about the base of the skull. External derivation, and the other means already ad- vised, were prescribed, and he continued to im- prove for two or three years. During a visit to town, he was exposed to several sources of disorder,and in the evening he was seized with violent convulsions. The surgeon called to him bled him to a very large amount; and on the following day, when I saw him, his pulse was very quick, irritable, extremely compressi- ble, and furnishing all the indications of much excitement, with defect of power. His man- ner and answers to questions were hurried, quick, and unusual. I expected a return of the seizure, or paralysis, or apoplexy, in the course of a few days; but he continued to improve slightly for some months, when hemiplegia, fol- lowed by apoplexy, soon terminating life, took place. Numerous other illustrations of this principle might be adduced if my limits could admit of them. 78. I). Remedies which remove Injurious Mat- ters, promote Excretion, and correct Morbid States of the Blood:— Many of the substances that evac- uate excrementitial irritating matters also ex- ert a salutary derivation, as respects the vas- cular afflux or determination. The old doc- trine, “ ubi irritatio ibi fluxus,” is correct in all situations, and in every sense, and particularly when the irritant is applied to mucous surfaces, and acts upon excreting glands. During many states of irritation, particularly when vascular action is materially excited by it, absorption is remarkably active, and morbid secretions accu- mulated, either in the biliary passages or in the intestines, especially in the cells of the colon and caecum, are more rapidly than in other circumstances conveyed into the circulation, thereby either favouring the production of, or actually producing constitutional disturbance of a serious nature consecutively upon the lo- cal irritation. The more stomachic, tonic, and alterative purgatives are essentially necessary in such circumstances, particularly combina- tions of the compound infusions of gentian and senna, with alkaline carbonates ; the spirits of turpentine, with or without castor oil; and oth- er medicines which produce a restorative, as well as an evacuant effect. In all instances of impaired excretion, or of excrementitial ac- cumulations in the circulating fluids, either contemporaneous with, or consequent upon lo- cal or constitutional irritation, the exhibition of stomachic purgatives, and the alternation of the more powerful tonics, are extremely servicea- ble. In this state of actual disease, the chlorate of potash, chlorides, hydrochloric aether, cam- phor, ammonia, the alkaline carbonates, and, when vascular action is excited, the nitrate of potash, the solution of the acetate of ammonia, and other stimulants, either separately or pref- erably, in conjunction with quinine, or with ton- ic infusions or decoctions, or with one another, according to their several compatibilities, will be found most beneficial, provided that the actions of the emunctories be at the same time duly promoted, and morbid accumulations evacua- ted. In cases where irritation is attended by accumulations of excrementitial matters in the blood, not only should the bowels be freely acted upon by the means just mentioned, but the kidneys ought to be excited by the more energetic diuretics, as the turpentines, the al- kaline carbonates, the nitric or hydro-chloric aethers, &c. When local, or even constitution- al irritation is attended by deficiency of blood, or by a deficient proportion of haematosine, then the preparations of iron, with alkaline solutions, as the mistura ferri composita, or the ferri am- monio-chloridium, the ferri potassio-tartras, &c., will be requisite, in addition to the other means which the circumstances of individual cases will suggest. 79. E. Alteratives and deobstruents, either alone, or conjoined with gentle restoratives, or with mild tonics, or with laxatives or ape- rients, are of the greatest service in the more chronic and slight forms of irritation. The most useful of these are Plummer’s pill, either alone or with soap and extract of taraxacum ; the hydrargyrum cum creta, similarly pre- scribed; the liquor potassae, or Brandish’s al- kaline solution, with any of the concentrated preparations of sarsaparilla, or with taraxa- cum ; and the solution of potash, with the hy- driodate of potash. The sub-borate of soda, either alone or with the bitartrate of potash, or both these with taraxacum, are of service for irritations of the biliary organs. A com- bination of several of the foregoing medicines with camphor, henbane, belladonna, or coni- um, or with any of the preparations of opium, according to the peculiarities of particular ca- ses, is often beneficial, especially when irri- tation is attended by increased sensibility. When there is much irritation of the cutane- ous surface, the alkalies and their carbonates, camphor, prussic acid, the narcotics just enu- merated, with emollients, &c„ employed both internally and externally, should never be over- looked. [In nothing is the skill of the practical phy- sician more clearly manifested than in distin- guishing irritation from inflammation, and suc- cessfully combating it with appropriate reme- dies. Dr. B. Travers, in his able work on “ Constitutional Irritation,” led the way to cor- rect views on this most important subject; and Marshall Hall, in his more recent essay, en- titled “ Researches on the Effects of Loss of Blood,” brought forth facts and observations of the highest practical import, which have been also confirmed by the publications of Drs. Abercrombie, Gooch, and others. With these views, American physicians, we believe, are very generally acquainted ; but yet we have so frequently witnessed erroneous treatment, from incorrect pathology—from mistaking simple ir- ritation for active sthenic inflammation, that we deem it proper to add a few remarks on this subject, supplementary to those of our au- thor. We have found, in a practice of many years, that it is not always easy to discriminate in these cases, from the fact that excessive irritability, as maintained by Broussais, very often depends on inflammation,or hyperaemia; it may be latent or chronic, and the irritation hence arising will accordingly be successfully combated by antiphlogistic measures, as evac- uants, revulsives, and contra-irritants. We do not, however, believe that blood-letting, ei- ther general or local, is as beneficial, or as fre- quently applicable in the treatment of these cases as is generally supposed. We are to bear in mind the remark of Mr. Travers, that “ extreme susceptibility, and consequent over- activity, are invariably coupled with, and most probably dependant on weak and insufficient powers of constraint and resistance. The same principle which renders a part over-irritable renders it over-active.” Medicines are not anti-irritant in proportion to their antiphlogistic effects, and therefore, as Dr. Williams has remarked, where irritation predominates over inflammation, those are to be preferred which act on the nervous as well as on the vascular functions. Physicians, especially those of the younger class, are in danger of regarding pain as necessarily indicative of inflammation,‘and hence calling for depletory measures ; whereas it oftener is the result of nervous derange- ment, and calls for soothing and anodyne rem- edies. The first rule to be laid down in the manage- ment of this affection, which can scarcely be called a specific disease, is to remove the irri- tating cause. This will generally suffice for the perfect cure of the patient. Thus, emetics are successfully employed to remove irritating matters from the stomach ; purgatives from the bowels ; acidity is relieved by an alkali; the irritation of dentition by lancing the gums ; of worms, by anthelmintics ; of a deep-seated abscess, by the escape of the purulent matter ; of hernia, by a division of the stricture; of stone in the bladder, by its removal, &c. But, unfortunately, as every practitioner must have observed, irritation, when once established, propagates itself, so as to become independent of its first cause, and we here have a compli- cation more difficult to manage. If now we are ignorant of, or cannot reach the cause, we must endeavour to diminish the irritability of the system, which is to be done by corrobora- ting measures, as pure air, exercise, cold and shower bath; vegetable and mineral tonics, with anodynes and other soothing remedies. As irritation results from a preponderance of nervous mobility, those agents which give tone and strength to the muscular system will un- doubtedly prove the most efficient remedies for its removal. As a late writer has observed, under the influence of tonics, disposition and power to act will go together, and within due bounds produce the harmonious balance of even health. Whether certain of them possess a specifically sedative property towards the ner- vous system, or whether this is their secondary effect, after their tonic and astringent influence on the vessels, is beyond our means of decis- ion ; but the fact is not less ascertained than important, that the continued use of nitrate of silver or sulphate of copper will cure the epi- leptic convulsions independent of organic caus- es, and often diminish them where the cause is irremoveable, by lowering in the nerves their IRRITATION—Tre ATME NT. susceptibility to its impressions. Thus, like- wise, bark, carbonate of iron, arsenic, sulphate of zinc, or sub-nitrate of bismuth sometimes remove the painful or spasmodic irritations of tic douloureux, hemicrania, sciatica, chorea, and gastrodynea, which the most powerful ano- dynes, antispasmodics, and counter-irritants fail to effect. The stomach and intestinal ca- nal, also, under the influence of a bitter tonic, will often lose various signs of irritation, which, however they may occasionally be accompa- nied by slight hyperaemia or fancied inflamma- tions, owe . their being to weakness and want of tone. The cold shower or plunge bath, or cold ablution, is another efficacious tonic ; the more eligible, often, because, without loading the system with medicine, it rouses it to the exertion of its own powers in a vigorous vas- cular reaction, under the habit of which nervous mobility is physically forgotten, and ceases. It is highly necessary that practitioners should be cautioned against resorting to anti- phlogistic measures in these cases, although temporary relief sometimes follows their em- ployment. When local pain returns after bleed- ing, it will often yield to fomentations and morphia, or hyoscyamus internally, when the repetition of the bleeding would entirely fail in procuring relief. We believe, with Williams, that there are frequent pseudo-inflammations arising in irritable states of the system which are best relieved by sedatives, a judicious sup- ply of nourishment, and an exclusion of all ex- citing or disturbing agencies ; and that we oc- casionally meet with diseases following excess- ive evacuations which put on the semblance of violent pleurisy, pericarditis, arachnitis, or hydrocephalus, and which may be completely subdued by hyoscyamus or opium, with a sus- taining nourishment, such as sago, arrow-root, or jelly, with small quantities of brandy or wine. The state of the circulation, as indicated by the pulse, is here to be our guide; and the local pains, palpitations, disturbance of the mind, with beating or noises in the head, should be viewed as partial reactions, to be subdued by opium or hyoscyamus, rather than by the lan- cet and evacuants.*] 715 * [In illustration of some of the preceding views, we quote the following case from the New-York Jour, of Medicine, vol. iv., p. 300, by Luther Ticknor, M.D., of Salisbury, Connecticut. “ Mrs. A., about the middle of November, 1844, in washing some small articles of dress, pierced the end of the middle finger with the head of a threaded needle, which she supposed penetrated the ball of the finger to the depth of one third to one half inch. The first sensation was that of numbness instantly following the infliction, extend- ing up the arm to the axilla and front part of the shoulder. This was followed immediately by numbness of the fingers of the other hand, and next with faintness and vertigo, which brought her pretty soon to her bed. Some mitigation of these symptoms was produced by laudanum, so that I did not see her until severe pain and febrile symptoms, op- pressed respiration and gastric sinking, excited some alarm for her safety, about forty-eight hours after the injury. I found her with hurried, anxious breathings, very frequent, obscure pulse, a moist surface, with temperature but little increased, almost constant chilliness, and what the patient called faintness. These two latter symptoms continued, with very little variation, for five or six weeks. A diffused swelling, not easily defined, occupied the upper portion of the ‘ pectoralis major muscle,’ extending upward to the ar- ticulation of the shoulder; certain points on this tumefac- tion were excessively painful and tender to the touch. These tender points changed their location from time to time, so as to encourage the hope that some improvement was going forward. “ The local treatment consisted of dry-cupping, epispas- tics, fomentations, anodyne poultices, anodyne liniments, &c., with very little apparent benefit; and yet anodyne 716 ITCH—Pathology. tate Morborum Genitrice. Jen., 1772. — A. Grant, Obser vat. on the Use of Opium in Dis. of Irritability, 8vo. Lond., 1785.— /. h. Gaultier, De Irritabilitatis Notione, Natura et Morbis, 8vo. Hal., 1793; et Physiologie und Pathologie der Reizbarkeit, 8vo. Leips., 1796. — Marcard, Beschrei- bung von Pyrmont, b. ii., p. 107.—M. Maraudal, Essai sur les Irritations, 4to. Paris, 1807.—Consbruch, in Hufeland, Journ. der Pract. Heilkunde, b. xiii., 3 st., p. 43.—I. G. If. Henning, Ideen fiber Idiosyncrasie und Krankliche Reiz- barkeit, 8vo. Gotha, 1812.—Humboldt, in M6moires de la Society Medicale d’Emulation, t. i., p. 302 ; t. ii., p. 323.— Monfalcon, Diet, des Sciences Medicales, t. xxvi.— P. I. Mongellaz, Essai sur les Irritations intermittentes, 8vo. Paris, 1820..— F. T. V. Broussais, Traite de Physiol, ap- plique a la Pathologie, 8vo. Paris, 1822; et Ex amen de Doctrines Medicales gfenfiralement adopts, 8vo. Paris, 2d ed., 4 vol., 1829 ; et de l’Irritation et de la Folie, 8vo. Paris, 1828. — I. M. Goupil, Exposition des Principes de la nou- velle Doctrine MOdicale, 8vo. Paris, 1824.— Charpenlier, in Journ. Gen6r. de M6d., t. lxxxvi., p. 6, 145.— /. Butler, Remarks on the Irritative Fever of Plymouth Dock-Yard, 8vo. Devonport, 1825. — Coutanceau, Diet, de Mdddcine, 8vo. Paris, t. xii.— V. Prus, De l’Irritation et de la Phleg- masie, 8vo. Paris, 1825.—/?. Travers, Inquiry concerning Constitutional Irritation, 8vo. Lond., 1826.—Also a Far- ther Inquiry concerning Constitutional Irritation, and the Pathology of the Nervous System, 8vo. Lond., 1835.—Roche, Diet, de Med. Pratique, t. x. — R. Williams, Elements of Medicine, vol. i.; On Morbid Poisons, 8vo. Lond., 1836.— C. B. Williams, Cyclop, of Pract. Medicine, 8vo. Lond., vol. ii., p. 875. [Am. Bibliog. and Refer.—Various Treatises on Phys- iology and Practice of Medicine, and occasional Essays in different Medical Journals.] ISCHURIA. See Urine. ITCH.—Syn. Psora, fupa (from fau, I rub, or scratch), Scabies (from scabo, I scratch). Phlysis scabies, Young. Ecpyesis scabies, Good. Scabiola, Auct., Lat. Kr'atze, jacken der haut, zaude, Germ. Gale, rogne, Fr. Rog- na, Scabbia, Ital. The Scab. Classif.—iv. Class, viii. Order [Cullen). 6th Class. 3 Order [Good). III. Class, I. Order [Author in Preface). 1. Defin.—An eruption of distinct, slightly acuminated vesicles, accompanied with constant itching, caused by contagion, the eruption being occasionally modified in character at its appear- ance, or during its progress, and unattended by constitutional disturbance. 2. Recent writers have supposed that the eruption mentioned by Galen, under the name of 'fupa, was really the itch ; but his descrip- tion of it is more applicable to squamous than to vesicular eruptions. The description, also, which Celsus has given of scabies is by no means distinctive of itch, and is more charac- teristic of prurigo than of it. Neither these writers nor Avicenna mention contagion as attending the eruption thus named by them. Guy de Chauliac, according to Rayer, w’as the first to point out this important feature of the disease. Subsequent writers have generally noticed it, although several of them have not distinguished between itch and prurigenous affections. More recently, Willan, Bateman, Biett, and Rayer have given the history of this eruption with much precision. 3. The modifications occasionally presented by the itch, both on its appearance and during its progress, have led to some difference in the classification of it. Thus, it sometimes as- sumes from its commencement a papular form, and during its course a pustular character. Hence Willan and Bateman arranged its vari- eties accordingly, and placed it among the pus- tular eruptions, the varieties being the Papuli- formis, Lymphatica, Purulanta, and Cachetica. MM. Biett and Rayer, however, have more accurately classed it with vesicular eruptions, the vesicular form being its primitive and most 80. F. The diet and regimen of diseases of irritation require much attention. While vas- cular action continues excited, the diet should be mucilaginous, or farinaceous, light and cool- ing, and suited to the powders of digestion and assimilation. If, however, the vascular system be not materially affected, and the functions of the stomach are not much impaired, a small proportion of light animal food may be allowed. In the more serious states of constitutional irri- tation, especially where there are marked asthe- nia, and a disposition to changes in the state of the blood, wine, and even alcoholic stimulants are often necessary, in aid of the means above recommended, in order to limit, or to prevent the extension of the mischief, by exciting the several vital endowments. In these cases, the diet should consist chiefly of such articles as are desired or relished by the patient, as being the most likely to be digested without disorder- ing the system. 81. Change of air: residence in a pure air, exercise taken regularly and short of fatigue, travelling, the use of those mineral waters, both internally and externally, that contain the alka- lies and alkaline carbonates and carbonic acid; the waters of Bath, Ems, &c., are usually ben- eficial ; but mineral springs should be prescri- bed with a strict reference to the specific forms of these complaints, after a due experience of their operation, and without being influenced by prejudices, by fashion, by guide-books, or by lo- cal interests. In many diseases of irritation the factitious mineral waters prepared at Brighton have proved of great benefit, even in the range of my own experience, having frequently pre- scribed them since 1824. In most cases, how- ever, much discrimination is requisite to the procuring all the benefits they are calculated to afford. In most instances, the milder waters, as those of Ems, of Saratoga, or of Salsbrunnen, should be first prescribed; and subsequently Mie more tonic waters of Kissengen, Marienbad, and Carlsbad, or of Eger, Pyrmont, or Spa, having recourse occasionally to the waters of Seidschutz or Pulna, when the bowels are tor- pid, or the biliary functions impaired or ob- structed. Several of these waters, also, may be procured in London ; and at Brighton their effects may be aided, in the cases that require it, by warm salt-water bathing. Bibliog. and Refer.—De Magny, An a Vasorum aucta aut imminutalrritabilitate omnisMorbus? 8vo. Paris, 1752. — G. Verschuir, De Arteriarum et Venarum Vi irritabili, ejusque in Vasis Excessu, et inde oriunda Sanguinis Direc- tione abnormi. Groning., 1766.—Baldinger, De Irritabili- poultices did the best. Internally, opium in some form, and in large quantities, was indispensable throughout her treat- ment. Profuse perspiration, subsultus, and incipient de- lirium pretty early suggested the use of tonics, of which sulph. of quinine was preferred, and freely and with advan- tage. About six weeks after the injury, a slight fluctuation was felt under the edge of the tendon of the pectoral muscle within the axilla. Forty-eight hours after it was discov- ered, a spontaneous discharge, of at least eight ounces, of rather thin purulent matter took place, and continued pro- fuse from this orifice, and one made subsequently a little lower down upon the chest, for about two weeks, when constitutional and local symptoms gave place to returning health. Immediately after the fluctuation was discovered, Mrs. A. made free use of London porter, it being the only stimulus of a diffusible kind her stomach would bear, and this it bore to good purpose. Mrs. A. is now entirely well, I believe, though, perhaps, the shoulder droops a little, from the awkward position in which the arm was kept for a long time, rather than from any imbecility in the muscles. A deep depression marks the site of the abscess, showing a pretty extensive condensation, or loss of cellular tissue.”] ITCH—Description of. 717 common state ; still it sometimes appears as a papular eruption, and as such Dr. Paget has arranged it. I shall here consider the disease as commonly vesicular, and the modifications or varietits presented by it as accidental or con- tingent upon the peculiarities or circumstances of individual cases. I. Description.—This eruption generally ap- pears first on the hands, between the fingers, on the wrists, on the flexures of the joints, on the abdomen, and on the insides of the limbs. It is most commonly confined to a surface of no very great extent; and, in some cases, con- sists only of a few vesicles dispersed between the fingers and over the wrists ; but it may af- fect the skin very generally. It does not occur on the face or on the scalp. It is essentially a contagious disease, and is neither epidemic nor endemic. v 4. 1st. Of its common vesicular form.—The eruption generally takes place in children at the end of four or five days from the period of con- tagion ; but this is uncertain, for in weak or delicate children it may be delayed beyond this period, while, in the plethoric and sanguine, it appears even earlier. It seldom occurs in adults before eight or ten days have elapsed, in spring and summer, or before fourteen or twenty days in winter. It is longer in appear- ing in the aged than in the young or middle- aged, and it attacks in preference the situations where the skin is most delicate. 5. The eruption commences with itching, at first slight, of the parts which have been expo- sed to contagion. The itching is increased through the night by the warmth of the bed, by indulgence in stimulating food, beverages, and spices, and by whatever heats or determines the blood to the surface. A number of small points or spots, very slightly elevated above the surface, now appear, and present a pale rosy colour, with small acuminated vesicles on each point or spot. If the vesicles be few, they occasion but little pruritus, and preserve longer their primitive form; but if they be numerous, the skin between each participates in the irri- tation, and the itching becomes urgent. The vesicles are then usually torn by the nails, and allow their viscid serous contents to escape, which concrete and form small, thin scabs, slightly adherent to the skin. If the scratch- ing has been violent, the scabs are black, and resemble those of prurigo. 6. ii. Varieties or Modifications.—Owing to peculiarity of constitution, to the amount of in- flammatory action attending the eruption, to the depth to which it extends in the tissues composing the skin, and to the existing state of health of the patient, itch presents certain modifications which have been arranged into species by Willan and Bateman.—A. The va- riety denominated by them the Scabies Papuli- formis, or rank itch, is that in which the erup- tion is more papular and inflamed at the base, but still presents a transparent apex, indicating its vesicular character. When much irritated by scratching, long red lines are left here and there, and the fluid exuded from the abraded vesicles concretes into little brown or blackish scabs. In sanguine temperaments, and when much irritated, a few of the vesicles assume a pustular form, from the fluid contained in them changing to a purulent matter. 7. B. The Scabies Lymphatica, 01 watery itch, differs from the foregoing chiefly in the ab- sence of the papular character and of inflam- matory redness, and in the larger size of the vesicles. When the vesicles are ruptured by scratching them, moist excoriations often form, and, after a time, dark scabs. This variety usually presents three stages, viz., the entire vesicle, the excoriation consequent on its rup- ture, and the scab covering the excoriated part. It is not so frequently observed as the former variety on the trunk, but is most com- monly found collected on the lower parts of the extremities, as the fingers, wrists, backs of the hands, and sometimes on the feet and toes. 8. C. The Scabies Purulenta, or pocky itch, is more distinct than the other varieties. The round pustules into which scabies, in a few in- stances, forms itself, resemble the pustules of smallpox. They occur chiefly in children and young persons who have been living on a heat- ing diet, and who have been inattentive to cleanliness. These pustules are distinct, with an inflamed base, and considerably elevated ; they maturate and break after a few days, hav- ing then often attained a diameter of two or three lines. The itching occasioned by them is attended by more tension and smarting than that of the other varieties. After they break they often leave a cracked excoriation or ul- ceration behind, or small fissures between the scabs, the stiffness and heat of which cause considerable uneasiness. The pustules rarely appear on the trunk, but usually on the hands, between the fingers, or near their flexures, more rarely on the feet and at the bends of the arms. They are largest on the hands and between the knuckles, especially between the index finger and thumb ; they often coalesce, and in these situations more especially, slight fissures or cracks form in the concretions cov- ering the excoriations or seats of pustulation. This variety, in plethoric children, is some- times attended by slight febril commotion. 9. D. The Scabies Cachectica, or scorbutic itch of Willan, is not, strictly, a variety, but mere- ly an imprecise modification, produced by de- bility and general cachectica, in consequence of intemperance, poor living, and unwholesome food, that assumes no very distinct or unvary- ing character. As may be expected, from the circumstances in which it occurs, it is the most aggravated state of the eruption ; and is more frequently than the true varieties, either form of which it may assume, complicated with oth- er eruptions, particularly with lichen, prurigo, ecthyma, and impetigo. When itch occurs in the dark races, it generally presents this state, and is severe and obstinate—is rank and ex- tensive, spreading rapidly over the body. As thus met with, it has been noticed by Bontius, and by Sauvages, who called it Scabies Indica. 10. E. The complications of itch often render the diagnosis difficult. Ecthyma is sometimes associated with it, and more rarely eczema, but is chiefly cured by the use of stimulating wash- es or ointments. Scabies is most frequently complicated with papular eruptions, particular- ly with lichen, in the young, and when the vesi- cles are generally or abundantly disseminated. Prurigo is often associated with itch in the more prolonged cases. Boils occasionally ap- pear in the more severe instances. These corn- 718 ITCH—Diagnosis—Causes. plications, as well as a pustular state of the eruption, are favoured by living on salt, acrid, and fat meats, and by acrid applications to the surface. Disorders of the digestive organs sometimes prevent the full evolution of itch ; or persons subject to these disorders, who have caught this affection, often readily recov- er from it when such disorders are aggravated by errors of diet. Scrofula does not materially modify scabies. In very unhealthy or cachec- tic subjects it sometimes assumes a livid hue; and, when its vesicles are crowded in any part, they are occasionally associated with ecthyma cachecticum. 11. F. The duration of this eruption depends upon treatment. If left to itself it never gets well, and may even continue through life when thus neglected. In southern climates, and in spring and summer, and in young, plethoric, and robust persons, the vesicles of itch run rapidly through their successive changes, when not broken by scratching ; but their progress is much slower in the north, in winter and autumn, and in the bilious, melancholic, and cachectic, and in the aged and infirm—in whom, also, it is longer in appearing after infection. When it is judiciously treated, and with strict atten- tion to cleanliness, and to the state of the lin- en and clothes, it may be cured, in very recent cases, in five or six days, and in the worst cases in from ten to fourteen days to three weeks; but it may be protracted beyond this period in the old, infirm, and cachectic, or when it has been long in appearing. In some rare instances, it disappears on an attack of an internal inflammatory disease, and returns again when that disease is removed. This cir- cumstance, however, has been doubted, some other eruption having been mistaken for the itch. In general, this eruption exerts no influ- ence upon internal complaints, nor do they pro- duce any effect on it; although an opposite opinion has been long held by pathologists, and is still entertained by a few. 12. II. Diagnosis.—It is of importance, not only as respects the reputation of the practi- tioner, but as regards the speedy recovery of the patient, and the protection of the other members of the family to which he belongs, that a correct diagnosis between this eruption and those which so closely resemble it should be made.—A. Prurigo is most frequently con- founded with the itch; but, independently of the former being papular, while the latter is vesicular, prurigo is usually seated on the back, shoulders, and on the outsides of the limbs, or on the surfaces of extension ; while the itch is observed chiefly on those of flexion, on the wrists, and between the fingers. Prurigo, also, occurs more frequently in adults and elderly persons than itch ; its papula are flat, and when abraded, a black spot of blood concretes on their centres. The itching attending prurigo is more vehement than that of scabies, more stinging or smarting, and less pleasurable. The former, also, is not contagious. 13. B. Lichen simplex most closely resembles the papuliform variety of itch. In the former no vesicles can be detected in the summits of the papulae, which pass away in a scurvy exfo- liation, and do not give rise to dark scabs. Lichen appears on the backs of the hands and on the external surface of the limbs, and hard- ly ever between the fingers. The itching at- tending it is not severe, and the papulae preserve the tint of the skin, while the vesicles of scabies are of a pale pink; the former being generally crowded together, the latter being much more distinct. Lichen is commonly accompanied with some constitutional disturbance ; but it is not contagious. The lichen urticatus is more acute, and sometimes presents a few vesicles among the papulae ; but its inflamed, wheal-like papulae, and the deep tingling, rather than itch- ing, sufficiently distinguish it. 14. C. Eczema, particularly C. Simplex, may be confounded with itch ; but in the former the vesicles are flattened and agglomerated in great- er or less numbers, while in the latter they are acuminated and generally distinct. The itching of eczema is a kind of general smarting, or stinging, very different from those exacerba- tions characterizing itch. The former is usu- ally produced by exciting or irritating causes, the latter by contagion only. 15. The association of scabies with other eruptions is of importance in the diagnosis. Such complications may be merely accidental, but they occasionally arise from the irritation of scratching, and of applications to the erup- tion. Vesicles of itch, pustules of impetigo or of ecthyma, and furunculi are sometimes met with in the same patient. The papulae of li- chen, also, may be either contemporaneous with itch, or consequent upon it. Scabies may even coexist with syphilis, without having its char- acters thereby modified, farther than has been noticed when mentioning the variety called ca- chectica. These combinations generally retard the cure, as well as often increase the difficulty of diagnosis. 16. III. Causes.—The great, and, perhaps, only cause of itch, is contagion. The only questions are, whether it does, in any circum- stances, arise spontaneously, and what is the nature of the infecting substance, or body. These will be answered in the sequel, as far as the state of our knowledge admits of answers. Scabies is one of the most universally dissem- inated contagious diseases, the momentary con- tact of the fluid secreted by its vesicles being sufficient to communicate the infection. It oc- curs in every climate, in every season, in all ranks and ages; but is most common in the poor and wretched, in persons negligent of cleanliness; in sailors, soldiers, in work-peo- ple, dealers in old clothes, in tailors ; and espe- cially in those crowded in jails, hulks, barracks, workhouses, and factories. It rarely is observ- ed in tanners, in dyers, and blacksmiths, or in the families of the affluent. It always spreads in consequence of contact, immediate or medi- ate ; and of want of cleanliness. 17. Several instances of itch transmitted from animals to the human species have been cited ; but most of the diseases thus named are inaccurately described, and are of a very doubt- ful character. M. Mouronval adduces cases of the communication of itch from the dog to man; but M. Rayer states that M. Leblanc showed MM. Sabatier, Littre, and himself dogs labouring under a disease called itch, con- sisting of a number of small acuminated vesi- cles, resembling those of scabies in the human subject; and stated that the man who attended them had not been infected by them, although they communicated the disease to their own species. This, however, is no satisfactory proof of the non-communicability of the affec- tion from the dog to man. Mr. Youatt, whose authority in this matter is the best possible, in- formed the author that the itch may be com- municated to the dog, and by the dog to man and other animals, but that it is never sporadic in the canine race. 18. Avenzoar, and, long subsequently, In- grassias and Jobert, hinted at the existence of an insect in the vesicles of itch ; but Mouf- fkt first mentioned it in his Theatrum Insecto- rum, in a particular manner. Several recent authors have described it under the name of Acarus scabiei. Hauptmann first published a figure of it, and represented it with six feet. Redi put the existence of this insect beyond doubt, and, aided by G. Lorenzo and H. Ces- toni, examined numbers of them, having re- moved them from the vesicles. Dr. Bonomo gave the following description of it: This in- sect moves with great vivacity ; has six legs, and a pointed head, armed with two small horns, or antennae, at the extremity of the mouth. It is, he remarks, difficult to distinguish these insects on the surface of the body, owing to their minuteness, and to their colour resem- bling that of the skin. They first insinuate their pointed heads, and then move about, gnaw- ing and pushing, until they have buried them- selves under the cuticle, where they form a kind of covered way of communication between one point and another, so that the same insect generally causes several watery pustules. The above physicians also discovered the eggs of these insects, and even observed their extru- sion from the hinder part of the animal. The eggs are white, nearly quite transparent, and hardly visible. These insects, they remark, pass readily from one person to another, by mere contact, for, being very active, and often on the.surface of the skin, they readily attach themselves to whatever they touch. 19. Morgagni, Linnaeus, De Geer, Wich- mann, Waltz, and others confirm the above description ; but, nevertheless, the existence of these insects having been called in question, M. Gales took up the subject, and his investi- gations, which were witnessed by many mem- bers of the Institute, farther confirmed the above statement. The circumstance of Gale- otti, Chiarugi, Biett, Lugol, and Mouronval having failed in finding these insects occasion- ed fresh doubts of their existence ; but their failure arose from having sought for them in the vesicles. Mouffet had long before stated that they are not found in the pustules, but by their sides ; Casal had made nearly a similar observation ; and Dr. Adams remarks, that they are not found in the vesicles, but in a reddish line going off from one of its sides, and in the red- dish and firm elevation at the extremity of this line, and at a little distance from the vesicle. Mr. Plumbe supposes that the insect is unable to live in the fluid of the vesicle, which is the result of the irritation it causes, and therefore escapes from it. Finally, M. Renucci, a med- ical student from Corsica, showed, in 1834, the physicians of Paris the mode of discovering this insect, which is the same as that formerly sta- ted by Dr. Adams. Since this time, M. Rayer ••emarks, the existince of the acarus of the itch ITCH—Treatment of. has been placed beyond a doubt. MM. Lemery, Gras, and Renucci had each shown him the mode of detecting it, and he had himself ex- tracted several. M. Raspail has given an ex- cellent description and figures of it; and M. A. Gras has entered into researches as to the share it has in producing this eruption. Al- though it has been proved that, in almost all who are affected with scabies, and who have not been subjected to treatment, a certain num- ber of sub-epidermic furrows, containing acari, are to be discovered, it is also undoubted that the number of these furrows and of these in- sects bears no proportion to that of the vesi- cles. It is, farther, rare to discover these in- sects on the abdomen and groins, where the eruption is, nevertheless, very common and ap- parent-, and, moreover, scabies is known to continue where no more acari are to be found. The experiments made to ascertain whether or not the acarus be the cause of the itch, or a par- asite produced by' it, are not altogether conclu- sive. [Dr. Watson remarks (Tract. of Physic), that there is good reason for believing that the parasitic animal is not merely a casual com- panion, but the veritable cause of scabies. Va- rious attempts have been made, and made in vain, to produce the disease by inoculation of the fluid from the vesicles. On the other hand, transportation of the acarus has always excited the eruption. These facts explain how it is that the itch, though readily communicable by direct contact or by fomites, is not communi- cable through the medium of the air; that fo- mites long retain the contagious property ; and that the disease is curable by whatever destroys the acari.”] 20. IV. Treatment.—As the itch is never spontaneously cured, but may continue even for many years, the treatment should be decided and unremitting. The experiments lately made by M. Gras have thrown much light upon this subject. They prove that a concentrated solu- tion of the hydriodate of potash kills the acarus of scabies in the shortest time—in from four to six minutes ; and he considers that an ointment, consisting of half a drachm of this substance to an ounce of axunge, is the best remedy for the itch. I have this ointment in several in- stances, and have found it the most speedily efficacious. This physician states that the itch insect lives sixteen hours in the vapour of burned sulphur, three hours in water, two hours in olive oil, one hour in the acetate of lead, one hour in pulverized brimstone, three quarters of an hour in lime-water, twenty minutes in vine- gar and spirits of wine, and twelve minutes in a solution of sulphuret of potash. 21. Where scabies is uncomplicated and re- cent, its cure is readily accomplished by local applications, and without any preparatory or constitutional means; but where it is of old standing, and associated with other eruptions, or with an inflammatory state of the skin, and particularly if the patient be young and pleth- oric, a bleeding from the arm, soothing lotions, and simple baths may be premised. Frictions with the sulphur ointment (sulph. sublirn. loti, fviij. ; adipis prcep., ibj.), or with either of the compound sulphur ointments {sulph. subl., 3ij. ; po- tass 100) that the granular deposites first noticed by Dr. Bright in connexion with dropsy, and described by him by the name of “ granular degeneration of the kidneys," appear to originate in the glandular bodies of Malpighi. Since the time of this anatomist, and more particularly by Ferrein, Bertin, Schumlanski, Eysenhardt, and Map- fes, the Malpighian glandules or bodies have been viewed as the structure more immediately concerned in the secretion of urine. As such they have been described by Meckel, Cloquet, and others, who observe that these bodies, glan- dules, or granulations, appear to consist of rounded corpuscles, visible to the unaided eye, in the form of very small points, which are connected with the minute and ultimate rami- fications of the blood-vessels. Under the mi- croscope, these bodies appear not only to con- sist of a reticulum of these vessels, but also to give origin to minute white, tortuous canals, the conduits of Ferrein, which canals form a considerable portion of the cortical structure, and convey the urine from the corpuscles to the tubuli. Meckel denominates these canals “ the excretory canals of the Malpighian cor- puscles.” (T. iii., p. 557.) 109. From what has been stated above ($ 100), I infer that inflammation of the Malpighian cor- puscles takes place in cachectic nephritis ; that an albuminous deposite forms in them, giving rise to a granular appearance ; and that, as the changes of these bodies and of the cortical structure advance, the other tissues are thereby altered more or less, until at last the tissues compressed by them become condensed or at- rophied, and the substance of the organ farther altered in consequence. These changes in the kidneys, which are nearly the same in both, especially the earliest changes, as the inflam- matory state of the Malpighian corpuscles, and the commencement of granular deposites in them, are excited by previous changes in the blood, as contended for hereafter (<) 141, etscq.); and the associated maladies arise chiefly from the same cause, and from farther alterations in it, owing to the morbid state of this very im- portant emunctory. [Dr. George Johnson recently read a paper before the Royal Medical and Chirurgical Society of London (Nov. 11, 1845; Lond. Lancet, Jan., 1846, p. 84), in which he maintained that “ Bright’s disease” consisted in a diseased state of the secretory or epithelium cells which line the urinary tubules ; that these cells natu- rally contain a minute quantity of oil, in the shape of globules, which, in this disease, is much in- creased ; in short, that there is a fatty degen- eration of the kidney, analogous to the fatty degeneration of the liver, described in recent pathological works. Dr. J. supposes that this accumulation of fat in the secretory cells is the result of constitutional causes, that it neces- sarily leads to the engorgement and dilatation of the tubules which they line, and that one or more convoluted tubes, thus gorged with fat, and projecting either on the surface of the gland, or on the surface of a section, consti- tutes one of the so-called “granulations of Bright.” The frequent connexion of albumin- ous and bloody urine with Bright’s disease, and the atrophy of the kidney, are attributed by Dr. J. to the mechanical operation of the above- described fatty accumulation; it being a sec- ondary phenomenon, and dependant on the pre- vious morbid changes. In short, Dr. J main- tains that, this deposite is the cause, and not the result of the congestion of the kidney, which finally leads to the presence of albumen in the urine. Dr. Quain, on the other hand, states {Lond. Lancet, Feb., 1846, p. 139) that, in more than 66 instances in which he has examined the kid- 744 KIDNEYS—Cachectic Inflammation of the. neys in this disease, the fatty condition was in only one case sufficient to attract attention ; that there are other deposites besides that of oil, as that called cacoplastic (badly organizable) by Dr. Williams, such as we find in other or- gans and tissues which have been the seat of unhealthy inflammation or degraded nutrition. This matter, Dr. Q. states, has been generally observed to assume, 1. The form of nucleated cells, varying in size and shape, and also in the number and character of the nucleoli; 2. As simple granular matter, nucleated cells being fewer in number ; 3. A distinct filamentous or fibrous character. The deposites in the kidney, according to Drs. Quain and Williams, assume the following characters: 1. The simple enlarged mottled kidney, the surface of which, on remo- ving the capsule, is generally smooth. In this the deposite consists of simple nucleated cells, more or less mixed with granular matter. This form is analogous to the hypertrophied mottled liver. 2. The truly granular or atrophied kidney, the surface of which is rough, irregular, and generally of a pale-red colour. In this form, the filamentous tissue, contractile in its nature, as such formations always are, exceeds the quantity of the cellular or granular matter. This latter sometimes extends to the convolu- ted extremities of the tubes. The contractile tissue surrounding the tubes and bodies can be readily supposed to give rise to the rough or granular formation. This form resembles the hob-nailed or gin-liver. 3. The large, flabby, fatly-looking kidney. In this the quantity of fat exceeds the amount of the other matters pres- ent. The fat is present in the substance, and probably in the tubes themselves. This resem- bles the fatty degeneration of the liver. Minor modifications of these forms are produced by the relative proportions present. There is no reason to suppose that one condition is the necessary antecedent of another, but that the character assumed in the first instance may be permanent. (See Williams’s Led., in Lond. Medical Gazette, 1845 ; et Princ. of Medicine. Quain, in Lond. Lancet, Feb., 1846. Johnson, in Ibid., Jan., 1846.] 110. ii. Diagnosis.—A. The acute form of cachectic or albuminous nephritis is readily recognised by the coexistence of an albumin- ous, and often a sanguinolent state of the urine, with the rapid development of anasarca, and occasionally of serous effusion into some inter- nal cavity. In a few cases, no* dropsy takes place ; but then the state of the urine, in con- nexion with febrile irritation and derangement of the general health, will sufficiently indicate the nature of the disease. It may, however, be mistaken for simple hcernaturia; but, in this lat- ter, pure blood passes, mixed with the urine, and fibrinous concretions or filaments, or even small clots of blood are voided; while these circumstances do not occur in cachectic nephri- tis. In haematuria, moreover, one or both re- gions of the kidneys are more pained, and more tender on pressure than in this disease. The urine also is rarely passed without pain, or having the same appearance at different hours of the day — circumstances rarely existing in this form of nephritis. In simple nephritis, and in some cases of the eruptive fevers, the urine contains albumen in a slight degree and for a brief period, but there is generally also a due proportion of urea, and the urates, and other saline matters, and hence the urine is not spe- cifically lighter. 111. B. The Diagnosis of chronic cachectic nephritis is more uncertain than that of the acute. When in a patient who experiences only trifling, if, indeed, any pain in the loins, the urine is found of a low specific gravity, and contains albumen with only a small proportion of urea and the urates, the existence of chronic cachectic or albuminous nephritis is almost certain, especially if he be free from disease of the heart. And, even when there is disease of the heart, the chances of mistake are small; for, if the congestion of the kidneys consequent upon disease of the heart give rise to the pres- ence of albumen or of blood globules in the urine, the quantity is small, and only occa- sionally observed ; and the specific gravity of the urine, and the proportion of urea and urates, are not materially affected. The dropsical ef- fusion, also, caused by disease of the heart usu- ally commences in the lower extremities and extends upward, whereas that arising from disease of the kidneys is often first perceived in the face. 112. M. Rayer remarks, that when, after a few days’ indisposition, a patient is affected with serious cerebral symptoms, or with re- peated attacks of vomiting, without dropsy, and when, at the same time, the urine is strongly charged with albumen, and is of a low specific gravity, and if we cannot detect any disease of the heart, or of the bladder or urethra, the ex- istence of chronic albuminous nephritis may be regarded as more probable than that of a pri- mary cerebral affection. And if it be ascer- tained that the patient has been exposed to wet and cold, or addicted to the abuse of spir- ituous liquors, or affected with dropsy some months before, the presence of renal disease may be asserted with still greater confidence. The milky or whey-like appearance of the se- rum of the blood is no proof of the existence of the disease under consideration, for it has been seen very frequently by Hewson, Trail, Babington, myself, and others, in various oth- er diseases besides this; and urea has been found in the blood after simple nephritis, and in atrophy of the kidneys, when the urine was not albuminous. 113. iii. Complications and Relations of Cachectic Nephritis to other States of Disease.—I have already stated that cachectic nephritis rarely occurs without some previous disorder, or even actual disease, and that such * [In a most remarkable case of cachetic nephritis, occur- ring in New-York several years ago, says Dr. Francis, the patient, a male subject, aged about 48 years, had long laboured under pneumonic oppression and serous effusion of the lower extremities ; his countenance, towards the lat- ter period of his sufferings, became extremely leucophleg- matic, and numerous grumous-coloured spots manifested themselves on different parts of the surface of his trunk. His urine was scanty, sometimes gelatinous, and often of an albuminous character. The occasional changes in the col- our of the urine gave reason to apprehend disorder of the kidneys of an inflammatory nature, inasmuch as his suffer- ings in the lumbar region were not unlike a paroxysm of gout, to which disease he had been a sufferer. On exam- ination after death, which was sudden and unexpected, both kidneys were found to be enlarged, the left much more than the right. Traces of their lobular structure were suffi- ciently apparent; their colour was of a pale or yellowish aspect; their texture soft and flabby: their weight ap- proached full sixteen ounces. In many respects it deserves to be classed under the first division of M. Rayer.] KIDNEYS—Cachectic Inflammation of the. 745 disorder is generally characterized by impaired organic nervous energy, by imperfect assimila- tion, and by the consequently morbid state of the blood. I have, moreover, contended (§ 141, et seq.) that the inflammatory condition of the kidneys in the acute form, and the lesions of these organs in the chronic, are consequences of these antecedent morbid conditions; and that several of the affections, which I now pro- ceed to notice, in relation to cachectic nephri- tis, often exist in a slight degree, either pre- viously to, or coetaneously with, the develop- ment of this malady ; while others, or even the same affections in different cases, do not ap- pear, or at least are not manifested, until con- secutively upon the renal disease. From this it will be evident that I view cachectic nephri- tis as a consecutive or secondary malady, and that the various affections with which it is more or less intimately connected are either pre-existent to it, or coexistent with it, or con- sequent upon it; that they are all, in many in- stances, progressive manifestations of success- ive changes in the economy, affecting more especially the circulating, or the assimilating, or the excreting organs, according to their sev- eral predispositions to disorder, or to inflam- matory action, or to structural change, or to the influence of incidental causes and exter- nal agents; while in other cases, certain of them may occur as coincident effects of path- ological causes—of pre-existing disorder, espe- cially of that already specified. It should be recollected that the associated affections or complications are rarely single ; that disease of several viscera, besides the dropsical effu- sion, generally appears in connexion with the renal malady even in the same case; but this will be seen more fully in the sequel. 114. A. Relations bf Cachectic Nephritis to Dis- orders of the Digestive Organs.—a. The mouth and pharynx are rarely affected in connexion with this disease unless consecutively upon it, when aphthae, and even ulceration of the pha- rynx. may occur at an advanced stage. It has been observed that mercurials more readily af- fect the mouth and salivary apparatus in the course of chronic cachectic nephritis than in most diseases.—h. The stomach is more or less disordered either previous to or at an early stage of this malady. At this early period the disorder of the stomach consists chiefly of the more severe symptoms of dyspepsia; but nau- sea and vomiting are frequently complained of, and generally occur early in the morning, or when fasting, especially in persons addicted to intemperance. In these cases, stimulants and food relieve the symptoms, and often compara- tively little loss of appetite is felt during the day. In the acute states of the renal disease, the disorder of the stomach is more or less se- vere ; while in the chronic form this disorder varies—is sometimes slight, at other times se- vere, or consists chiefly of a sense of load or weight at the stomach, with eructations, acid- ity, and other symptoms of indigestion. These disorders are generally functional; but struc- tural changes of the stomach are sometimes coincident with the advanced progress of the renal disease, especially inflammatory states and softening of the villous coat, ulceration, with or without perforation of the coats of the organ, and fungous or encephaloid tumours. In these cases, particularly where ulceration or perforation has occurred, thickening or indura- tion of the margins of the ulcerated part, and adhesions of the adjoining viscera, may have taken place. 115. c. The intestines are more or less affect- ed in many cases of this malady, and most frequently in the form of diarrhoea. Both Dr. Christison and M. Rayer have noticed the frequency of this complication, it having oc- curred in more than one half of their cases, but Dr. Bright and Dr. Prout have observed it less frequently. It is observed chiefly in the chronic disease, and is sometimes preceded or attended by colicky pains in the abdomen, and occasionally by vomiting ; but, in this latter case, there is often also pericarditis complica- ting the malady. The diarrhoea is generally consequent upon the renal disease, and it some- times assumes a dysenteric character; the stools containing blood, and more rarely a floc- culent whitish matter. However abundant or watery the discharges, they have no influence in diminishing the attendant dropsy, which may even increase during the diarrhoea. After death, the intestines do not always present le- sions co-ordinate with the amount of disorder during life. In many cases, little or no red- ness of the mucous surface is observed. In others, redness of this surface, with enlarge- ment of the follicles, with or without ulcera- tions, and often with anaemia of other parts, is remarked. Frequently, although the diarrhoea has been great and obstinate during life, the mucous membrane, and, indeed, the intestinal canal, have been anaemic throughout. Ulcera- tions are most common near the termination of the ileum, and in the large intestines. In the former situation they are generally conflu- ent ; in the latter, disseminated and small. 116. d. Peritonitis in rare instances occurs consecutively upon cachectic nephritis. Cases of this complication are recorded by Dr. Bright, Dr. Gregory, Dr. Christison, M. Rayer, and others. In some instances the peritonitis is granular or tubercular; in others it is attended by considerable effusion of a sero-puriform flu- id. The peritonitis may be consequent upon enteritis, with or without ulceration (see arti- cle Intestines) ; or it may arise without the intestinal disease having been manifest. It is generally caused by the influence of cold and humidity during the existence of the renal drop- sy, and is often not the only affection com plica ting this latter ; both pleuritis and pericarditis, either singly or conjoined, being also present. In these cases, the symptoms of peritonitis are more or less manifest, generally with vomit- ing, diarrhoea, &c. ; but as frequently they are by no means decisive. 117. e. Lesions of the liver are often found in connexion with cachectic nephritis; but, in many cases, the lesion is slight. Dr. Bright found the liver quite sound in 40 cases out of 100 ; the change was slight in 35, and serious in 18 cases. M. Rayer states that this organ was more or less altered in about a third of the cases which he examined after death, in some throughout its whole extent, in others only in parts. It was enlarged in a small proportion of instances (one sixth), and chiefly in those cases where the heart was also diseased. Oc- casionally some portion of its peritoneal sur- 746 KIDNEYS—Cachectic Inflammation of the. face was adherent to adjoining parts. It was softer than natural in a few instances, but it was much oftener harder, or even indurated and diminished in bulk. In this latter case its surface was irregular, of a deeper colour than usual. When divided, its substsnce was found tuberculated, presenting the lesion which has been denominated cirrhosis, or the tubercular liver of drunkards. This particular lesion seems to be more frequently associated with granular kidney than any other alteration of the liver. In some cases the liver is enlarged, pale, and fat; a portion of its structure leaving an oily stain in paper. In a few instances, it contains large whitish tubercular masses. The bile is generally more or less changed from the healthy state. It is probable that the advanced stages of these lesions are consequences of the renal malady; but it is at least equally proba- ble that their early stages, or the functional disorders preceding them, exist antecedently to the development of this malady. The nephrit- ic disease and the attendant dropsy are not in- frequently farther associated with affections of the lungs, or of the heart, or of the alimentary canal, or with chronic peritonitis. The com- plication with hepatic disease is often rendered manifest by the usual symptoms of chronic af- fections of the liver, and attended by vomiting, diarrhoea, and ascites. 118. /. The Spleen and Pancreas are some- times diseased in cachectic nephritis. In all the cases in which the liver is affected, the spleen is also more or less altered, most fre- quently enlarged, and occasionally its sub- stance is loaded with grayish granulations anal- ogous to those found in the liver (Rayer). The structure of this organ is sometimes soft- ened, occasionally firm or indurated. The pan- creas has been found diseased only in a few instances, and in a slight degree. The disease has in a few instances appeared in the course of pregnancy, and M. Rayer details some cases thus associated. 119. As far as I have been able to observe the phenomena of the early stage of cachectic nephritis, and to learn the history of the pa- tient’s previous ailments, there has been more or less manifest disorder of the digestive or- gans, generally of a functional kind, but prob- ably advancing to structural change in some cases, as the disease made progress. The in- fluence of such disorder upon the state of the blood, and upon the processes of secretion and excretion, is sufficiently evident. In all these cases, and before dropsical effusion or vascu- lar reaction had taken place, depression of the organic nervous energy, and consequent im- pairment of the functions of digestion, sangui- faction, and assimilation, were more or less remarkable. The vascular excitement, which sometimes appears at an early period of the disease, is the consequence, as I have already shown, of the morbid state of the blood, and of its influence upon the ganglial and vascular systems. 120. B. Relations of Cachectic Nephritis to Diseases of the Respiratory Organs.—a. Inflam- mation of the throat, extending to the pharynx and larynx, occurring in the course of scarlati- na, sometimes is continued, with more or less severity, during the progress of the renal drop- sy following this fever; and when the larynx becomes affected, the disease of this part may be so remarkably severe as to be speedily fa- tal. This form of complication, however, is not so frequent as inflammation and ulceration of the larynx, trachea, and even of the larger bronchi, which so frequently occur in the course of phthisis, the pulmonary malady giving rise not only to the affection of the respiratory pas- sages, but also to renal disease and its conse- quent anasarca. In two cases, in which there existed a venereal taint, the progress of which I closely watched, and where it was difficult to decide whether the laryngeal or the pulmonary disease was the primary one, renal dropsy ap- peared at early periods of their progress, ad- vanced remarkably far, and accelerated the fa- tal issue. 121. b. Bronchitis is one of the most frequent affections consequent upon renai disease. M. Rayer states, that he has observed it in seven eighths of the chronic form of this malady. The bronchitis that occurs is rarely acute; it is almost always chronic; and while the res- piration is very slightly affected in some cases, it is much accelerated, and very difficult in others, particularly at an advanced period of this malady. The matter expectorated is chief- ly mucus, occasionally thick and yellowish, in some instances glairy, and in others very abundant. The bronchitis generally aggravates the disease, and is sometimes the more imme- diate cause of death. It frequently occurs without any manifest cause ; is rapidly propa- gated throughout the bronchi; is little influ- enced by treatment or ameliorated by deple- tions ; and often passes into oppletion of the minute ramifications and air cells, and exten- sive oedema of the lungs. Its more acute form is sometimes followed by lobular pneumonia. On dissection, the mucous membrane of the bronchi is found red throughout. 122. c. Pneumonia sometimes occurs as a sec- ondary complication in the advanced stage of ca- chectic nephritis, and is more or less extensive and severe. The inflammation attacks some- times several lobes, sometimes only the whole or part of a lobe, and occasionally it affects many lobules of the lungs. In this latter case, the in- flamed points are disseminated and isolated in the substance of the organ, some of them being in the state of red hepatization, others of gray hepatization, and closely resembling the lobular form of pneumonia, which occurs after morbid poisons, and sometimes after surgical opera- tions. One or both lungs may be affected, more frequently both. The symptoms and signs of this pneumonia are usually masked by the general cachexia, by the dropsical effusion, by affections of the heart, and by other pulmonary lesions. Even the stethoscopic signs are ascertained with great difficulty, or are altogether absent. The expectoration also is seldom characteristic of the disease, being more frequently catarrhal or bronchitic, than of the kind distinctive of pneumonia. Hence the inflammation is either latent, or not detected during life. In some cases, however, the sputa and the stethoscopic signs evince the existence of the disease. This complication is most dangerous, owing to the state of the constitution, and to the ineffi- cacy or even injurious effects of blood-letting, and of many other means of treatment. It is often associated with pleuritis, or with bronchi- KIDNEYS—Cachectic Inflammation of the. 747 tis, or even with both, when it occurs consecu- tively upon renal disease. 123. d. Pleuritis is rare as a secondary dis- ease, in its simple form, in connexion with ca- chectic pleuritis ; but associated with pneumo- nia, or with pulmonary tubercles, and with se- rous effusion in the pleuritic cavities, or with pericarditis, it is by no means unfrequent. It is generally latent or overlooked, or masked by dyspncea or by bronchitis. It is sometimes chronic, and occasionally acute and manifest. In some of the more chronic, masked, or latent cases, the disease assumes much of the char- acter of hydrothorax, owing to the amount of fluid effused, and the slight grade of inflamma- tory action. 124. e. CEdema of the lungs, with or without bronchitis or bronchorrhcea, is the next frequent secondary affection to bronchitis which occurs in the course of albuminous nephritis. Dr. Bright and M. Rayer found this lesion in about one third of the fatal cases. Emphysema of the lungs occasionally occurs, and pulmonary apoplexy more rarely, in the progress of the re- nal malady. 125. /. Tubercular consumption is very fre- quently connected with cachectic nephritis, but the connexion is most commonly of a different kind from that usually observed in the other pulmonary affections with which this malady often becomes complicated in its course; the renal disease is almost always consequent upon the tubercular malady. M. Rayer believes that, in rare instances, the latter may be secondary of the former; but, although I have seen very many cases, since 1828, of renal dropsy super- vening in the course of phthisis, I have never met with one in which this order was reversed. The renal malady may appear during any peri- od of the tubercular disease, and in every form of it; in the most acute and febrile, and in the most chronic and apyretic. Generally the urine becomes more or less albuminous before any signs of anasarca appear. In a few cases the urine has been albuminous, and less dense than natural, in the advanced state of phthisis, and the kidneys have been found granular after death, and yet anasarca had not occurred. This may have arisen from the continuance of the colliquative perspirations, as these often cease upon the occurrence of the anasarca. Diar- rhoea frequently continues during the renal dis- ease, without diminishing the dropsical effusion. Bronchitis, pneumonia, pluritis, laryngitis, pneu- mo-thorax, pleuritic effusion, or oedema of the lungs, or even two or more of these, may far- ther complicate the tubercular malady and its consecutive renal disease. 126. C. Relations of Cachectic Nephritis to Diseases of the Vascular System.—a. Diseases of the heart are often associated with cachectic nephritis, but the connexion between them is not altogether evident. In some cases the car- diac, in others the renal disease seems to be primary. The frequency of this complication, also, is not fully ascertained. M. Rayer states, that it occurred in one fifth only of his cases, w'hile Dr. Bright found it in sixty-five cases out of a hundred. The cardiac affection may appear, in some instances, as the primary, in others as the consecutive, and in others as an accidental malady; and yet both it and the re- nal disease may only be the more or less remote effects of previous changes in the states of organic nervous power, and of the circulating fluids, either of which may precede the other in the order of succession or sensible manifest- ation, in different cases, or in different circum- stances. This view of the subject, which is equally applicable to some other complications of this malady, has been unaccountably over- looked by those who, in most respects, have written well on the disease, and contributed greatly to its history and elucidation. The oc- currence of this complication has great influ- ence upon the production and increase of the dropsy generally consequent upon the renal malady, and usually causes the anasarca to commence in the lower extremities. Dr. Bright and Dr. Christison think that the cardiac dis- ease is most frequently secondary, while M. Rayer believes that the kidneys are oftenest consecutively effected ; and I consider that in- terrupted circulation through the heart and lungs favours remarkably the occurrence of the chronic states of this malady. That the urine is often albuminous in persons affected with disease of the heart, when there is no se- rious affection of the kidneys, cannot be denied; but if, along with this character, it is of a pale citrine colour, strongly coagulable, and of a low specific gravity, these are strong proofs of the presence of structural disease of the kid- neys. 127. 1. The ‘pericardium often contains a small quantity of limpid serum, from four to five ounces, in fatal cases of cachectic nephri- tis ; but rarely so much as to constitute true pericarditis. Lesions of the pericardium may be either antecedent to, or consequent upon those of the kidneys. The relative dates of these lesions may be often inferred from the history of the case, in connexion with their ap- pearances upon dissection. There can be no doubt that, when the heart or its valves are diseased, the pericardium becomes more liable to inflammation, or to be the seat of effusion ; and that this liability, more especially to inflam- matory action, is much increased by the renal disease and the morbid state of the blood. Hence old lesions of the pericardium, or recent changes in it, or even both, will occasionally be found after renal dropsy, although they may be detected with difficulty during life, whether they be associated with other cardiac lesions or not. The remarks I offered above (wn, and often contains a portion of blood mixed with it. Generally, a flocculent whitish matter may be seen suspended in it, resembling unclarified whey, or, when there is any admixture of blood in the urine, like the water in which raw meat has been washed. Its specific gravity is more or less below the healthy standard. The ac- tion of the heart is frequently strong or tumult- uous ; the skin is hot, and the breathing is quickened and oppressed. In some cases the head, in others the chest, and in others the ab- domen, is the chief seat of suffering. Such usually is the acute form of the disease as oc- curring consecutively upon scarlatina; but it has occasionally appeared more suddenly, par- ticularly when the patient has been exposed, at or soon after the period of desquamation, to cold and humidity, and it has then, in a few ca- ses, terminated fatally in forty-eight hours after its appearance, from the supervention of coma, or convulsions, or asphyxia. In the chronic state consequent upon scarlatina, there is com- monly little or no fever, and the action of the heart is much less exerted. The symptoms are less severe, and more gradual in their ap- pearance and progress. The urine is deeply coloured, but always albuminous, and of lower density than natural. 136. In the acute form of the disease conse- quent upon scarlatina, vomiting, dilatation of the pupils, slowness and irregularity of the pulse, stupor, coma, paralysis, convulsions, &c., sometimes appear, and indicate a most dangerous affection of the brain, often with se- rous effusion within the ventricles or under the arachnoid. Pulmonary complications are very common in the acute cachectic nephritis fol- lowing scarlatina. These are either inflamma- tion of the bronchi, or of the lungs, or of the pleura ; or serous effusion in the cavities of the pleura or in the pericardium, or oedema of the lungs, these effusions being consequent upon an inflammatory or congested state of these parts, the vessels, owing to the cachectic con- dition of the constitution, and to the states of vital power and of the blood, being incapable of throwing out coagulable lymph, but allowing a liberal discharge of serum. These inflamma- tory complications were frequently observed in the epidemic scarlatina which occurred in Flor- ence in 1717 ; and Borsieri remarks, that the Florentine physicians “ mortuorum cadavera secuerint, inveneruntque pulmones, pleuram, intercostales musculos, diaphragma, rencs, et intestina plus minusque inflammatione correp- ta.” Cachectic inflammation of the kidneys may occur after scarlatina, the urine being al- buminous, a'nd yet no anasarca may take place. Generally, in these cases, there is either a very scanty secretion or an entire suppression of urine, and the patient is more or less sudden- ly carried off by internal congestion, or inflam- mation, or serous effusion, stupor, coma, pa- ralysis, convulsions, or asphyxia ushering in dissolution. The occurrence of this form of nephritis after other fevers, as typhoid, remit- tent, and intermittent fevers, has not hitherto been observed. 137. F. Relations of Cachectic Nephritis to Scrofula.—Most of the instances of this disease that I have observed have been in children and adults of the scrofulous diathesis; and the ex- perience of Bright, Gregory, Christison, Hamilton, and Rayer is to the same effect. Strumous children who are insufficiently cloth- ed and fed, and exposed to cold and humidity, are liable to be affected with this malady; and some of them possessed of this constitution be- come the subjects of this form of nephritis with- out being exposed to these exciting causes ; and, indeed, all the patients who are attacked with it, independently of these causes or of in- temperance, more especially those who are young, present more or less decided evidence of a scrofulous taint, which acts, as shown hereafter (§ 148, 152), both as a predisposing and as an exciting cause. In many of these cases, evidence of anterior scrofulous disease is manifest, while in others scrofulous abscess- es or diseases of the bones coexist with chron- ic cachectic nephritis. 138. G. The connexion of this malady icith the syphilitic taint has been pointed out by M. Ray- er ; and it may be doubted whether or no this connexion is owing to a syphilitic cachexia or to the means which had been employed to cure it, as a liberal or excessive use of mercury. Wells and Blackall ascribed the appearance of dropsy with coagulable urine, in such cases, to this particular cause. In two cases, both professional, but not medical men, this form of nephritis occurred during an advanced stage of their maladies. They both had had severe secondary syphilitic symptoms, for which mer- cury had been employed, and soon afterward tubercular consumption manifested itself. Du- ring the treatment of this latter, the usual signs of cachectic nephritis appeared, and hastened death much sooner that it probably might oth- erwise have taken place. A similar instance is recorded by M. Rayer. 139. H. The connexion of cachectic nephritis with rheumatism has been insisted upon by Dr. Christison, who remarks that, in every in- stance of obstinate chronic rheumatism that 750 KIDNEYS—Cachectic Inflammation of the. comes under his care, he examines the state of the urine as to its coagulability and density. The rheumatic affection which is sometimes thus connected is commonly of the neuralgic kind, and precedes, rather than attends, the dropsical affection. This complication occurs chiefly in those who have been habitually ex- posed to cold and humidity. The connexion of this form of nephritis with gout is compara- tively rare. [Dr. Williams, of London, has recently treat- ed of this affection (The Med. Times, Jan., Feb., 1845, p. 375, &c.) in so able a manner that we think some of his views well worth presenting to the reader. Dr. W. does not regard albu- minaria as purely inflammatory, but places it under the head of congestive diseases of the kidney, affecting the cortical structure. It oc- curs in two forms, acute and chronic ; and that it is the result of congestion simply, Dr. W. thinks is demonstrated by the fact that, in ca- ses of obstructive diseases of the heart, attend- ed with great congestion in the venous circu- lation, the urine becomes albuminous for a time, and the same occurs whenever any febrile af- fection supervenes on this congestive state of the vessels, the albumen disappearing from the urine as this affection is removed or diminished. Hence we often find albuminous urine in con- gestive fevers, and in the paroxysms of fever, and especially in scarlatina, in which there would seem to be a tendency to disease in the kidney itself. Hence it is that Bright’s dis- ease is so often caused by exposure to wet and cold, in persons w'hose kidneys have been pre- viously excited by intoxicating liquors, &c. Here there is a predisposition to congestion of these organs, and the influence of cold, acting on the whole surface, drives the blood inw-ard, and the congestion that ensues interferes with the secreting powers of the kidney, and the se- rum of the blood passes through unchanged, but often coloured by blood, and highly charged with albumen. After noticing the symptoms usually characterizing the acute stage of the disease, as pain and tenderness in the loins, feverishness, and dry state of the skin, thirst, accelerated pulse, nausea, vomiting, and vari- ous nervous symptoms, as delirium or stupor, anasarca, rheumatic pains about the joints, with effusions under the capsules containing some of the constituents of the urine, he pro- ceeds to state that fluxes also occur from the mucous membranes : humid bronchitis is fre- quently present, with diarrhoea, and a variety of symptoms which arise from the retention of urea in the blood, thus poisoning the system, and producing a noxious effect on all the func- tions. These secondary effects, caused by the retention of urea and the other constituents in the blood, differ according to the predisposition of the individual; in some we observe ner- vous derangement, nausea, vomiting, diarrhoea, and flux from the mucous surfaces ; in others, affections of the serous membranes, dropsy, and low inflammations, &c. Owing to a dete- rioration of the red globules, and diminution of the albumen and fibrin, the blood becomes preternaturally thin, hence causing a disposi- tion to effusion into the several tissues. The prevention of the proper excretory function of the kidney thus impairs the healthy condition of the blood, and all the other sequela; and com- plications are owing to this cause. Hence nu- trition is impaired—that function by which the growth of the textures is supplied ; but if it goes on, the nutritive material, from the loss of colouring matter in the blood, is of a low or degraded character, and hence any new depos- ite that takes place presents a less organizable property than in the natural condition, consti- tuting what Dr. Williams calls the cacoplastic exudation. To this cause we trace, in granu- lar degeneration of the kidneys, the deposition of tubercle in the lung ; functional and organic derangements of the liver; atheromatous de- posites in the coals of the blood-vessels, ren- dering them brittle, and liable to rupture, and often leading to apoplexy ; hypertrophy and dilatation of the heart are also occasioned by the same imperfect constitution of the blood, besides a multitude of other changes, as chron- ic diarrhoea, terminating in ulceration of the intestines; chronic dyspepsia, leading to ulcer- ation of the stomach ; and, in short, all the chronic diseases of the system. All these are referred by Dr. W. to a primary diseased state of the kidney, leading to a retention of excre- mentitious matters in the system, which, from their poisonous effects, sometimes occasion coma, stupor, and sudden death. Scrofula, or the tuberculous diathesis, Dr. W. thinks, is one of the causes of granular degeneration, inasmuch as it leads to a degradation of the textures of the whole system. Intemperance, bad diet, and low living are also frequent caus- es of this affection. Its connexion with gout and rheumatism, and chronic diseases of the heart, is too obvious to dwell upon. Conges- tion of the heart from functional disease of the organ will, sooner or later, terminate in struc- tural disease. Owing to the impaired secretion of the kidneys consequent on such congestion, superfluous or morbid matters are retained in the system, and are liable to be deposited in the different organs. In chronic albuminaria, as remarked by our author, the kidneys become contracted and atrophied, owing to a wasting of the texture, as in cirrhosis of the liver. This is occasioned probably by the deposition of the granular matter around the vessels, thus compressing their structure ; and as the ves- sels are pressed upon, the blood is unable to pass through them ; the nutritive supply is thus cut off, and there is a wasting away of the tis- sue, causing a reduction in the bulk of the or- gan in proportion as the disease advances. Owing to the same cause, the quantity of albu- men and urea in the urine is diminished, and the watery portion increased ; there is no room for the solid parts of the urine to pass through, and the watery portion alone is excreted.] 140. iv. Nature of Cachectic or Albumin- ous Nephritis.-r—From what I have already stated with reference to the causes and the associations, or complications of this malady, views as to its nature, and more especially the one entertained by the author, may be readily understood. Hitherto it has not been suffi- ciently considered as a merely secondary dis- ease, all the phenomena in any way connected with it being considered rather as signs and symptoms of its pre-existence, in some one or other of the forms of lesion described above (§ 100, et seq.), than as concomitant changes, many of which depend more upon antecedent KIDNEYS—Cachectic Inflammation of the. 751 disorder than upon the associated or otherwise related affection of the kidneys. The ques- tions, therefore, are : 1st. In what does this pri- mary disorder consist 1 2d. In what manner does the renal malady arise consecutively upon it 1 and, 3d. Wherefore is this consecutive dis- ease so very generally associated with others, in some part of its course 1 What has already been advanced will render it unnecessary to enter upon lengthened details in answering these questions. 141. 1st. The several circumstances con- nected with the origin of the malady—the pre- disposing and the concurring and exciting caus- es ; the existence and the character of antece- dent disorder affecting either the general con- stitution or the functions of some vital organ— all combine in evincing that the earlier morbid states are impaired organic nervous power, and, consequently, insufficient sanguification and assimilation, with disordered secreting and excreting functions. It will necessarily fol- low, even from an early stage, or from a slight grade of these morbid conditions, that the blood will be more or less affected, and that a change in the blood will, according to the na- ture of such change, affect also other organs. 142. 2d. It is difficult to state with any de- gree of precision what are the changes which impaired organic nervous power, and conse- quently weak digestive and assimilative func- tions, will produce in the blood at early stages of their existence ; but, in more prolonged pe- riods of their influence, the results are fre- quently remarkable to the senses, although not so precisely determined by chemical or physi- cal analysis. It is probable, from the results of observation and of analysis as partially em- ployed, and from analogy, that the chyle is not fully elaborated in the first instance, and sub- sequently changed into healthy blood ; that the serum contains more oily or fatty matter than natural, the result of insufficient assimilation ; and that the several constituents of the blood, in relation to each, other and to the system in which they circulate, are held together by a weaker vital affinity. During this state of the organic nervous power and of the circulating fluids, the excretory functions necessarily be- come impaired; and, although those substan- ces which* are the ultimate results of assimila- tion may not be abundantly produced, certain of them, as urea, may be present in excess in the blood, owing to insufficient excretion, es- pecially by the skin and kidneys. The result- ing morbid condition of the blood will thus be- come an exciting cause of vascular disease of the kidneys progressively advancing to organic change ; and, once these important eliminating organs are diseased, the blood will become more and more altered, and sanguification the more impeded or altogether arrested. In all cases, also, both kidneys will be affected ; for as in other diseases, where the causes are con- stitutional, consisting of cachectic states, or of changes in the blood, double organs, or similar- ly constituted tissues, will experience similar, or even identical changes. 143. 3d. The chief reasons for the appear- ance of cachectic nephritis in connexion with other maladies are apparent in the very condi- tion or circumstances of the constitution, and of the health of persons in which it occurs. There is not only the pre-existing impairment of the di- gestive and assimilating powers just insisted upon, but there are also, in many cases, other antecedent maladies, which are always attend- ed by weakness of these functions, as-phthisis, scrofula, scarlet fever, &c., and which readily give rise, especially in certain states of predis- position, to the renal malady as a secondary or more remote effect. In these cases, the associa- ted or related disease is primary, and favours the production of that state of the blood which affects the circulation, and ultimately the struc- ture of the kidneys. Other complications are either associated results of the previous disor- der—are equally with the renal malady effects of the previous changes in the states of organ- ic nervous energy, and of the blood—or they are consequences of the disease of the kidneys, through the medium of the blood, a morbid state of this fluid being much increased by the affection of these organs ; and being such as readily inflames or irritates parts which, from predisposition, former disease, or the influence of concurring causes, or prevailing influences, become more liable to those consecutive affec- tions. 144. The dropsy so generally attending this malady arises from more than one of the path- ological states constituting it. In the acute, or early state of the disease, and especially when it is consequent upon scarlatina, the an- asarca is chiefly owing to the weakened vital affinity subsisting between the constituents of the blood, and to the weakened tone of the ex- treme capillaries. Probably something is also owing to the suppressed functions of the skin : exhalation from the external surface of the in teguments being interrupted, it becomes in- creased into the areolar tissue. The action of the kidneys is also impaired in most of the acute states of the disease ; the watery parts of the blood become excessive ; excrementitial plethora is thus produced, and effusion takes place from the overloaded vessels. In the chronic and far advanced states of the disease, the dropsy is owing chiefly to the change in the blood itself; to its thin and impoverished condition, and to impairment of the vital affin- ity between its several constituents, and be- tween it and the blood-vessels. That the drop- sy is not owing to excess of serum, is shown by its coexistence with a free discharge of urine, and with diarrhoea, and with an aneemic state of the vascular system, in many instan- ces. It may, however, be increased by the sup- pressed perspiratory functions of the skin.* 145. v. Prognosis.—The very serious and dangerous nature of this disease may be in- ferred from what has already been stated re- specting it.—A. In the acute state, death some- * [N. Corrigan makes two distinct varieties of this dis- ease (Land. Med. Times, April 5, 1845), corresponding to the acute and chronic states of Copland and Williams. In the first, he says that “ the kidney becomes larger than natural, of a mottled yellow colour, which gradually spreads over the whole gland, and the lubuli uriniferi extend fur towards the cortical part of the kidney. In the other va- riety, the kidney becomes smaller than in health, the tubuli uriniferi traverse a much greater space through the kidney than in the former, running, in this variety, almost to the capsular covering ; its surface becomes studded with mi- nute tuberosities, which project above the capsule, as if nu- merous grains of small shot were irregularly distributed through, and sunken into, the cortical portion of the kidney ; the two varieties corresponding, in fact, to hypertrophy ■ nd cyrrhosis of the liver.] 752 KIDNEYS—Cachectic Inflammation of the. times takes place suddenly, owing to the rapid development of disease in the brain, lungs, or pericardium. Hence the propriety of attend- ing to the states of these organs as long as the urine continues to be albuminous or sanguino- lent. This form of the disease is less danger- ous when it occurs after scarlatina, or during the early stage of pregnancy, than in other cir- cumstances. The nature of the chief causes should always be considered before a prog- nosis be given in any case ; for when the mal- ady proceeds chiefly from intemperance, the chance of associated visceral disease, although it may not be very manifest, and the danger, are always increased. The prolonged influence of cold humidity, and of low or damp residen- ces, generally occasions a more dangerous mal- ady than the temporary operations of these causes. 146. B. In the chronic form, the prognosis is still more unfavourable than in the acute: a fatal issue may be more remote, but it is more certain ultimately. As long as the urine is coagulable, and of diminished density, the pa- tient is in a most precarious state, from the tendency in these circumstances to dropsy, pleuritis, pericarditis, cerebral affections, and to various other maladies, which assume the most dangerous forms when associated with renal disease. Any marked diminution of the quantity of urine, when it is of morbid com- position, should always be viewed with great suspicion, as often preceding the maladies now mentioned. A still more remarkable dim- inution of the quantity of urine, or its entire suppression, is generally a precursor of a cere- bral attack, and of a fatal issue. The more manifest, also, the cachectic state of the con- stitution, and the more important the affection complicating the renal malady, the more un- favourable does the prognosis necessarily be- come, and still more so when these two cir- cumstances are conjoined in the same case. 147. An increase of the quantity of urine, relatively to the amount of fluid taken, coinci- dently with a diminution of the dropsy and of the albumen in the urine, is generally a favour- able omen ; but, unfortunately, it is not rare to see this change arrested suddenly in the course of a few days, and followed by an increase of all the symptoms. A return of the specific gravity of the urine to the natural state, owing to an increase of the urea and salts naturally existing in it, coincidently with a marked dim- inution of the albumen, is a very favourable circumstance; but it is very rarely observed in the chronic form of the disease. The dimin- ished density, on the other hand, of the urine, is an unfavourable circumstance, more partic- ularly if the quantity voided be not augment- ed. Upon the whole, the prognosis in this form of the disease should depend upon the number and nature of the primary concomi- tant or consecutive affections complicating it, rather than upon its duration and history. Of these affections, some are acute, as cerebral attacks, pneumonia, pericarditis, &c., and speedily fatal; others are chronic, as scrofula, tubercular consumption, organic lesions of the stomach, or of the liver, or of the heart, the syphilitic cachexia, &c., and place the patient in equal, although not in so immediate danger. 148. vi. Remote Causes.—A. The predispo- sing causes of cachectic nephritis are whatever depresses vital power, and tends to render the system cachectic. The scrofulous diathesis and a syphilitic taint, the former especially, fa- vour the operation of the more direct or exci- ting causes. This disease rarely attacks in- fants, or very aged persons ; but it is frequent in children, in the acute form, chiefly as a se- quela of scarlatina, and occasionally in the chronic form in children of the scrofulous di- athesis, both primarily and consecutively upon scarlatina, and upon febrile or other disor- ders. It is most prevalent in cold and humid countries, and in places where spirituous liquors are most indulged in. It occurs more frequent- ly in males than in females, probably in conse- quence of the former being more exposed to its exciting causes ; and it is most prevalent be- tween the ages of twenty and fifty. My own observation fully confirms the following state- ment of Dr. Christison. In the greater pro- portion of cases, he observes, in almost all those of a chronic nature, as well as in a few of the acute, the disease appears to be formed gradually, without any obvious exciting cause, under the influence of some depraved state of the constitution. And even in many of the acute cases, arising apparently in decided ex- posure to cold, the malady has silently origina- ted in some constitutional cause at an earlier period, recent exposure having merely super- added some acute secondary affection, or given an acute character to pre-existing essential symptoms. It is clear, too, from the character of the disease in the generality of instances, as well as from the very peculiar nature of the morbid deposition in all, that there must al- ways coexist some constitutional infirmity, or otherwise some essential predisposing cause. This circumstance, however, does not exclude from the disease the constitutions of the robust and athletic. Dr. Christison has several times witnessed it in persons of robust habit and pow- erful frame; and M. Solon makes the same remark as to his experience. But a robust frame is not incompatible with infirmity of con- stitution in respect of morbid predisposition, as is familiarly exemplified by phthisis. 149. In this country, that state of constitu- tion which results from habits of intemperance is the most influential in predisposing to the disease. Dr. Christison remarks, that from three fourths to four fifths of the cases he has met with in Edinburgh have been in persons who were habitual drunkards ; or who, without deserving this appellation, are in the constant practice of using ardent spirits several times in the course of the day, and of occasionally in- dulging to intoxication. In these persons, this habit is both a predisposing and an exciting cause, no other remote cause concurring to develop the morbid conditions constituting the disease. In most of the cases that thus ori- ginate, we find both tubercular liver and gran- ulated kidneys, and the resemblance between both kinds of lesion is very close. In many, however, of the cases which appear thus to ori- ginate, it will be found upon a strict examina- tion—upon inquiring into their previous states of health, their hereditary predispositions, their apparent diathesis, and the evidences of either external or internal pre-existent affections— that they present more or less conclusive KIDNEYS—Cachectic Inflammation of the. 753 proofs of the scrofulous constitution ; habits of intemperance, and various other concurring or exciting causes, chiefly aiding this condition in originating the disease. The frequency of its occurrence in persons who have had enlarged or inflamed glands, or have presented other evi- dence of scrofulous or tubercular affections in early life, and in persons labouring under tuber- cular consumption, is an additional proof of the truth of this inference. Among this class of causes, intemperance in sexual indulgence and manustupration may be added.* 150. Previous disease of the digestive, as- similating, and circulating organs of the stom- ach, liver, lungs, and heart—tubercular forma- tions, and continued and eruptive fevers, more especially scarlatina—favour more or less the occurrence of this malady. In many instances scarlet fever both predisposes to and more di- rectly occasions it; no other causes but this being apparently concerned in producing it. 151. B. Exciting Causes.—a. Exposure to cold and humidity, or to either singly, and whatever has the effect of suddenly checking perspiration, as drinking cold fluids when the skin is perspi- ring, are the most frequent causes of the acute state of the disease; which most frequently occurs in persons who are most exposed, by occupation, to those causes and to vicissitudes of temperature, or who live in cold and damp cellars or localities. These causes also often co-operate with others, not only in originating the malady, but also in producing relapses or exacerbations. They frequently, even in their slighter grades, are more or less influential in developing the disease after scarlatina, espe- cially during or soon after the period of desqua- mation. 152. b. The chronic form of the disease is generally occasioned either by intemperance or by the prolonged influence of cold, humidity, and low, damp residences, or by both classes of causes. M. Rayer considers cold and damp the most frequent cause of the disease in France. Poor, innutritious, or unwholesome food, phys- ical misery and destitution, are also influential in producing it. The inordinate or liberal use of mercury was considered by Dr. Wells and Dr. Blackall to be occasionally productive of albuminous urine; but Dr. Rayer has met with no proof of this effect of- mercury. He states that pregnancy seems to give rise to an albu- minous state of the urine. I have seen two instances of this change in the urine in preg- nant females, but had no opportunity of ascer- taining the results in these cases. The pre-ex- isting diseases which seem to be most influential in exciting, as well as in predisposing to cachec- tic nephritis, are scrofula, scarlatina, disorder of the functions of digestion and assimilation, diseases of the lungs, of the heart, and of the liver, and the syphilitic taint. It appears in the advanced course of tubercular consumption in a very large proportion of cases, and is always the consecutive affection, as remarked by M. Solon and Dr. Christison ; but this connexion of the disease is more fully insisted upon above ($ 125). 153. vii. Treatment.—The treatment of this disease should depend much upon the form it assumes, upon its stage or duration, upon the causes which have induced it, and upon the complications it presents.—A. In the acute form and early stage of the disease, the treatment should be decidedly antiphlogistic, but yet with strict reference to the predisposing and exciting causes. —■ a. Blood-letting, general or local, is always necessary, especially at the commence- ment of the disease ; and it should be carried to an amount which the circumstances of the patient and the degree of febrile action will sug- gest. In the majority of cases, cupping on the loins is the most appropriate method of vascu- lar depletion ; but, in the most acute states, and in more robust persons, a general blood- letting should be premised ; and, in these, cup- ping on the loins may be even repeated in some instances. In children, after scarlatina, cupping should be the chief or only mode of depletion. 154. When the anasarca is great, vencesection should be practised with caution, as respects this operation itself; for, although there is a necessity for blood-letting, there is a great tendency to inflammation of the vein, if the in- cision be imperfectly closed, or exposed to the air. It is chiefly in the febrile, acute, and early stage of the disease, that vascular depletion can be employed with advantage, and especially when the disease is caused by exposure to cold and humidity. When acute or sub-aoute symp- toms appear in the course of the chronic form of the malady, even local depletions should be practised with caution ; the previous and pres- ent states of the disease, the complications, and the constitutional and vascular conditions being the only guides by which the practice ought to be directed. In most cases, cupping is a preferable mode of depletion to the appli- cation of leeches, inasmuch as the quantity and state of the blood drawn are more accu- rately ascertained by the former, and erysipelas is less likely to follow it than the latter. 155. b. In the acute and early stage of the malady, the warm or vapour bath may he em- ployed, and be aided by warm bed-clothes, so as to promote the cutaneous transpiration. Diaphoretics may also be prescribed ; and their operation may be assisted by warm diluents, demulcents, &c., containing small quantities of nitre, or the spirits of nitric ether. If the patient leave his bed, especially if the season be cold, the clothing should be warm, and he ought to wear flannel from head to foot, and avoid currents of cold air and stimulant bever- ages. 156. c. Purgatives are always requisite, and the more so when the dropsical effusion is great. They ought to be exhibited at the com- mencement of the treatment, and instantly after the first blood-letting. The selection of purga- tives should be guided by the complications, by the form and amount of the dropsy, and by the state of the urine. The compound jalap pow- der, elaterium, gamboge, the more common purgative pills (see Appendix), the saline aperi- ents, &c., may be prescribed according to cir- cumstances, and to the states of the stomach and bowels. When vomiting, or much irrita- bility of stomach is present, blood-letting, as just advised, will often allay this symptom, and prepare for the exhibition of purgatives, which * [Alcoholic liquors, we believe, are by far the most fre- quent cause of this disease in the United States; indeed, among the many cases we have seen in hospital, dispensary, and private practice, in adhlts, we recollect none in which stimulant drinks have not been freely used.] 754 KIDNEYS—Cachectic Inflammation of the. may be conjoined with colchicum ; but if this symptom continue, creasote or the hydrocyanic acid will generally allay it. Dr. Prout remarks that, when the more active symptoms have subsided, the purgatives may be associated with diuretics ; or the diuretics may be given alone, as the case may indicate. Of diuretics, the nitrate, tartrate, or super-tartrate of potash, conjoined with nitre and the spiritus aetheris nitrici, are among the best, and may constitute a part, at least, of the prescription. Blisters are doubtful remedies ; though, if not kept ap- plied too long, they may be sometimes useful. But strong mustard poultices, or other irri- tants producing speedy and decided effects, are preferable. When diarrhoea accompanies this state or stage of the disease, warm baths, small doses of opium, or of Dover’s powder, and leeches* applied to the perinaeum or anus, are the most beneficial remedies. 157. When the urine has assumed its usual quantity and properties, we may conclude that the acute state has subsided; though the urine will be found to contain more or less serum for a considerable time subsequent to the attack, particularly after meals. In the latter stages, purgatives must be given with caution ; but di- uretics are occasionally required to the last; and warm baths are often of service, particu- larly when they are used by the bedside of the patient, and shortly before the hour of repose. If, after a week or two, the quantity of albumen in the urine again become increased, and if other signs of a recrudescence of the renal dis- ease be present, cupping on the loins should be repeated, and this may be followed by the ap- plication of external irritants, and these by emollient cataplasms in the same situation. During the acute stage of the disease, the diet and regimen should be antiphlogistic. M. Rayer states that he has found a milk diet, continued for some days after the subsidence of the acute symptoms, of great service. 158. B. Treatment of the Chronic Form.— While the treatment of the acute disease is simple, that of the chronic is difficult and com- plex ; and while it is often efficacious in the former, it is generally ineffectual in the latter. In the majority of cases, all that we can hope to effect is, to arrest or suspend the morbid ac- tion ; a complete cure is hardly within our reach. The treatment, nevertheless, should embrace the various considerations suggested by the states of the urine and kidneys, by the attendant dropsy, by the constitution of the patient, and by the antecedent disorder and present complications. 159. a. Whenever there is reason to suspect the existence of active congestion of the kid- neys, either from a feverish state of the system or from local uneasiness, cupping on the loins may be resorted to ; but we should be careful not to employ too large depletions, more espe- cially when the renal malady has been prolonged and is far advanced, or structural lesion very serious. Great mischief will be done by low- ering the powers of life in these circumstances, and the local change will be increased rather than diminished by the depletion. Unless at a very early stage of the chronic malady, the morbid state of the blood, and even its deficien- cy, forbid the abstraction of it unless in small or moderate quantity, when the supervention of acute or sub-acute symptoms, or of inflam- matory attacks of other organs, as of the pleu- ra or lungs, demands a recourse to this meas- ure ; for the occurrence of these attacks during the course of the renal disease is the conse- quence of the attendant state of the blood chief- ly, and not of the lesion of the kidneys per se—a state of the blood which generally contra-indi- cates vascular depletion, although the nature of the complication may seem to require it. The circumstances which more especially should suggest great caution in prescribing even local depletion are, debility and a manifest cachectic appearance consequent upon previous ill health, or a chronic continuance of the renal disease. The coexistence of chronic incurable maladies, as tubercular phthisis, lesions of the heart and valves, particularly insufficiency of the valves, organic changes in the stomach, altogether con- tra-indicates a recourse to general or local blood-letting. 160. h. In the chronic as well as in the acute form of the malady, warm or vapour baths, flannel clothing next the skin, and the avoid- ance of cold, humidity, spirituous liquors, and other exciting causes, are requisite. M. Rav- er states that he has found setons, issues, and other exutories in the loins very advantageous ; and that from four to twelve drops of the tinc- ture of cantharides, given for a dose in some emulsion, have also been of service. I have given equal quantities of this tincture with the tincture of the sesqui-chloride of iron, with marked benefit, in a few instances. Ioduretted and mercurial ointments have been prescribed to the loins without any service ; and the bal- sams have been taken internally wTith little or no advantage. 161. c. In the more advanced states of the disease, the preparations of iron, judiciously chosen, and combined with other medicines, are often more or less beneficial. I have seen more advantage derived from them than from any other class of medicines. The circumstances of particular cases can alone suggest those preparations which should be selected. When the dropsical effusion indicates a recourse to hydrogogue cathartics or to diuretics, some preparation of iron should be added, particular- ly when debility or cachexia is very manifest. 162. d. Of all diuretics, M. Rayer prefers a decoction of the wild horseradish. It may be made a vehicle for other medicines. He agrees, however, with Dr. Bright in having little con- fidence in the most of diuretic remedies, and thinks that Dr. Christison has overrated their value. In this disease, many substances disor- der the stomach, thereby farther impair diges- tion and assimilation, and accelerate its unfa- vourable progress. Many diaphoretics, partic- ularly when given in full doses, have this effect, as Dover’s and James’s powders. The decoc- tion or tincture of guaiacum is the best of this class of medicines, especially when the skin is cool as well as dry. Diaphoretics, diuretics, and purgatives or aperients, when clearly indi- cated, should be selected and conjoined with strict reference to the states of the digestive organs, of the vital powers, and of the circu- lating fluids, as shown in preceding sections. It is chiefly owing to a neglect of such refer- ence that an injudicious recourse to punctures of the skin has been had in this disease, in or- KIDNEYS—Cachectic Inflammation of the. 755 der to allow the escape of the effused fluid. The states of the system just alluded to favour the occurrence of inflammation and consequent gangrene of the punctured parts. Dr. Prout advises a recourse to a seton or issue in the region of the kidneys, and to the infusion of diosma with sarsaparilla. As a diaphoretic he prefers the citrate of ammonia, and, as the dis- ease proceeds, the pareira brava, or the uva ursi, combined with other medicines, according to the circumstances of the case. 163. C. The treatment of the complications of cachectic nephritis is always difficult and often hopeless. When they assume an acute form, they must be promptly met, and subdued or ar- rested within twenty-four hours from their ap- pearance. If they are of a chronic kind, we can expect only to palliate the more urgent symptoms. Of the diseases which are associated with the renal malady, it will be necessary to notice the treatment only of a few; for the means which are appropriate to the rest are either so manifest, or depend so entirely upon the circumstances of individual cases, that the physician will readily perceive them, and apply them accordingly. 164. a. In relation to diseases of the digest- ive organs (<$ 114), the treatment of cachectic nephritis requires the utmost attention to diet and regimen. The food should consist of arti- cles which are the most readily assimilated, es- pecially of the lighter kinds of animal food, and of milk boiled with farinaceous substances. The bitter tonics, sarsaparilla with liquor po- tassae, or lime-water, or with Brandish’s alka- line solution, and other restoratives, are espe- cially necessary when the dyspeptic affection is attended by acidity and flatulence. In these as well as in other circumstances, the prepara- tions of iron, but especially the Mist. Ferri Composita, are also beneficial, and should be taken for a considerable time. When irrita- bility of stomach or vomiting is present, creo- sote, with or without opium, is a valuable med- icine. Whea the bowels are also irritable, opium or morphia may be combined with crea- sote with advantage; but, in other cases, the latter may be given with bitters and aromatics. Hydrocyanic acid may also be prescribed in sim- ilar combinations. If diarrhoea be present, opium, cretaceous mixtures or powders, lime- water, and aromatics, are requisite. In either of these affections, also, embrocations or fo- mentations may be applied over the epigastrium and abdomen, consisting chiefly of rubefacient and diseutient substances, as the turpentine embrocation, &c. In the more obstinate eases of diarrhoea, the sulphate of zinc or of copper, or the nitrate of silver, or the acetate of lead, may be given with opium, &c. If peritonitis supervene, vascular depletion ought to be promptly prescribed; but with the knowledge that in most states of the disease, and in the more advanced stages especially, the loss of blood is not attended by much advantage. This is particularly the case if the dropsical effusion is considerable, and leucophlegmasia or ca- chexia manifest. The peritonitis, in these cir- cumstances, is most successfully combated by fomentations with warm turpentine applied over the abdomen, and by opium with camphor ta- ken internally. Lesions of the liver or spleen, even when recognised, are hardly influenced by medicine, when associated with this mala- dy. The exact nature of the hepatic lesion frequently cannot be ascertained during life ; and, if correctly inferred, the most appropriate treatment is neither manifest nor generally beneficial. In these, as well as in other unfa- vourable complications, the chief indication is to support the powers of life by attention to diet, by residing in a dry and warm air, by ta- king gentle restoratives with alteratives, and by attending to the alvine excretions. 165. b. The associations of this disease with affections of the respiratory passages and lungs require the most cautious use of the remedies usually prescribed for either the former or the latter; and those which are most serviceable for the one are most injurious for the other. —a. Bronchitis is generally extended to both lungs; and, although it may be slight for a time, it may be suddenly aggravated so as speedily to terminate life. In most cases, the treatment advised for the more asthenic states of Bronchitis 81, et seq.) should be prescri- bed.—(3. Pneumonia, also, when it occurs, gen- erally affects both lungs, and is often of the kind usually denominated asthenic or nervous. Un- less in the earlier stages of the nephritic disease, and in the more robust subjects, vascular deple- tions are seldom beneficial in these complica- tions. A free use of tartar emetic, aided by ex- ternal derivation, is much more deserving of confidence, especially in pneumonia, than deple- tions ; but all means often fail in these cases. —y. The same- remarks are applicable to pleu- ritis, when it appears in the course of this mal- ady. The disposition to effusion requires the prompt use of suitable means ; but these means are not the same as are generally found ser- viceable in the early stages of common pleuri- sy. Blood-letting and mercury must be spa- ringly, cautiously, or not at all prescribed; while the repeated application of blisters, of the turpentine fomentation, &c., and a recourse to the hydriodate of potash internally, with oth- er means suggested by circumstances, are most to be depended upon.—ut this subject is more fully discussed in the article on Scarlet Fever. 169. /. The treatment of the other associations of Cachectic nephritis mentioned above hardly requires farther remark. When the disease is very obviously complicated with scrofula, and particularly with scrofulous abscesses or ul- cerations, the Mistura Ferri Composita, liquor potasste, with small doses of the iodide of po- tassium, sarsaparilla, the iodide of iron, &c., and other restorative remedies, with change of air, or change to a dry and warm atmosphere, and attention to the digestive, assimilating, and excreting functions, are most deserving of at- tention. The frequent occurrence of the dis- ease in the scrofulous diathesis indicates the propriety of having recourse to the same means as have been found most beneficial in scrofu- lous affections. The appearance of cachectic nephritis during secondary syphilis (<) 138), or consequent upon it, although occasionally oh- served, has not been satisfactorily elucilated; inasmuch as it is not proved whether or not the renal disease is a consequence of syphilis, or of the inordinate use of mercury in the treat- ment of it. The two cases alluded to above ($ 138) occurred in scrofulous constitutions ; mercury was largely employed ; the secondary symptoms became aggravated, phthisis super- vened, and in this state they came under my care. Hydriodate of potash with sarsaparilla was then prescribed, and, during the use of it, and in an advanced state of the pulmonary dis- ease, albuminous urine and anasarca appeared. These cases prove only the tendency of this disease to appear whenever a state of general cachexia is produced by causes depressing vi- tal power, and impairing the assimilating pro- cesses so as to overturn the healthy crasis or constitution of the blood. I have never met with an instance of this disease connected with rheumatism, unless where the treatment has been of a lowering kind ; and in this complica- tion the preparations of iron, quinine, and cam- phor have been generally prescribed with greater benefit than any other medicines. I have generally preferred the following, or sim- ilar combinations: No. 283. It Ferri sulphatis ; Quinise sulphatis, &5 3j.; Camphor* rasse, 3ss.; Extract. Aloes purif., 3j.; Extr. IIu- muli (vel Extr. Hyoscyami), 3ij.; Mucilag. Acacia;, q. s. 31. Contunde bene et divide in Pilulas xxxvj. quarum ca- piat duas vel tres, bis terve quotidie. [The treatment of acute alhuminaria, accord- ing to Williams {loc. cit.), consists of four in- dications. The first indication is, to remove the congestion ; the second, to restore the se- creting function of the kidney; the third, tc counteract the effects of the diseased state of the blood ; and the fourth and last, to treat the various symptoms of disease that may arise out of this disordered condition of the blood. The first indication will be effected by the rem- edies for congestion, especially blood-letting and cupping at the loins. This remedy should be employed freely, in proportion to the strength of the patient and the fulness of the blood-ves- sels. This is to be aided by derivatives. Hydra- gogue purgatives tend to diminish the amount of blood in the system, and to drive out its watery parts. One of the best of these is cream of tartar, or combined with jalap, but in its gen- eral effect it is better alone; or half an ounce of it may be combined with half a grain of ela- terium, unless the latter prove too nauseating. The indication of derivation may be powerfully aided by sudorifics, by warm or vapour baths, and by the hot air bath. Where the circulation is excited, antimony, with Dover’s powder, for the purpose of increasing the cutaneous secre- tion, will prove useful after active congestion has been relieved. Diuretics will be proper: among the best of these are the tinctures of digitalis and cantharides, super-tartrate of po- tass in small doses, combined with opium, or hyoscyamus, to obviate any irritating effects they might otherwise produce. In the early stage of congestion, there is no doubt that diu- retics are liable to do much harm, from a ten- dency to excite inflammation in the kidneys; cupping over the loins, combined wfith strong counter-irritation, as recommended by our au- thor, are highly useful, and they should be con- tinued until the urine loses its albuminous de- position, when they may be withdrawn. We KIDNEYS—Inflammation of Pelvis, &c., of the. 757 are, as yet, but little acquainted with the best means of counteracting the effects of diseased blood, though there can be but little doubt that hydragogue cathartics do this by expelling urea. It has been ingeniously suggested whether mat- ters containing oxygen in excess will have any influence in this respect. The Indian hemp {Apocynum cannabinum), which is a powerful hydragogue cathartic and diuretic, has been tried, with considerable advantage, in the New- York hospital, in these cases, in the form of decoction and extract. We have known such positive benefits result from its use in the treatment of this disease, that we think it well worthy of farther trials. The greatest disad- vantage attending it is the extreme uncertain- ty of its effects -, but these, we think, may be partially obviated by greater care in gathering and preserving it. A portion of its activity depends on a volatile oil, which escapes by drying and long exposure to the air. The troublesome symptoms attending the acute form of this affection are to be combated in the usual manner—vomiting by effervescing potions, or mustard to the epigastrium; diar- rhoea, by astringents, as the sulphates of zinc and copper or acetate of lead; bronchitis by blisters, opium, &c. ; dropsical accumulations by hydragogue purgatives and diuretics. Per- haps, however, there is no class of remedies more decidedly useful in the treatment of this affection, and all its complications, than diaph- oretics. The patient is to be kept warm in bed, and a gentle diaphoresis kept up for a con- siderable time by external warmth and mild diluents, and under this course we often find a decided improvement both in the quality and quantity of the urine, independent of other means. Dr. Osborne even assures us that, in treating of this disease, he found that “ when- ever general perspiration came on, either spon- taneously, or in consequence of medicine, the eases always terminated favourably.” In ad- dition to the diaphoretic remedies already men- tioned, we may name the acetate of ammonia, carbonate of ammonia, with camphorated mix- ture, and the ammoniated tincture of guaiacum. We are inclined to believe, with Corrigan, that when the disease has arrived at that stage which this writer terms cirrhosis of the kidney, it is nearly, if not altogether, incurable. Dr. Williams recommends in this form cupping at the loins, and hydragogue purgatives, repeated from time to time, according as the strength of the patient will bear, together with external counter-irritants, warm, vapour, and hot air baths, warm clothing, &c. Croton oil, or the Emp. tart, ant., forms the best mode of exciting counter-irritation. In addition to the diuretics already mentioned, we think the iodide of po- tassium one of the best. Tonics we regard as indispensable, for* by improving the general health, we increase the tonicity of the relaxed vessels of the kidney. The best of this class of remedies are quinine, nitric acid, combined with cascarilla, pareira brava, diosma, or uva ursi, iodide of potassium, sarsaparilla, and espe- cially the persesquinitrate of iron. The bowels are to be kept free, and all aggravating causes avoided, such as cold, considerable exertion, irregularities of diet, use of stimulating drinks, mental depression, &c. Mercury is regarded by many as a hazardous remedy in every form of this disease. Dr. Bell, however, of Phila- delphia (Bell and Stokes' Pract., vol. i., p. 599), states that, “ as a purgative either alone, and followed by castor oil, or rhubarb and magne- sia, or combined with jalap or rhubarb, it is en- titled to a preference over most of the class. In the first mode, it is particularly useful where diarrhoea is present, a complication contra-indi- cating resinous or irritating purgatives. In smaller doses, as of one or two grains, or an equivalent proportion of blue mass, I know of no medicine, next to antimony, which acts generally so well on the skin, by rendering it soft and moist, certainly none which acts so kindly on an inflamed or irritated kidney One of the peculiar advantages of these mercurial preparations is their ready and tranquillizing operation on inflamed secretory glands and surfaces. My own experience makes me as confident of the propriety of administering cal- omel or blue mass after venEesection, for an ex- cited kidney, whose secretory function is impe- ded, as I would be of its use in a similar condi- tion of the liver.” Where bronchitis is asso- ciated with granular disease of the kidney, Dr. Bell also states, that he knows no adequate substitute for the calomel. So far as we have observed, our experience in the use of this ar- ticle coincides with that of Dr. Bell. It should, however, be recollected that salivation is easi- ly induced in this disease, and, when brought on, produces highly injurious effects.] 170. III. Inflammation of the Pelvis and CAlices of the Kidney. — Synon. Pyelitis (from nvehoc, pelvis).—Pyelite, Rayek.—Pyeli- tis, Prout. 171. Inflammation of the mucous membrane lining the pelvis and calices of the kidneys is distinct from the species of nephritis already described, no-t only in its seat, but also in its symptoms and consequences. It sometimes assumes an acute form, but more frequently a sub-acute or chronic state. It may affect the pel- vis and calices of only one kidney or of both; and it may be limited to a portion only of their surface, or extended to several calices. 172. i. Symptoms.—Pyelitis assumes varied states, according to its grade of activity, its causes, and other circumstances. It sometimes attends or supervenes upon catarrhus vesica, or inflammation of the mucous surface of the blad- der ; and it sometimes even follows gonorrhoea, especially when suddenly checked by astringent injections, and retentions of urine from strictures or other causes. But it occurs in its most def- inite and best marked form when it proceeds from the irritation of sabulous or calculous mat- ters in the excretory portion of the kidneys, or is connected with the oxalic acid diathesis. It is occasionally, also, connected with certain cutaneous affections remotely allied to syphilis. 173. A. When pyelitis supervenes upon ca- tarrhus vesica, or upon gonorrhoea, the symp- toms are usually uneasiness, or more or less pain and sense of heat in the loins, attended by low febrile action, sympathetic irritation of the testicles, and sometimes by nausea, particular- ly when the secretion of mucus or muco-puri- form matter is unusually large. If the inflam- mation of the mucous surface of the bladder still continue, the symptoms referable to this viscus predominate, and often mask those more immediately connected with the kidneys. In 758 KIDNEYS—Inflammation of Pelvis, &c., of the. all cases the symptoms should be examined in connexion with the states of the urine. 174. B. When pyelitis arises from the irri- tation of calculous or sabulous substances in the excretory portion of the kidneys, the symptoms vary with the constitution and age of the pa- tient, and with the nature, and form, and situa- tion of those substances. When a calculus or calculi are situated so as not to obstruct the passage of urine from the organ, the inflamma- tion is frequently slight and limited in extent. But when it is large, and is situated at the out- let of the pelvis, or at or in the commencement of the ureter, so as to obstruct more or less, or entirely to close this opening, the parts above the obstruction generally become inflamed throughout, and distended by urine, mixed with mucus, and often with puriform matter and blood. In these cases, the kidney is greatly increased in bulk, and the local and general symptoms aggravated. 175. Pyelitis from calculi may be slight, and not exceed a state of irritation not amounting to that grade of inflammation developing gen- eral febrile reaction. In such cases, the grav- elly matters pass from the calices into the pel- vis, and thence, by the ureters, into the blad- der, occasioning only more or less pain in their transit. But when the calculi, from their size, sharpness, or roughness, irritate greatly these parts, or cannot readily pass along them, in- flammatory action, with more or less severe symptoms, is produced. 176. a. In the more acute cases, a sharp, severe, or lancinating pain is felt in the region of ei- ther kidney, descending thence, in the course of the ureter, to the bladder, attended by chills or rigours more or less marked. The urine is scanty, voided by drops, with a sense of heat, sometimes with gravelly matter and a small quantity of blood. The pulse, at first small and oppressed, becomes developed and more frequent, and febrile action supervenes, espe- cially after nausea and vomiting have occurred. If the calculus or gravel is not voided in the course of the following two or three days, the symptoms continue ; and if it does not entirely shut up the passage to the bladder, and if only one kidney is thus affected, the urine always contains some mucus and blood. On cooling, the mucus appears in the urine in the form of flocculi, which afterward fall to the bottom of the vessel, and the blood globules, when pres- ent, form a slight layer on the surface of the sediment. All these symptoms may quickly cease when the calculus has passed into the bladder, and the urine becomes natural. 177. b. When calculi remain in the calices or pelvis for a considerable time, the inflamma- tion becomes chronic, and the pain ceases to be acute. The patient complains chiefly of unea- siness or of weight in the region of either kid- ney ; but pain, sometimes obtuse, at other times sharp, occurs upon a sudden effort, or unusual movement of the trunk, or when riding either in a carriage or on horseback, and the pain generally extends to the bladder and the course of the ureters, and to the testes and limb corresponding with the affected organ. Numbness as well as pain of the limb is often also felt. Decubitis on the abdomen, or on the side opposite the affected organ, where one only is affected, straining at stool, coughing, sneezing, a deep inspiration, the warmth of bed, &c., generally augment the pain ; which, how- ever, may be slight, although several calculi are contained in the pelvis and calices. These pains, thus varying in severity and character— being occasionally slight, sometimes colicky and severe—frequently are independent of any febrile action ; but they are usually attended by retraction of the testes, and by a reddish, scanty, and mucous state of the urine, which is slightly coagulable by heat. Sometimes the urine is sanguinolent ; at other times it is per- fectly transparent, particularly after diluents and demulcents have been freely used. These different states of the urine may be observed in the same person in the course of twenty- four hours. Upon cooling, uric acid, or the salts, are deposited with the blood and mucus, these latter forming the surface of the sedi- ment. 178. When the gravel consists of uric acid, as is most frequently the case, the urine is acid, and the sediment contains rhomboidal crystals of a yellowish-red colour. When it consists of the phosphates, the urine is alkaline and tur- bid at the time of emission. Dr. Prout ob- serves, that when the concretion is litliic acid, the quantity of mucus in the urine, though con- siderable, is not so striking and characteristic as it sometimes is when it consists of the oxa- late of lime. This arises partly, perhaps, from the diminished quantity of mucus secreted, and partly from the quantity of lithate of ammonia and other matters usually present, which in- volve and conceal it. Where the calculus is oxalate of lime, the mucus is sometimes void- ed in large, transparent, greenish gelatinous masses of considerable tenacity, which occa- sionally, in passing dowm the ureter, excite all the acute symptoms. When the renal concre- tion consists of phosphate of lime, the symp- toms are much the same, and the mucus often contains the earthy matter intermixed with it in considerable quantity. 179. c. At a more advanced stage of chronic pyelitis from calculous concretions, irregular chills or rigours occur, especially towards night, or after a meal, and various morbid sensations are felt in the loins—as of pulsation, of tension, of numbness, and even of cold—which often extend down the corresponding thigh. The urine is sometimes sanguinolent, but oftener turbid and whitish, allowing a puriform and white, or slightly greenish-white, sediment to fall, consisting chiefly of pus and urinal salts. The discharge of blood in the urine is occa- sionally the first remarkable symptom, espe- cially w’hen the pelves of both kidneys contain calculi. Subsequently the urine becomes tur- bid and puriform, and passes frequently and in small quantity, with or without sabulous mat- ter in it. In the course of the disease, the pa- tient experiences exacerbations, characterized by more acute symptoms, by vomiting, and fever. 180. The urine is usually bloody or purulent every time that it is voided, unless one kidney only is affected, and the secretion from the diseased one is partially or entirely interrupted. Great variations, however, both in the frequen- cy of the calls to pass the urine, and in the physical and chemical characters of it, are ob- servable. When purulent urine coming from the inflamed pelvis of a kidney is retained only KIDNEYS—Pyelitis—Diagnosis. 759 partially in its cavity, it is mixed in variable proportions with the urine from the other kid- ney, which may be then perfectly healthy. Hence the urine may, in the course of the same day, be different in appearance at different times —it may be charged with pus or blood, or with both, at one hour, and be clear and healthy at another hour. The urine, therefore, should be frequently inspected. In some cases, M. Ray- er states, the suspension for a time of the un- healthy urine is accompanied with an aggrava- tion of the renal distress, and with a febrile state of the system, probably in consequence of the ureter of the aflected organ becoming obstructed, and the urine therefore accumula- ting in its pelvis. The symptoms usually sub- side when the urine exhibits a purulent admix- ture. When this fluid is at all purulent, it is found also albuminous ; the amount, however, of the coagulum produced by heat or nitric acid is by no means proportionate to the quantity of purulent matter in it. 181. d. When chronic pyelitis has existed for a long time, and the excretion of urine along the ureter is much obstructed either by the presence of a calculus in it or in the pelvis, or by any other cause, a swelling may sometimes be distinctly felt in the lumbar region, the swelling occasionally evincing an obscure fluc- tuation, and appearing irregular or lobular on examination. This tumour is formed by the accumulation of puriform matter in the cavity of the pelvis and calices of the kidney; and, when very large, is- felt in the corresponding flank, where it may extend from the margins of the ribs to the iliac fossa. M. Rayer has seen tumours formed by purulent matter dis- tending the pelves and calices of the kidneys weighing as much as from ten to fifty pounds. Owing to the development of such tumours, the lumbar region is more or less swollen, enlarged, and deformed on the affected side. On percus- sion, the swelling emits a dull sound behind, and generally also anteriorly, unless the colon, distended by air, pass before it. When, how- ever, the tumour is large, the colon is general- ly pushed aside by it. The right kidney, when thus distended, sometimes adheres to the mar- gin of the liver, and thus seems, on percussion and palpation, to form one structure with this organ, and is often mistaken for a tumour, or for enlargement of it. Tumour thus formed of the left kidney is not so readily mistaken for enlargement of the spleen, unless the examina- tion is very superficial. When the tumour is very large, it generally seems knotted or lobu- lated, and fluctuation may be perceived in it. Pain is rarely acute in this state, although it may be produced by pressure or succussion of the trunk. 182. e. In a few instances, the mucous mem- brane of the pelvis and calices of the kidney surrounding the calculus becomes thickened, indurated, so as to secrete little or no purulent matter, and these parts form, with the atro- phied substance of the kidney, a sac, or shell, more or less closely surrounding the calculus. If the opposite kidney is healthy, this change may not be even suspected during life, the pa- tient experiencing no pain, and the urine con- taining no pus ; but if disease, calculus, or ob- struction affect the sound organ, suppression of urine and death soon take place. In the less severe and chronic cases of the disease, suppression of urine and death may also occur, especially when both organs are seriously af- fected, or when calculi obstruct both the pelvic outlets or ureters. 183. These several states of pyelitis may be denominated nearly as M. Rayer has named them : 1st. Pyelitis, characterized by sharp pain, or nephritic colic, and suppressed or scanty urine (§ 176, a); 2d. Pyelitis with mucous urine and occasional pain (§ 177, 5); 3d. Pye- litis with purulent urine, and without renal tu- mours (<$ 179, c); 4th. Pyelitis with purulent urine and with renal tumour (depa, pellis, exuvium, or “ Angine Couenneuse," by M. Bretonneau, who wrote on this subject, and confounded this form of an- gina—the “Angina Memhranacea" of the older writers—both with Cynanche Maligna and with Sporadic Croup; and in this he has been fol- lowed by several of his contemporaries. One part of this mistake has arisen from inattention to the characters of the attendant fever, and to the superficial manner in which the local af- fection has been viewed. Attention to the fol- lowing facts will more fully explain the source of this very egregious mistake : a mistake fraught with danger as regards the appropria- tion of the means of cure. 60. Inflammations of the throat frequently occur, both as sporadic and as epidemic diseas- es ; they may be simple, or they may be the chief complication and source of danger in erup- tive fevers. In many instances, and particu- larly when they are epidemic, they are accom- panied with an exudation of lymph on the in- flamed surface ; and whether the inflammation commences in the tonsils and soft palate, or in the pharynx, or whether it assumes a sthenic or an asthenic character, owing to the nature of the constitutional disease of which it is a paid, and the circumstances connected with the patient, it is more or less prone to extend itself through the various passages leading from the pharynx; and when the larynx and epi- glottis thus become affected, the disease then assumes a different and a much more danger- ous character, death sometimes taking place in a few hours. In all cases, when the inflamma- tion extends from the fauces, tonsils, and pha- rynx to the respiratory passages, the local ap- pearances and the character of the attendant fever indicate the nature and tendency of the malady. In some epidemics, and in a few spo- radic cases, both the local appearances and the constitutional affection indicate an acute and sthenic disease, an albuminous exudation, or a firm and continuous coating of albuminous lymph, forming on the inflamed surface, and the attendant fever being inflammatory or sub- inflammatory. 61. In other epidemics, and. even in a few sporadic cases, but more commonly when the affection of the throat accompanies the ady- namic or putro-adynamic or malignant forms oj eruptive fever, the inflamed parts present a dark red, approaching to a brown or livid hue, and the exudations, instead of being pellicular, firm, te- nacious, and whitish, or yellowish white, as in the sthenic form, and adhering firmly to the sur- face, are soft, broken into crusts of an ash col- our, become darker after their formation, and are much more easily detached. In these latter cases the vital powers are depressed, and the circulating fluids deteriorated ; hence their as- I thenic form and rapidly fatal tendency, as ob- served in the more adynamic and malignant states of scarlatina, smallpox, measles, or in certain epidemics, and in rare sporadic cases. (See $ 68.) 62. These forms of angina, which are thus distinct from each other, whether appearing primarily or as a complication of exanthema- tous or of other diseases—whether limited to the throat only or extending to the respiratory passages—have been confounded together by several pathologists. All of them may occur in adults as well as in children, although the latter are most predisposed to them, and es- pecially those of a delicate, scrofulous, and in- flammatory constitution. When the inflam- mation extends to the larynx, many of the symptoms of croup are present; and hence M. Louis described consecutive or complicated laryn- gitis as croup occurring in adults ; and M. Bretonneau gave it the name of “ Diphthe- rile,” because of the albuminous exudation at- tending it, and without reference to the othei local characters, and the form or state of the attending fever: matters of the utmost impor- tance in describing the nature and treatment of anginous affections, particularly when compli- cating the eruptive fevers. 63. Consecutive or complicated sthenic laryngi tis generally commences as above indicated, but the inflammation, instead of advancing from the pharynx to the larynx, may com- mence- in the trachea and extend upward to the larynx, as in some cases of croup ; although this course is much more rare than the other. This form of laryngitis, as it appears either sporadically or epidemically, or as a complica- tion of the more sthenic eruptive fevers, com- monly commences with pain in the throat, dif- ficulty of swallowing, and fever. The tonsils are swollen and red, and present on their sur- faces patches of an opaque whitish concretion. If allowed to proceed, the inflammation and the membranous exudation spread continuously to the soft palate and pharynx, the glands at the angles of the jaws begin to swell, and degluti- tion becomes more difficult. Upon detaching the membranous concretion from the inflamed sur- face, the redness is increased in it, and a thick- er concretion is produced on it, that adheres to it more tenaciously than the former one. Fre- quently, some days after the commencement of the attack, the disease becomes milder, less dis- posed to spread, and sometimes ceases altogeth- er without reaching the larynx; but, in most ca- ses, laryngeal symptoms appear at the end of four or five days. A hoarse cough, altered sou nd of the voice, difficult deglutition, and dyspnoea supervene. The breathing soon afterward be- comes laborious, sonorous, and quick, inspira- tion being prolonged, and expiration short and hissing, and the voice extinct. The counte- LARYNX AND TRACHEA—Inflammation of—Asthenic. 789 nance is now pale, leaden, and often livid, par- ticularly during the fits of suffocation which occur, and the pulse small and intermitting. 64. The duration of the disease is various. The morbid action may continue in the ton- sils, palate, and posterior part of the pharynx for six or seven days before it extend to the larynx ; but, after it has reached this part, death may take place in twenty-four or forty- eight hours, either from a paroxysm of suffo- cation, or in the slower mode of asphyxia no- ticed above (<$ 57) as often terminating the more simple form of the disease. In some ca- ses, the laryngeal disease follows more rapidly upon the affection of the throat ; and, in a few, it seems almost coetaneous with this af- fection. In these cases, especially, the inflam- matory action extends not only to the trachea, but frequently also to the larger bronchi, as demonstrated by post-mortem examinations, and as more fully shown in the article Croup ($ 13, 35). 65. Consecutive sthenic laryngitis is some- times a complication of the more sthenic forms of scarlatina, measles, and smallpox, particu- larly in certain epidemics. But when it is thus complicated or associated, it generally as- sumes a less sthenic character, and approach- es, in some cases at least, and especially in the constitutional affection, the asthenic or the next form to be noticed. In these associations the local affection varies considerably, particularly as respects the appearances of the albuminous exudation, which may be scanty, partial, or al- most wanting. (See art. Throat, Diseases of.) 66. b. Asthenic Acute Laryngitis.—This may occur either as a primary and simple disease, or consecutively upon, or as a complication of, another malady. It is comparatively rare in its simple form ; but it is one of the most fre- quent and fatal complications of eruptive fever, It sometimes, also, occurs in the course of other maladies, as will be shown hereafter. 67. a. Simple Asthenic Laryngitis.—Oedema of the Glottis.—CEdeme de la Glotte, Bayi.e.—In simple sthenic laryngitis there is generally more or less swelling of the margins of the la- rynx and epiglottis, owing to submucous infil- tration of serum and lymph; but in the con- secutive form, or that attended by albuminous exudation, such infiltration takes place to a much less extent, this exudation not merely mechanically obstructing the passage, but also irritating and producing spasm of the glottis. In the form of laryngitis now to be considered, the chief alteration which takes place is an in- filtration of serum, and, in some instances, of a sero-puriform fluid, not only in the submucous cellular tissue, but also in the adjoining cellu- lar tissue, or in that at the base of the epiglot- tis and surrounding parts. The disease com- mences with a continued and an increasing impediment to respiration, and with a feeling of fulness and constriction in the larynx, and as if the passage was closed by some foreign body. The voice is at first hoarse, then sharp, stridulous, and hissing, and afterward croupal or extinguished. There is a dry, hoarse, and convulsive cough, with fits of suffocation, caus- ing the utmost agitation and distress. While inspiration is prolonged and difficult, expira- tion is comparatively easy. Deglutition is not materially impeded, and pain, soreness, or ten- derness in the laryngeal region are not much complained of. In some instances, however, these are all more manifest, and considerable fulness or swelling is observed in the region and vicinity of the larynx. The constitutional symptoms are not acute or inflammatory, and fever may be slight or almost absent ; but, as the disease advances, the pulse becomes weak, soft, small, quick, and irregular, and the system betrays imperfect aerification of the blood. In some cases, the attendant disorder is still more decidedly adynamic. The pa- tient makes numerous efforts to expel from the larynx, by forcible expirations, matters which he feels to be a source of uneasiness and of obstruction, and to remove them by fre- quent attempts at deglutition. The fits of cough and suffocation generally terminate by expelling a little glairy mucus, which affords only slight relief. As the disease proceeds, the dyspnoea becomes more permanent, the fits of suffocation more frequent, and the cerebral functions disturbed. At last death takes place in the manner already described (<$ 57). 68. (3. Consecutive or complicated asthenic lar- yngitis occurs during the course of scarlatina, measles, smallpox, erysipelas, low or adynam- ic fevers, and of diffusive inflammation of the cellular substance of the throat. Most com- monly the laryngeal affection is merely an ex- tension of that of the throat, which commences m the tonsils and fauces, extending to the pharynx and larynx, and often, also, to the other passages connected with the pharynx. The local changes vary much with the nature of the primary malady and state of the patient. In some cases, especially in those consequent on angina maligna, there is not only much dif- fused swelling of the parts, but also an ex- udation of soft, dark lymph, which concretes imperfectly into crusts or patches, and these irritate the larynx and epiglottis, especially when they become partially detached. Infiltra- tion of the sub-mucous cellular tissue, with ' swelling and softening, also takes place, the in- filtrated fluid being either serous, sero-puriform, or sero-sanguinolent, or of a dark colour, from the presence of blood globules in it. The col- our of the inflamed parts depends partly upon the character of the infiltrated fluid, upon the state of the lymph thrown out upon the dis- eased surface, and upon the grade of intensity or malignity marking the constitutional as well as the local malady. The affection of the throat in these cases, particularly when it ex- tends to the larynx, is attended by impaired vital cohesion of the mucous and sub-mucous tissues, and by a soft or less tenacious state of the lymph effused on the affected surface, which is, in some cases, membranous, but in others pultaceous, assuming a gangrenous-like appearance, from its colour and softness, and from the odour exhaled. In the more malig- nant cases, the crusts or patches of lymph be- come darker and more foul, owing to the exu- dation of dark blood, or of a bloody ichor from the inflamed surface, when they are being de- tached from it. In this form of the disease, the states of vascular action and tone, and the condition of the blood, which is always more or less altered, prevent the formation of a firm con- cretion on the inflamed surface, and give rise to the morbid and gangrenous-like exudations 790 LARYNX AND TRACHEA—Inflammation of—Chronic. characterizing it, as more fully shown in the articles Scarlet Fever and Throat. 69. When the larynx is consecutively affect- ed in these asthenic or malignant cases, the progress of the disease generally is fatally ac- celerated. The breathing becomes laborious or convulsive; the inspiration difficult and prolonged; the voice croupal, whispering, or suppressed; cough frequent, suffocative, and harsh; the veins of the neck distended ; the throat and laryngeal region tumid or swollen externally, and tender to the touch. In this state, sunken eyes, pallid countenance, dilata- tions of the nostrils, threatened suffocation, restlessness, anxiety, and distress are rapidly followed by a leaden or livid countenance ; by convulsions, especially in children, or by coma and death. In many of these cases, as well as in the more sthenic complications, the morbid action invades the trachea to a greater or less extent, but generally in a much slighter degree. (See art. Croup, Complications of, t) 18.) 70. C. Chronic Laryngitis.—Phthisis La- ryngea.—Under this head have been comprised a number of chronic affections and alterations of the larynx, which are often associated with changes in either the epiglottis or the trachea, or even in both. These affections are fre- quently complicated still farther with other maladies, especially with those of the lungs, and with chronic constitutional diseases. They may be, 1st. Primary, simple, or the chief ail- ment : or, 2d. Consecutive and symptomatic. They are commonly inflammatory at their com- mencement ; although the character of the in- flammation may be either catarrhal, or sthenic, or asthenic, or specific. 71. a. Primary and simple Chronic Laryngitis. —A comparatively slight form of inflammation, or, rather, a state of catarrhal irritation, may af- fect the mucous membrane of the larynx for several weeks, or even for many months, and produce merely hoarseness, a frequent husky cough, scanty mucous expectoration, and a sense of soreness at the top of the windpipe. This affection may be limited to the larynx, or be associated with relaxation of the uvula, or with indications of a similar irritation in the fauces, pharynx, and trachea. It is most com- mon in persons exposed to cold and wet, and in the intemperate, and generally follows a neg- lected catarrh, or repeated catarrhal attacks. This form of chronic inflammatory action may exist for a considerable period without produ- cing farther change than thickening of the mu- cous membrane and submucous tissues ; but it occasionally gives rise to farther changes, es- pecially to ulceration, to softening, to serous or sero-puriform infiltration, and several other le- sions about to be noticed. 72. The more severe states of chronic laryn- gitis may commence in the above catarrhal form ; they may even follow the acute attacks ; but much more frequently they appear with hoarseness, and with a dry, husky cough ; and are considered as catarrhal only, until they are followed by disorganization and serious consti- tutional disturbance. They are thus insidious, not only in their primary and simple forms, but also, as will be noticed hereafter, in their con- secutive and complicated states. The symptoms which require the closest observation are those connected with the voice, the cough, the respi- ration, the sensibility of the part, the physical signs referable to the chest, and the expecto- ration. The voice is variously altered. At first the defect of the voice is apparent only when speaking loud, or when varying the tone ; but it generally becomes more and more crack- ed, until its healthy tone is quite lost. Hoarse- ness is then always present, and is, in the more catarrhal and slight cases, loose, mucous, and deep; but in the more severe and prolonged instances it is commonly stridulous, dry, and squeaking, or whispering. In the worst at- tacks it is more and more affected until it is altogether lost. The cough is, in the early sta- ges, short, dry, and hacking; but in the latter stages, and when the glottis is incapable of be- ing closed, it is loose, continuous, and hawking or peculiar, as noticed by MM. Trousseau and Belloc. The respiration is usually affected sooner or later in the course of the malady. Difficulty of breathing frequently occurs in the night, and on any physical exertion, and is characterized by spasm of the glottis. In pro- portion to the mechanical impediment to the passage of air, and to the degree of oedema of the glottis attending the disease, are the dysp- noea, and the hissing and stridulous noises on respiration, increased. After the dyspnoea be- comes permanent, or amounts to orthopncea, death generally takes place in fifteen or twenty days. The sensibility of the larynx is seldom very acutely affected, although it is always slightly increased. In one half the cases, pain is not much complained of; still it is felt, with a sense of soreness or tenderness when the la- rynx is handled or pressed, or rubbed against the spine. The morbid sensibility of it is evinced chiefly by the effect of cold air upon it, and by the readiness with which cough is excited by this or by other causes. 73. The expectoration is at first scanty and mucous ; but as the disease advances to disor- ganization, or becomes more intense or acute, it is muco-puriform, sanious, or streaked with blood, or even foetid ; occasionally it is adhe- sive and ropy. Purulent expectoration some- times relieves the difficulty of breathing; and when this is observed in connexion with pain and soreness in coughing, and with hoarseness or loss of voice, ulceration may be inferred to have taken place. As the ulceration and dis- organization proceed, dead or ossified portions of the arytenoid and cricoid cartilages, or cal- careous substances formed in the larynx, are sometimes expectorated, and more rarely they fall into the trachea and pass into the bronchi, causing irritation, and consequent inflammation in the parts where they lodge. 74. Difficulty of swallowing is occasionally felt, particularly when the epiglottis is more or less implicated, or when irritation extends to the pharynx. In these, paroxysms of cough and suffocation are induced by the attempts at deglutition, and by portions of the substances taken passing into the glottis. The physical signs indicating either the exemption of the bronchi and lungs from disease, or the exist- ence of disease also in these parts, are much obscured by the impediment to the circulation of air through the larynx, and more dependance may generally be placed upon percussion than upon the respiratory murmurs in evincing this exemption. At almost any period of the prog- LARYNX AND TRACHEA—Inflammation of—Chronic. 791 ress of chronic laryngitis an acute state of in- flammatory action may occur, generally with more or less oedema, or sero-mucous infiltra- tion of the sub-mucous tissues, and terminate the life of the patient in a very short period; and this may take place almost at any stage of the disease, either previously or subsequent to ulceration. In simple or idiopathic chronic laryngitis, death is occasioned either by this oc- currence, or by the paroxysms of orthopncea, caused by spasm in addition to oedema, by dis- ease of the cartilages and other lesions, or bv the suffocative paroxysms induced by the pass- age of matters into the diseased larynx. 75. h. The complicated and consecutive states of chronic laryngitis are very much more com- mon than the primary and simple. The most frequent of these complications is that with tu- bercular phthisis. M. Louis has remarked that upward of one fourth of the cases of this mal- ady were complicated with chronic laryngitis, this latter being the consecutive affection. It may also be associated with chronic tracheitis, with ulceration in the trachea and large bron- chi, and with chronic inflammation of the pha- rynx ; but the association is rarely thus limit ed, being generally extended also to the lungs. When chronic laryngitis extends to the trachea, or when chronic tracheitis extends to the la- rynx, and laryngo-tracheitis is thus present in a chronic form, tenderness and soreness are oft- en felt in the course of the trachea; and, in some instances, I have observed great swelling of the throat along the whole tube; but in all these the lungs were also diseased. This swelling in the course of the trachea arises from the existence of ulceration in the internal surface of the tube, and from the oedema or in- filtration of the cellular tissue external to the cartilaginous rings. 76. The epiglottis may be inflamed and ulcer- ated without the larynx itself being materially affected, although the epiglottis is often impli- cated when the larynx is diseased. M. Louis states, that of eighteen cases of inflammation and ulceration of the epiglottis, the larynx and trachea were free from disease in six. Of these latter, pain, more or less severe, was felt by four in the superior part of the thyroid cartilage, or between this cartilage and the os hyoides. The pain was compared to that of a sore, to a pricking sensation, or to a heat of the part. In some cases it had lasted a month or two, but in others it had occurred but a few days before death. In these ca- ses, although the pharynx was healthy, deg- lutition was difficult, fluids sometimes being thrown back through the nose. The twelve patients who had ulcerations at once in the epiglottis, larynx, and trachea, complained of dysphagia, pain, and occasionally regurgitation of fluids by the nose. 77. It has been shown that simple chronic lar- yngitis is generally attended by great mechan- ical obstruction and stridulous breathing; but when the laryngeal affection is consequent upon, or complicated with pulmonary disease, the obstruction in the larynx is commonly much less, and stridulous breathing is hardly remark- ed. This is owing to the circumstance of pri- mary chronic laryngitis giving rise to more edema, or infiltration of the sub-mucous tis- sues, than laryngitis consecutive upon pulmo- nary tubercles. In this latter the inflammatory irritation and the consequent ulceration is more superficial and less obstructive to respiration than the former. In both acute and chronic laryngitis, the vesicular murmur becomes fee- ble in proportion to the obstruction, as shown first by Dr. Graves and Dr. Stokes ; and in se- vere cases it can hardly be perceived, the fee- bleness or absence of this murmur being equal in all parts of the chest. In order to ascertain the presence of lesions of the lungs in cases of chronic laryngitis, more reliance maybe placed on percussion than on the stethoscope. Where the mechanical obstruction is but slight, as Dr. Stokes remarks, this instrument may be used with exactness; but even in cases where the lung is fully and treely inflated, it will occasion- ally be next to impossible to determine whether the symptoms proceed from laryngeal disease alone, or from its complication with an affection of the lung. 78. The principal fact to be kept in recollec- tion in cases of chronic laryngitis is the very frequent association of pulmonary disease with it, even when the larynx has been the part seem- ingly first attacked. There is no doubt that chronic laryngitis is in some cases first devel- oped, and that the lungs become secondarily affected, particularly where a predisposition to pulmonary disease exists ; and in these espe- cially the susceptibility of the larynx to causes of irritation is much increased ; but both mala- dies may commence simultaneously, and even proceed pari passu, that of the larynx only be- ing manifest, owing to the nature of its organ- ization ; and thus the pulmonary disease may seem to be consecutive, even while it is coeta- neous with the laryngeal, or even primary. The obscuration of the physical signs of pul- monary diseases by laryngeal affections is so great that the former are generally masked by the latter from those who trust chiefly to these signs, to the neglect of those physiological and rational phenomena which generally accompa- ny even the early stages of pulmonary consump- tion, and in which the closely observing physi- cian confides more surely than in the proofs furnished by the stethoscope. It is only in the far-advanced stages of pulmonary tubercles that the physical signs are manifested, when they are complicated with chronic laryngitis, as shown hereafter (§ 86). It may, however, be conclu- ded, that where there are laryngeal cough, mu- co-purulent or purulent expectoration, hoarse- ness or aphonia, semi-stridulous respiration, emaciation, and hectic fever, pulmonary tuber- cles exist in advanced stages, whether they are indicated by the physical signs or not; and this inference is strengthened by the occurrence of night perspirations, irritability of the bowels, incurvation of the finger nails, and various oth- er symptoms. 79. c. Syphilitic Chronic Laryngitis.—Chronic laryngitis sometimes occurs in the course of secondary syphilis, and it then assumes a spe- cific form, soon passes into ulceration, the ul- ceration apparently extending from the tonsils and pharynx by continuity of surface to the la- ryngeal mucous membrane. Hence syphilitic chronic laryngitis is almost always associated with syphilitic inflammation of the tonsils, fau- ces, and pharynx. Mr. Carmichael considers venereal ulceration of the larynx as the conse- 792 LARYNX AND TRACHEA—Inflammation of—Chronic. quence of the phagedenic venereal disease ; and he believes that the ulceration always propa- gates itself at its edges by continuity of surface from the fauces to the pharynx, and thence to the larynx. 80. ii. Appearances after Death.—A. In the acute forms of laryngitis, the lesions observed on dissection vary with the character and com- plications of the disease.—a. In the sthenic and simple forms, the mucous and sub-mucous tis- sues of the larynx are not only red and inject- ed, but also swollen or thickened; and these appearances may be confined chiefly to the la- rynx, or extended to the upper part of the tra- chea. The epiglottis is very red, injected, thick- ened, or swollen and erect. The folds of the glottis, and the cellular tissue extending from the epiglottis to the glottis, are red and swollen from infiltration of serous lymph, or even of pure lymph, patches of which are sometimes found on the mucous surface of the larynx and the inferior surface of the epiglottis. In cases which have not proved very rapidly fatal, a sero-puriform fluid, or even pus, escapes when these parts are divided. Ulceration is more rarely observed. In the complicated state of sthenic laryngitis, or when the disease has been consequent upon inflammation of the throat, with albuminous exudations—or upon angina membranacea—a more or less complete and consistent coating of albuminous lymph is found in the pharynx, the larynx, and, to a greater or less extent, along the trachea; and often, in some degree, also in the large bronchi. The exudation, however, is either scantier, or con- sists of a tenacious or semi-consistent matter in the lower part of the trachea and in the bron- chi. Occasionally, the false membrane formed in the larynx seems to have been partially de- tached, and is loose and ragged, or is altogeth- er removed. The mucous membrane and sub- mucous tissues are red and injected, and fre- quently, also, more or less swollen. 81. h. The asthenic form of laryngitis is at- tended by a serous infiltration of the sub-mu- cous cellular tissues, causing great oedema and swelling of the parts, the mucous membrane itself being but slightly injected. In some ca- ses, the folds of the glottis are so infiltrated with serous or sero-puriform fluid as nearly to close its aperture. In many of these, the epi- glottis is but slightly altered ; but in others, the part close below, or at the root of the epiglot- tis, and at the anterior and upper part of the larynx, are most infiltrated, the former being, in some instances, separated from the latter by the effusion in this situation. In the complica- ted states of asthenic laryngitis, particularly in the associations with scarlet fever, measles, smallpox, erysipelas, or with diffusive inflam- mation of the cellular tissue in the vicinity, the sub-mucous tissues of the larynx and epiglottis are often infiltrated with a dirty, sero-puriform matter, or with a foul serum and lymph, which fills the ventricles, and surrounds the vocal lig- aments, and sometimes extends to the cellular tissue at the root of the tongue and external to the larynx, and even to the adjoining parts. In these more malignant cases, all the tissues are more or less softened and discoloured ; and .the alterations frequently extend to the pha- rynx and fauces on the one hand, and to the trachea on the other. 82. B. In chronic laryngitis, the structural le- sions are numerous: 1. The mucous mem- brane is red in patches, and exhibits a granular appearance, even when it is not ulcerated, ow- ing to enlargement of its follicles : it is also, apparently, thickened ; but this change is seat- ed chiefly in the sub-mucous cellular tissue, and causes enlargement and imperfect mobility of the parts, with partial obliteration or linear con- traction of the ventricles of the larynx. 2. Se- rous, puriform, or tuberculous infiltrations of the cellular tissue, and of the internal laryngeal muscles, either with or without softening and atrophy of these muscles and of the ligaments, are often observed. 3. Wasting and fibrous de- generation of the muscles which move the car- tilages of the larynx, and contractions of the ligaments, are frequently met with. These le- sions account for the loss of voice in this dis- ease. 4. Purulent collections, or small abscess- es in the sub-mucous cellular tissue, particu- larly in the ventricles and around the cricoid cartilage, are seen in a few cases.* 5. Ulcer- ations of the mucous and sub-mucous cellular tissues occur in various forms and situations, and are among the most frequent lesions in chronic laryngitis. The ulcers sometimes are small and round, and penetrate only the mu- cous membrane ; occasionally they are large, irregular, and superficial, with purulent secre- tion on their surfaces. In some instances they are still more extensive, and, in the syphilitic laryngitis, accompanied with warty excrescen- ces. Ulcers are not infrequently found in the ventricles, particularly in cases of phthisis, and are either rounded and superficial, or deep and irregular. The arytenoid, and even portions of the other cartilages, are occasionally destroy- ed by ulceration, but chiefly in young subjects. In most instances, and in older persons, ossifi- cation takes place in the cartilages before the ulceration reaches them. Ulcers are most com- monly seen between the vocal chords and the * [In his work on “ Phthisis,” published in 1825, M. Louis states, that he had never met, in a single instance, with tu- berculous granulations in the substance, or on the surface of the epiglottis, larynx, or trachea ; and in the second edi- tion of his “ Researches,” recently published by the Syden- ham Society (1845), he says that, from his additional expe- rience, it may be regarded as a law of the system, that tu- bercles, so commonly and abundantly developed in the lungs, are not produced, at least after the age of fifteen, in the upper air passages; if such an occurrence ever does take place, it can only be regarded as a singularly rare exception to the ordinary course of things (p. 45, Syd. ed.). Dr. Will- iams, in his valuable work on “ Pulmonary Consumption,” remarks, that “ if tubercles be, as we suppose, a degraded condition of the fibrin or nutrient principle of the blood, we may expect it to be deposited wherever the nutrition or the secreting process is carried on; wherever lymph or pus is occasionally found ; wherever, in short, blood-vessels run Tuberculous matter has been met with in coagula in the heart, spleen, and blood-vessels ; and it may be deposited in tissues and on surfaces, independently of irritation of these parts.” Dr. Carswell also observes, that “the mucous system is by far the most frequent seat of tuberculous mat- ter ; that the presence of tuberculous matter in the larynx, in the trachea, and its larger divisions, is not often observed,” but that “ he has met with it in a few instances in the fol- licles of these parts, and occasionally in the sacculi laryn- gis.” He continues : “ May it not be owing to the facility with which tuberculous matter escapes, that we do not find it accumulated on the mucous surface of the larger bronchi, or the trachea, or that of the intestines V’ Dr. Carswell evidently believes that tuberculous matter is often secreted upon the free surface of the membranes of these parts, but that, not being entangled or confined in any mucous crypt, it is removed by expectoration as soon as it is poured out. This fact should be borne in mind, as it has an important bearing on the diagnosis of laryngeal and pulmonary affec- tions.—(See remarks of Dr. Green, in New-YorkJour. Med and Col. Sci., vol. iv., p. 254.)] LARYNX AND TRACHEA—Inflammation of—Chronic. 793 epiglottis, but they are often found in other parts of the larynx, and in the laryngeal sur- face and edges of the epiglottis, and more rare- ly at the lower part of the larynx and com- mencement of the trachea. 6. In some cases, ulcerations, varying in size, form, and depth, are found in the trachea, especially its upper part; and in one instance I found a fistulous opening into the oesophagus. The ulcers are chiefly in the musculo-membranous portion, es- pecially when the affection of the larynx and trachea is consequent upon disease of the lungs. 7. Ossification of the cartilages is generally ob- served in the more prolonged cases. The osse- ous matter is irregularly deposited, generally on the surface of the cartilages. The cricoid and thyroid cartilages become naturally ossified in advanced life ; but MM. Trousseau and Bel- loc have shown that chronic laryngitis of two years’ duration produces the same change in young persons, irritation eccelerating those changes to which the tissues are naturally lia- ble in the course of time. 8. Instances of ne- crosis of the arytenoid, cricoid, and even of the thyroid cartilages, have been recorded by Law- rence, Porter, Cruveilhier, Otto, Ryland, Andral, and others. MM. Trousseau and Bel- loc found this lesion in more than one half of the cases of laryngeal phthistis which they ex- amined. They describe the cartilages to be denuded of their perichondrium, and of a dull, dirty hue. The sequestrum of dead cartilage is not readily thrown off, and the cellular tis- sue adjoining it is generally infiltrated with a fcetid pus. These purulent collections often open and discharge their contents, sometimes with dead portions of the cartilages, or with ossific deposites, or with carious portions of the ossified cartilages. The opening and dis- charge of these matters usually take place in the larynx, but in rare instances they have occur- red into the oesophagus, or outwardly through the integuments of the neck in still rarer cases. These mortified portions of the cartilages, as well as carious portions of the ossified cartila- ges, and phosphatic concretions in the diseased larynx, are sometimes discharged without any preceding or attendant abscess, and merely as a consequence of ulceration. When their es- cape from the larynx is impeded or attended by much spasm, or when they cause much irri- tation on being detached, they act as foreign bodies, and occasionally produce suffocation. They may even fall into the trachea, and pro- duce effects such as are mentioned when treat- ing o{foreign bodies in the larynx and trachea. 9. The epiglottis is often enlarged, thickened, or swollen; frequently, also, it is ulcerated; chiefly, however, in the inferior surface, and at the edges, in connexion with ulceration of the larynx and disease of the lungs. In the syph- ilitic form of the disease, the ulceration ex- tends from the lingual to the laryngeal surface, and sometimes destroys the whole of the epi- glottis. In less common cases, it is contracted and shrivelled, and more rarely expanded and thinned. 10. Besides the above, cauliform ve- getations, warty excrescences, tubercles, and, more rarely, cancer and hydatids of the larynx have been remarked ; and some of these lesions have been seen extending to the epiglottis. 11. The trachea has been observed to contain morbid secretions proceeding from ulceration of its internal surface, or from disease of the bronchi or lungs. Itffs sometimes remarkably thickened from deposition of lymph in the sub- mucous cellular tissue, and in a few instances a similar deposition is observed in the cellular tissue external to the cartilaginous rings. Red- ness and injection of the internal surface of the trachea, and ulceration as above mentioned, are commonly associated with tubercular ex- cavations in the lungs, and are most frequently observed in its posterior or membranous part. In some cases, these changes, ulceration par- ticularly, are confined to, or most remarkable on one side of the trachea, which invariably corresponds to the diseased lung; or, if both lungs be diseased, to that most affected. 12. In a remarkable instance which occurred to my friend Mr. Worthington, of Lowestoft, sever- al of the rings of the trachea were absorbed, and, in consequence of the fibrous structure be- ing deprived of its antagonizing power at that part, the canal was constricted so remarkably as hardly to admit a quill, and as to suffocate the patient. 13. Tumours of various kinds, ab- scesses, aneurisms, &c., have been found press- ing upon the trachea, and even on the larynx, and causing not only permanent obstruction to respiration and spasm of the glottis, but also •morbid secretions from the internal surface of these passages, and partial destruction or per- foration of their parietes. 83. The lesions just described will, in the va- rious stages and grades of their development, sufficiently explain the phenomena of acute and chronic laryngitis. When infiltration of the sub-mucous cellular tissue obstructs the pass- age of air into the lungs, or when the exuda- tion of albuminous lymph upon the surface of the larynx produces the same effect, respira- tion, voice, and speech are more or less impe- ded, and the various morbid phenomena con- nected with these functions are developed. When a thickened, granular, or superficially ul- cerated state of the mucous membrane of the larynx is present, the muscles and ligaments be- ing uninjured, and the mobility of the parts of the vocal apparatus is not materially affected by infiltration of fluids or other lesions, respira- tion is not impeded, but hoarseness, and alter- ation of the tone of voice, are present. When the muscles and ligaments are diseased, and when the subordinate parts of the apparatus are incapable of the requisite motions, aphonia is more or less complete. 84. iii. Diagnosis.—A. Of the Acute.—The stridulous hissing and difficult breathing; the prolonged inspiration, the larynx being always drawn downward most forcibly during the act, as first pointed out by me in the article Croup, and the reference made by the patient to the top of the windpipe as the source of his distress, are sufficiently distinctive of the nature of the disease.—Abscesses in the vicinity of the larynx may be mistaken for acute laryngitis ; but ex- amination of the upper part of the throat, and the partial or general swelling and tenderness observed externally, the confined motion of the larynx, particularly from side to side, and the difficulty of moving the jaw, will indicate the nature of the affection. Spasm of the glottis may be mistaken for laryngitis; but it rarely affects adults, and only hysterical persons. In these, however, a slight form of laryngitis, as 794 LARYNX AND TRACHEA—Inflammations of that sometimes consequent upon cold and com- mon sore throat, is often attended by severe accessions of spasm, and may be erroneously viewed as hysterical spasm of the glottis mere- ly. I have met with several instances of this association of inflammatory and nervous affections of the larynx, and the importance of recognising their exact nature has been made apparent in all of them. The previous catarrh, or sore throat, the existence of fever, the symptoms referrible to the larynx, especially the stridu- lous breathing, the hoarseness or aphonia, and the mere exasperation of the suffocative feel- ings by the nervous or hysterical state of the patient, will indicate the association here con- tended for, and which consists of a slight form of acute laryngitis, presenting violent ex- acerbations, owing to the nervous tempera- ment of the patient. 85. It has been remarked above ($ 59), that laryngitis is sometimes complicated with trache- itis, the complication taking place in two, or per- haps three ways: 1st. The inflammation may advance upward from the trachea to the la- rynx. 2d. It may extend from the pharynx to the larynx and trachea. 3d. It may attack both the larynx and the trachea at nearly the same time. In cases of primary or sporadic croup, the inflammation appears in either the first or the third of these modes, and is gener- ally at the commencement, or at an early peri- od of its course, a laryngo-tracheitis, often ex- tending, at an advanced stage, to the large bronchi, as shown in the article Croup. On the other hand, that complication of laryngi- tis which is consecutive of, or complicated with pharyngitis, and which has been called “ croup in the adult,” “ secondary croup,” “ epidemic croup,” &c., commences and extends always in the second of these modes. Between these two kinds of croup, as they have been denomi- nated by several writers, or, rather, between these forms of complicated acute laryngitis, as I have termed them, the distinctions are of great practical importance. Yet they have not been made with sufficient precision. Dr. Stokes has pointed out many of the most important of them, but as some of them have not been con- sidered by him with reference to the characters of certain epidemics, 1 shall modify a few of the distinctions he has adduced. 8. Dysphagia either ab- sent or very slight. 9. Catarrhal symptoms oft- en precursory to the la- ryngeal. 10. Complication, with bronchial or pulmonary inflammation, frequent. 11. Absence of any charac- teristic odour of the breath. 12. Necessity for antiphlo- gistic treatment, and the frequent success of it. 8. Dysphagia common and severe. 9. Laryngeal symptoms oc- curring without the pre- existence of catarrh. 10. Complications with these diseases rare. 11. The breath often char- acteristically foetid. 12. Antiphlogistic treatment very rarely requisite. Re- storative, tonic, stimula- ting, and other remedies necessary. 86. B. Diagnosis of Chronic Laryngitis.—A peculiar laryngeal cough, a permanent change in the voice, difficult and sibillous breathing, and pain or tenderness in the larynx, generally characterize chronic laryngitis. But difficulty of breathing and pain may be wanting in the early stages of the disease, or may occur only occasionally in the advanced periods. When the laryngeal swelling or constriction is consid- erable, the difficulty of respiring, and the pe- culiar sound attending it, are sufficiently indic- ative of the disease; and, when these are want- ing, the stethoscope will detect, as Dr. Stokes has shown, a harshness in the sound of the air passing through the larynx, suggesting the idea of a roughness of surface. When the laryn- geal constriction and the laryngeal respiration are slight, or altogether absent, disease of the larynx may yet be inferred as the cause of the cough and other symptoms by the negative in- dications of the thoracic organs, the sounds of percussion and of respiration being good throughout the chest. In abscess and mortifi- cation of the cartilages of the larynx there are laryngeal cough, foetid purulent expectoration, and even hectic, and there may be no disease in the chest; but these cases differ from ordi- nary phthisis laryngea, particularly in the prom- inence and rapidity of the purely laryngeal symptoms. The difficulty of determining the complication of the disease with pulmonary tubercles in their earlier stages, or true phthisis laryngea, should lead to a careful investigation of the history of the case, with the view of as- certaining whether the laryngeal affection was primary, or whether it supervened upon disease of the lungs. If it be found that the first symptoms were sore throat, relaxed uvula, dif- ficulty of swallowing, and were followed by those of a laryngeal character, or that a syphi- litic taint had existed, there is a great probabili- ty that the first morbid action was manifested in the larynx, and that the lungs were unaffect- ed. But if, on the other hand, as Dr. Stokes observes, it is ascertained, that previously to any hoarseness, stridor, or dysphagia, there has been cough without the laryngeal character, particularly if it was at first dry; that the breath has been short; that there has been pain in the chest about the collar-bones or shoul- ders ; that hoemoptysis has occurred ; that hec- tic has been observed, although the expectora- tion continued mucous; and that the patient has emaciated, it is almost certain that the case is in reality one of pulmonary tubercles, in the course of which laryngeal disease has occurred. If, moreover, the patient is of a scrofulous di- athesis, or has already lost brothers, sisters, or a parent, by tubercular disease, we may be certain that this is the nature of the case, al- though we can detect no physical sign of pul- Distinctions between the chief Forms of complicated Laryngitis. Tracheo-laryngitis, or Primary Croup. 1. The windpipe first at- tacked. 2. The local disease the chief cause of the at- tendant fever. The fe- ver symptomatic. 3. The fever inflammatory. 4. Children principally at- tacked. 5. The disease sporadic, and in certain situations endemic, but never in- fectious. 6. The exudation of lymph spreading from the tra- chea to the glottis, or from below upward. 7. The pharynx healthy Pharyngo-laryngitis, or Secondary Croup. 1. The laryngeal affection consecutive of disease of the pharynx and fauces. 2. The local disease occur- ring in the course gener- ally of a constitutional, and most commonly of a febrile malady. 3. The fever sub-inflamma- tory, adynamic, or malig- nant. 4. Both adults and children attacked. 5. The malady frequently epidemic, and generally infectious. 6. The inflammation, and the exudation attending it, spreading from the throat, or from above downward. 7. The pharynx diseased. LARYNX AND TRACHEA—Inflammations of. 795 monary tubercles. In examining such cases, a careful comparison of the sounds emitted on percussion by corresponding opposite portions of the chest, and an investigation by success- ive investigations or at different periods, will show the state of the disease. If, co-existent with laryngeal cough, muco-purulent expecto- ration, semi-stridulous breathing, and hectic, we lind a notable difference between the sounds of opposite corresponding portions of the chest, there is almost sufficient evidence of tubercu- lar disease of the lungs. When there is copi- ous muco-purulent expectoration of considera- ble continuance, we may infer the existence of suppurating tuberculous cavities in the lungs. When there are dulness on percussion, or cav- ernous rhonchus in some part of the chest, par- ticularly under a clavicle or scapular ridge, with copious expectoration, night sweats, ema- ciation, &c., an advanced period of the tuber- cular disease is present. 87. iv. Prognosis.—A. In acute laryngitis the prognosis is considered more unfavourable than in any other inflammatory disease by Drs. Cheyne, Bayle, and others. Mr. Bayle states, that of seventeen cases observed by him during six years, only one recovered; but this is much below the average recoveries. Mr. Ryland refers to twenty-eight cases treated by different practitioners, and of these ten recovered ; but he believes that this proportion conveys too fa- vourable a view of the usual termination of the disease, a greater number of successful than of fatal cases having been recorded. There can be no doubt of the correctness of the opin- ion given by Dr. Williams, that the prognosis should be very unfavourable, and the more so, the more progressive the difficulty of breathing. When the face becomes pallid, and subsequently livid, and the patient lethargic, the danger is extreme. The complicated, and asthenic forms of acute laryngitis are especially fatal, partic- ularly when they occur in an advanced stage of exanthematous, or epidemic, or malignant diseases. Hopes of recovery may be enter- tained in the milder forms or states of the mal- ady, and when the breathing becomes less dif- ficult, and is attended by a freer expectoration. The slight catarrhal form is merely a state of catarrhal irritation of the glottis, to which no risk is attached, unless it pass into the acute or chronic inflammatory states. Mr. RylanI) found that, of the eighteen cases which termi- nated fatally, death occurred within the first twenty-four hours in four, on the second day in one, on the third day in four, on the fourth day in five, on the fifth day in one, on the sixth day in one, and on the eighth day in two instances. 88. B. The prognosis of chronic laryngitis en- tirely depends upon the states in which it is presented to our observation. In its simple and mild forms, a favourable yet cautious opinion may be given ; for, although they will generally yield to judicious treatment, exacerbations, cedema, or even ulceration, may take place. If, however, even these forms occur in a faulty or scrofulous constitution, a much more unfavour- able opinion should be formed of the result. If, however, the disease has continued for any time; if it have not been amenable to treat- ment ; if the expectoration has become abun- dant ; and especially if the history and existing state of the case, and the presence of the I symptoms noticed above (§ 86), indicate its con- nexion with pulmonary disease, a most unfa- vourable result may with certainty be anticipa- ted. Fcetor of the breath and sputa indicate mor- tification of the cartilages, and is very unfavour- able ; but in simple laryngitis there is still a chance of the dead portions being thrown off, but there is no chance of laryngeal disease be- ing cured when it is dependant upon tubercular excavations in the lungs. In the syphilitic form of chronic laryngitis, if the general health has not suffered much, and if the lungs be sound, the patient may recover ; but the chances will depend entirely upon the degree of local lesion and the general state of the frame.* 89. v. Causes.—A. Acute laryngitis may di- rectly follow exposure to cold, wet, and cur- rents of air, continued or very great exertion of the voice, and accidental attempts to swal- low acrid, corrosive, or scalding fluids. + Mr. Porter observes, that when a person attempts to drink any of these by mistake, a convulsive action of the pharynx and upper portion of the oesophagus takes place, and throws the offend- ing fluid out through the mouth and nostrils, under the epiglottis, thus irritating and infla- ming this part and the rima glottidis. Drinking boiling water by mistake by children who have been accustomed to drink from the mouth of a teapot, as in the cases recorded by Dr. M. Hall ; the inhalation of very hot air, or of flame, as in some cases of burning, as shown by Mr. Ryland ; and the inhalation of very acrid vapours, as the strong fumes of ammonia, or of iodine, or the chlorine gases, &c., are also exciting causes of the disease. I attended a case many years ago with a practitioner, which * [In 193 cases of autopsic examinations of phthisical sub- jects by M. Louis, he found the larynx ulcerated 63 times, or in somewhat less than one third of the cases ; the epi- glottis 35 times in 135 cases; the trachea'll times in 190 cases; the bronchi 22 times in 49 cases examined. The same pathologist states, that in subjects who had fallen vic- tims to other affections than phthisis, of a chronic kind es- pecially, he, among 180 individuals, found but one example of ulceration in the larynx, and two of the same lesion co- existing in the larynx and trachea. Hence M. Louis in- fers that ulcerations of the larynx, more especially those of the trachea and epiglottis, must be regarded as lesions proper to phthisis; for in his late edition, “ Researches on Phthisis,” 1845, he repeats, that among upward of 501 non- tuberculous subjects, carried off by chronic diseases, and examined by himself, not one presented ulcerations in the larynx or trachea.—(Sydenham ed., p. 46.) There are five cases, however, quoted by MM. Trousseau and Belloc, in which death is supposed to have arisen from an affection of the larynx, attended with ulceration of its investing mu- cous membrane, while the lungs were free from tubercles. M. Valleix, however, as well as M. Louis, questions the authenticity of these cases. It is, moreover, worthy of re- mark, that MM. Trousseau and Belloc do not appear to have themselves observed a single case of laryngeal ulcera- tion without pulmonary tubercles. It has been fully estab- lished, by the researches of modern pathologists, that the point of junction of the chordae vocales, where they are sometimes superficial, is the most common seat of these ul- cerations ; next in order of frequency come the chordae vo- .cales themselves, especially at their posterior aspect, the base of the arytenoid cartilages, the upper part of the la- rynx; and, lastly, the interior of the ventricles. This ac- counts for the extreme frequency of aphonia in cases of chronic laryngitis.} t [The late Dr. D. Palmer, president -of the Medical School of Woodstock, Vt., accidentally inhaled, through a glass tube, while lecturing on chemistry at Pittsfield, Mass., / Oct. 12, 1840, a very minute quantity of concentrated sul- phuric acid; severe inflammation of the larynx followed, and although tracheotomy was early performed, the disease terminated fatally in a short time by causing asphyxia. (Bost. Med. and Surg. Journ., vol. xxii., p. 182.) We have attended two cases where death resulted from the same ac- cident.] 796 LARYNX AND TRACHEA—Inflammations of. was caused by swallowing a large quantity of mustard, in order to produce an emetic effect after poisoning from opium. The man recov- ered. In the consecutive or secondary forms above described ($ 63), the disease occurs in the course of Cynanche tonsillaris, of C. pha- ryngea, and of C. parotidcea; and in a decidedly asthenic form, in the course of scarlet fever, measles, smallpox, erysipelas, and typhoid fe- vers. It may be consequent even upon glossitis, and diffusive inflammation of the cellular tissue of the neck or throat. Mr. Lawrence and Dr. Williams have met with it in the course of aneurism in the arch of the aorta. Acute lar- yngitis also may supervene at any stage of the chronic state of the disease. 90. The circumstances more especially pre- disposing to an attack are, frequent or habitual occurrences of sore throat; indigestion con- nected with biliary disorder, or with accumula- tions of bile in the biliary organs, and of mor- bid secretions in the alimentary canal; habitual intemperance, either in eating or drinking; par- ticularly the latter; severe or prolonged cour- ses of mercury, and unusual exertions of the voice. When inflammations of any kind attack the throat, or parts adjoining, their extension to the larynx is favoured by accumulations of morbid secretions and excretions in the abdom- inal viscera, and by depressed states of the powers of life: a fact of great practical impor- tance, and hitherto insufficiently attended to both in our pathological reasoning and in our therapeutical indications. 91. B. Chronic laryngitis may arise from the same causes as have been now enumerated; but it sometimes succeeds the acute disease, and much more commonly it follows the fre- quent recurrence, or neglect, of the slight or catarrhal state of irritation mentioned above 52). Great or prolonged exertions of the voice, particularly by those addicted to the use of spirituous liquors, and the combination of neglected catarrh with intemperance, are the most common causes. Mercurial courses, the extension of syphilitic ulcers from the throat, dust or grosser foreign bodies inhaled or passing into the larynx, and injuries of the throat, also sometimes occasion chronic laryn- gitis. Persons of a scrofulous diathesis, those liable to cutaneous eruptions, or who have been suffering for a long time the more severe forms of indigestion, particularly cardialgia with acrid eructations, and all disposed to, or already af- fected by tubercular disease of the lungs, are especially predisposed to this affection. Its de- pendance upon pulmonary consumption is most frequent and intimate. It is most common at the middle period of life, or probably somewhat earlier, at least according to my experience; and is nearly equally frequent in both sexes. MM. Trousseau and Belloc think that it af- fects males oftener than females ; Mr. Ryland, that it more frequently attacks the males. [According to M. Louis, ulcerations of the larynx are more than twice as frequent in males as in females. Thus, of nine cases of ulcera- tion of the epiglottis recently reported (Syden- ham ed. of Researches, &c.), eight occurred in males; of 13 cases of deep ulceration of the larynx, two only were furnished by females; and of nine patients affected with similar ulcer- ations of the trachea, six were males, and in no instance was partial destruction of the rings of the trachea observed in a female.—{hoc. cit., p. 43.)] 92. vi. Treatment.—A. In the acute sthenic laryngitis, particularly in its primary and uncom- plicated form, the treatment should be prompt, early, and decided, in order to arrest the dis- ease before effusion, in any form, or in any sit- uation, takes place. The necessity for having a very early recourse to treatment is shown by the rapid fatality of some cases ($ 58). The intentions with which remedial means should be prescribed are, 1st. To reduce inflammatory action, and thereby to prevent or arrest those consequences of it usually productive of a fatal issue ; 2d. If effusion, or infiltration of the la- ryngeal tissues have taken place so as most dangerously to obstruct respiration, to obviate such obstruction and its consequences ; 3d. To promote the removal of such lesions as have taken place. 93. a. The first intention involves a recourse to blood-letting; but a cure of the disease is not to be expected from this means alone, although it should be instantly and decidedly employed, and in the manner advised by me in the article Blood (§ 64), so as to make a decided impres- sion on the pulse without producing syncope, and within the first twelve or twenty-four hours from the accession of the disease. After effu- sion or infiltration has taken place, so as to in- terfere with the purposes of respiration, blood- letting will be then too late to be of any service. A repetition of the blood-letting, and the quan- tity of blood taken, must depend upon the se- verity of the disease, the habit and constitution of the patient, and the effect produced by it. Cupping on the nape of the neck, after the first or second venaisection, should not be neglect- ed. By its means a very large or small, but always a definite quantity of blood may be ta- ken, and with a derivative effect. A recourse to leeches is seldom so satisfactory as to cup- ping, in this disease. After the first blood-let- ting, a full dose of calomel—five or six grains, with three or four of James’s powder, and a third of a grain of opium, as advised by Dr. Cheyne—should be given every third, fourth, or fifth hour, until the gums become affected. I have never seen any benefit derived from the application of blisters, and I am sure that I have seen them injurious. Dr. Cheyne properly ob- jects to them. A recourse to strong liquor ammoniae, as suggested by Dr. J. Johnson, may be preferable ; still it acts only as a vesicant, and, when applied over the throat, it is so near the seat of inflammatory action as to excite its activity rather than to diminish it by deriva- tion. Romberg, Campbell, and others, advise the croton oil to be externally applied, but it is more appropriate in the chronic form of laryn- gitis. [To show the extent to which blood-letting has been carried in this disease, we may refer to the case of Dr. J. W. Francis, of New-York, as detailed by Dr. J. B. Beck, in the 12th num- ber of the New- York Medical and Physical Jour- nal. Dr. F. had complained for three days of soreness of the fauces and thirst, when he was attacked with pain, difficulty of breathing and swallowing, and a sense of strangulation, for which symptoms 152 ounces of blood were ab- stracted, as follows : On the 17th of November, LARYNX AND TRACHEA—Inflammations of. 797 1823, fxi.; evening, jxxx.; 18th of November, fxvi.; evening, fxvi.; 19th of November, §vi. ; evening, ?xvi.; 20th of November, jxvi. ; 22d of November, fxii.; total, 153 5. For three or four days after, Dr. F. was still in a precarious condition, and required a repetition of the blood- letting. Dr. Cheyne, in his valuable essay on laryngitis in the Cyclopedia of Pract. Med., p. 110, has given cases to prove the inefficacy of blood-letting in this disease, and attempts to point out the circumstances which should lead to the employment of this remedy; the princi- pal of which is, that v. s. will be useful if re- sorted to early, while the complexion is good, and the blood properly arterialized in the lungs ; and that, after the skin becomes dusky or livid, it is hazardous to resort to it.] 94. For more than twenty years I have had recourse, immediately after blood-letting and. the first dose of medicine, to the application of flannel, wrung out of hot water and freely sprinkled with spirits of turpentine, or with a combination of this substance with camphor, or with compound camphor liniment, around the whole neck and throat. This application, when duly managed and modified as respects its continuance and the combination of sub- stances used, is the most efficient remedy in all the forms, simple and complicated, of acute laryngitis; and, as it does not vesicate, or at least very slightly, it is not in the way of the operation of tracheotomy, which will rarely be necessary when it has been early resorted to. It has a remarkable effect in restraining inflam- matory action in parts near those to which it is applied, and in preventing and arresting the effusions and infiltrations consequent on inflam- mation. The success of this application will entirely depend upon the decision with which it is employed. Dr. Cheyne objects to the use of tartar emetic in any way, lest it should ex- cite vomiting, and, by throwing matters against the erect and exposed epiglottis, cause vio- lent convulsive irritation ; and Dr. Williams, for a similar reason, argues against the propri- ety of applying leeches on the tonsils, as pro- posed by Dr. Cheyne and Mr. Crampton. The irritation of the bites, and of the blood proceed- ing from them, can hardly be supposed to be otherwise than injurious. The above meas- ures may, although early resorted to, only de- lay the unfavourable progress of the disease, may fail in arresting the inflammation, and in preventing its consequences from dangerously or even fatally obstructing respiration. It is now that the second intention must be adopted ; but the third should not be neglected from the commencement; for the removal of the lesions, or consequences of inflammation already pro- duced, should be attempted forthwith ; and the means best calculated to attain that end are, also, those best adapted to fulfil the first indi- cation, more especially the free use of mercury, and the application of the embrocation already mentioned around the neck. 95. b. The second intention must be resorted to as soon as the lesions consequent upon in- flammation begin to obstruct respiration, so far as to prevent the necessary changes from taking place in the blood. If the strength fail, and pallor, with lividity of the lips, appears, blood- letting and the other means advised above will be of no avail, and tracheotomy is then indispen- sable. It may have been even too long delay ed; for it should be performed before the blood is altered so far by the obstruction to respira- tion as to change its sensible qualities. Dr. Cheyne justly remarks, that if the symptoms be such as to contra-indicate blood-letting, and yet asphyxia is imminent, the operation should be instantly performed. As long as the complex- ion is good, and asphyxia not threatened, it may be delayed. Mr. Lawrence says that it should be resorted to as soon as the symptoms enable us to ascertain the nature of the dis- ease ; and, although this may be too precipi- tate a recourse to a surgical operation in itselt and consequences not without some risk, it is preferable to delaying it too long. The effect of treatment, particularly of blood-letting and of the application around the throat, which I have advised, should be first observed ; and if these do not give relief in a period varying from twelve to twenty-four hours, according to the urgency and peculiarities of the case, tracheot- omy should be resorted to. But no precise time ought to be assigned before the operation is performed ; for the local symptoms, and the states of the vital functions caused by the la- ryngeal obstructions, should alone guide both physician and surgeon in respect of it. There are pathological circumstances connected with too prolonged a delay of the operation which should not be overlooked, as they are the most powerful arguments against such delay. These are the increased disposition to bron- chial and pulmonary congestion with obstruc- tion to the respiratory function, and with inter- rupted change of the venous into arterial blood ; and the fact that these changes, when they reach a certain pitch, often lead to fatal results, although the obstruction to respiration may have been removed previously to the occur- rence of any immediate risk of asphyxia. Still the operation may be tried even when asphyxia approaches, as a few instances have occurred of its success at the last extremity; but the engorged state of the lungs and congestion of the bronchial surfaces, which increase with the progress of the local obstruction, generally pass into effusion or into an asthenic state of inflam- matory action, when the respiratory actions are restored by the operation after having been too long delayed. An early recourse to the operation is particularly indicated when laryn- gitis has been caused by swallowing acrid, or corrosive, or boiling fluids, as the means of cure recommended do not act so rapidly in these cases as in many others, and an early opening into the trachea facilitates the treatment of the injured parts. 96. After the operation, care should be taken not to insert too long a tube into the windpipe, as such a one will excite serious irritation ; and equal care should be observed that expectora- tion be not prevented by constantly expiring through this tube, otherwise the accumulation of mucous or muco-puriform matter in the tra- chea and bronchi will prevent all benefit from accruing from this measure. The tube, there- fore, should frequently be closed after a full in- spiration, and the patient be told to expire for- cibly through the glottis, so as thereby forcibly to expel the accumulating matter. Until the obstruction in the glottis is removed by the mercurial treatment, which should be persisted 798 LARYNX AND TRACHEA—Inflammations of. in until its effects become manifest, active counter-irritants should be applied on the chest or between the shoulders, and the most effi- cient of these are terebinthinate embrocations and blisters. These, and a recourse to cup- ping, or to dry-cupping on the chest, according to circumstances, will diminish or remove the congestion of the bronchial surfaces and lungs, and the disposition to inflammatory action in these parts, which often destroy patients after tracheotomy had apparently for a time saved them, and which generally arise in the manner just stated, and less frequently are propagated along the respiratory passages as the disease proceeds and the powers of life are reduced. [The mustard cataplasm is a very useful ap- plication in these cases, as is also a warm poultice in which the leaves or an infusion of tobacco have been mixed, as recommended by Dr. Chapman (Dis. of the Respiratory Organs, Phila., 1845, p. 122); or a segar may be smoked, if the patient is unaccustomed to it. Active purgation has also been highly recommended, and Dr. Regnin relates two cases in females where imminent suffocation was prevented by the administration of croton oil. R 01. Tiglii, gtt. iv.; Extr. Col. Comp., gr. xx. M. Div. in pil. iv.: give one every two hours, till copious evacuations are produced. Although we regard copious venesection as indispensable in the treatment of acute laryn- gitis, we believe that mercury is a still more important remedy, and that without it the for- mer would rarely prove successful. We think very favourably of mercurial inunction in these cases, as well as mercurial inhalation, and cal- omel should be given internally in doses of one grain every hour, combined with extract of gen- tian, until evident constitutional effects are produced. In this manner we prevent the necessity of the excessive loss of blood, and recovery is consequently expedited. Dr. Chapman (loc. cit.) is an advocate for the most energetic bleeding in the early stages of this disease, carrying it even to fainting; re- marking that, “ less extensively used, it is al- together inadequate to an extreme emergen- cy. The only cases of the disease I have ever cured, or seen cured, were mainly by this ener- getic course. Washington’s death, humanly speaking, may be ascribed to his having been so sparingly bled in the very commencement of the attack. The subsequent and larger bleedings were too late, effusion having taken place. He was a very robust man, of a san- guineous temperament, in whom such an im- flammatory attack required the freest depletion.” (Loc. cit.) After free blood-letting, Dr. C. rec- ommends copious emesis, by calomel, tart, an- timony, and ipecacuanha, promoting its action by the warm bath. The late Dr. Armstrong regarded emetics, also, as almost a specific in the treatment of this disease, repeating their use as soon as the slightest signs of stricture in the larynx returned. If the disease does not yield, Dr. C. next advises leeches to the throat, then emollient poultices, and, finally, a blister, with inhalation of the mildest vapours. The tobacco cataplasm here comes in with fre- quently beneficial effect. As soon as the time has arrived when the directly depleting meas- ures can be carried no farther, Dr. C. recom- mends recourse to sweating, by the Dover’s powder and the vapour bath, continued for sev- eral hours. He also places much dependance on the alterative influence of calomel, in com- bination with opium and ipecacuanha, and, as a last resort, recommends tracheotomy. “ By opening the windpipe in due season,” says Dr. C., ” respiration would proceed in spite of the obstruction of the glottis, the irritated structures restored to quiescence, or, at least, relieved from the existing violent agitation, so exasper- ating in its effects, and which, by continuance, must produce pulmonary implication, or effu- sion into the cellular tissue of the larynx itself. From the wound, the danger is in no respect enhanced. The aperture is to be allowed to remain open until the inflammation subsides, and the natural passage re-established by the subsidence of the tumefaction, or the removal of other impediments.”—(hoc. cit.) In that form of acute laryngitis attended with an cedematous disposition, as we often observe in persons of a lymphatic temperament, the loss of blood is rarely beneficial ; here emetics, with strong counter-irritants to the throat, and swabbing the fauces, and even the larynx, with a strong solution of nitrate of sil- ver, or alum, will be found the most efficacious treatment.] 97. B. The complicated forms of sthenic laryn- gitis require a different treatment from that ad- vised in the simple sthenic form. In that com- plication which is consequent upon, or coetane- ous with tracheitis, and which constitutes a very large proportion of the cases of croup, nothing can be added at this place to what has been fully adduced in that article, from a tolerably extensive experience. When laryngitis occurs from the extension of inflammation, with albu- minous exudation from the fauces and pharynx —is consequent upon angina membranacea—and when the local and constitutional symptoms in- dicate a more or less sthenic disease, the treat- ment should be such as may subdue increased vascular action, and be especially and early di- rected to the state of the fauces and pharynx, in order to prevent the extension of the morbid action from them to the larynx. The means most beneficial in this form of disease are fully described in the article Throat, Diseases of. When the larynx becomes implicated, a vigor- ous recourse to calomel, and the application of the terebinthinate embrocation around the neck and throat, sometimes preceded by cup- ping on the nape of the neck, are chiefly to be relied upon. Venaesection is rarely indicated, and as rarely beneficial in this disease, unless in its most sthenic states, and in plethoric and robust persons, where it should be employed with a careful observation of its effects; but the treatment will depend much upon the char- acter of the epidemic. The topical applications of alum, in the form of a paste or otherwise, or of nitrate of silver, or of muriatic acid, as ad- vised for angina membranacea (see art. Throat), are now generally of no avail; and if the former means are inefficacious, tracheotomy must be resorted to, and should not be too long delayed, although a successful result from it is even less to be expected in this malady than where it is performed in simple laryngitis ; for there is a much greater disposition of the morbid ac- tion to propagate itself from the larynx down- ward in the complicated than in the simple dis- LARYNX AND TRACHEA—Inflammations of—Treatment. 799 ease, and patients are more likely to be carried off by the consecutive bronchitis. 98. C. In the treatment of acute asthenic laryn- gitis, blood-letting is inefficacious or injurious, whether the disease appear in its simple form ( 13), to have been the chief causes of this malady. “ I find the cause of the leprosie to be the air and the dyet; for here is a pretty cold and moist air, which usually causeth the scurvy to those that lead a solitary life, and this hath a great affinity with leprosy. Besides, the meat of all, specially of the poorer sort, is half-rotten flesh or fish, all their nourishment in summer being likewise fresh fish and sweet milk, without any salt; wherefore he that is not of a strong and good complexion, may easily have his blood cor- LEPROSY—Causes of—Treatment. 813 rupted, the sickness gnawing itself through the body before it breaketh out, and when any one is so infected, he may easily give it to another that is of the same complexion with the sick.” “ It has also been taken notice of, that two liv- ing together in marriage, though the one be found infected, they live together as before as long as one doth but murmur of it, till the mag- istrate doth separate them ; and yet the sound remaineth uninfected, whereas another is often taken with the disease by a very little conver- sation.’'’—(P. 312, 313.) 29. Dr. Ainslie expresses a doubt of the contagious character of the disease ; but he admits, with all others who have had oppor- tunities of investigating the nature of the mal- ady, that it is hereditary. On this subject, Dr. A. Edmondston remarks that this disease is hereditary, “ and has been transmitted to suc- cessive generations, without extending itself to individuals living under the same roof, or even to all the offspring of the same parents ; nor does it seem to propagate itself by infec- tion, unless in those cases where a matter is generated and discharged from the sores. This is the certain medium of communication, and an inattention to this circumstance has given rise to contradictory views of its nature.” —(Edin. Med. and Surg. Journ., vol. vi., p. 164.) I believe that there is much truth in the latter part of this quotation ; I quite agree with this opinion of my late friend. He adds, at another part, “ that it was propagated by contagion can- not admit of a doubt. We have seen that it prevailed very generally in the Shetland Isles, about sixty-five years ago, and all the inhabi- tants were deeply impressed with a conviction of its contagious nature ; and the history of the disease but too well confirms the accuracy of the opinion.” 30. The investigations of Mr. Stewart, at Tranquebar, where tubercular leprosy is very prevalent, has induced him to give the follow- ing as the results: 1st. That women are less liable to this malady than men ; 2d. That it is hereditary ; 3d. Its being contagious is ex- tremely problematical; 4th. That every leper, suffering from an advanced stage of the mala- dy, doubts whether he is capable of propagating his species ; 5th. That a fish diet is found to render every symptom worse ; 6th. That poor living, want of cleanliness, mendicant misery, and exposure to cold and damp, are but too constant attendants of this dreadful affliction. 31. From my limited observation of this mal- ady, chiefly in Africa, as well as from other sources of information, I believe that it owed its origin principally to the use of smoked, wind-dried, and semi-putrid or rancid flesh meats and fish, and of rancid oils ; to the want or disuse of salt; to the use of unripe, or spoiled, or mouldy grain ; to the want of vege- table productions as articles of diet; to inatten- tion to personal cleanliness; to the nature of the clothing; and to the contact of the matter discharged from the leprous sores, when the disease was far advanced, and when the mat- ter came in contact with the skins of those who were already predisposed to it by the modes of living alluded to, and by want of cleanliness. 32. Y. Treatment. — Much good may be done by avoiding the presumed causes of the malady. The cure, when the disease is fully advanced, is hopeless ; but ih the early stages it may be either entirely removed, particularly if it have recently commenced, or if the malady is confined to the extremities, or it may be ar- rested for many years in its progress. The Arabian physicians trusted chiefly to mercury. Dr. Hillary avoided mercury, and prescribed sarsaparilla. Dr. Towne thought that anti- monials afforded the greatest relief, and that mercury aggravated the disease. I believe, however, that the bi-chloride of mercury, given with the compound tincture of bark, or with the compound decoction of sarsaparilla, so as to produce both a tonic and an alterative effect, is really of great service in the early stage of the malady. Dr. Ainslie always endeavoured first to improve the health by nourishing diet, cleanliness, and exercise ; and afterward to act upon the disease by a cautious use of the bi- chloride of mercury and warm baths, support- ing the frame at the same time by generous living. He also mentions the mineral acids and the combination of antimonials and aro- matics with approbation. The Hindoo physi- cians consider the white oxide of arsenic as a powerful remedy for this disease ; but Dr. Ains- lie was disappointed in his trials of it. Of all the alterative and deobstruent remedies, he adds, employed by the native practitioners of India, none is of equal repute with the concrete milky juice of the Asclepias gigantea, given with sulphur, and continued for some weeks. Dr. Heberden states that he cured a patient in five months, by means of a mixture of an ounce and a half of powdered cinchona and half an ounce of powdered sassafras root, made into an elec- tuary with sirup, the patient taking the size of a nutmeg twice daily. M. Rayer supposes, however, that a recourse to these and other tonics, as arsenic, &c., is apt to kindle the in- ternal inflammations, which often carry off lep- rous patients. 33. Although I saw several cases of this dis- ease in different parts of Africa, my residence in any one place did not exceed three or four months. I had not, in consequence, opportu- nities of observing the effects of treatment. But a few years ago I was consulted by a phy- sician who had resided for some years in a warm climate and treated cases of this malady in all its stages. He had had patches of a tawny colour on his extremities, with thicken- ing of the corion, and enlargement of the hair bulbs and follicles, and loss of the hair of the parts. The patches were slightly insensible ; and the sensibility of the toes and feet was somewhat impaired. When I saw him, he had been the subject of the affection during fifteen or sixteen years ; and, at an early part of the treatment, the patches in the upper extremities had nearly disappeared ; but those in the lower continued, the highest being situated in the flexures of and little above the knees. He at- tributed the disease to contagion, and said that he fully recollected the occasion of his infec- tion. The disease had retrograded by his at- tending to his general health, by his removal to a temperate and equable climate, and by the occasional use of the bi-chloride of mercury with sarsaparilla, or of small doses of Fowler’s arsenical solution, other alteratives and tonics having been employed in the intervals. He 814 LEPROSY—Treatment. subsequently had recourse to sulphur fumiga- ting baths, and to various medicated warm baths. His pulse was slow, soft, and weak; the impulse of the heart weak ; and the com- plexion pale and unhealthy. The patches in the lower extremities had been stationary for about ten- years; but, during that time, a few tubercles had formed in them, had broken, and, after continuing to discharge an ichorous mat- ter, had healed up. The nails of the toes and of the fingers were affected as above mention- ed. He complained of dyspeptic symptoms. I first prescribed for him the chlorate of potash, in decoction of bark; and, subsequently, put him upon a course of iodide of potassium, with liquor potassa, in the compound decoction of sarsaparilla. After this course was continued about six weeks, the above symptoms began to disappear, and within three months his skin and lower extremities were quite clean. Three years afterward there was no return of the malady. This case was evidently one in which the anaesthesia was the most prominent phenom- enon. Notwithstanding the success of these means, I believe that, in the far advanced state of the malady, the prognosis of Holler—“ Con- firmata elephantiasis non curatur” (De Morb. Inter., p. 64)—may be viewed as just. [Leprosy in Mexico.—One of the forms of lep- rosy above described would seem to be not an uncommon disease in Mexico. Kendall, in his Narrative of the Texan Santa F6 Expedition (vol. ii., p. 220), thus speaks of the lazarinos, or lepers of hospital San Lazaro : “ The appear- ance of the unfortunate lepers is loathsome and hideous to a degree that beggars descrip- tion. It makes its appearance by scaly erup- tions on different parts of the face and body of the victim, and these eruptions are never per- fectly healed. The limbs of many, and more especially the hands, at first appear to be drawn and twisted out of all shape. Gradually the nose and parts of the feet are carried away, while the features become distorted and hide- ous. The voice assumes at times a husky and unnatural tone, and again the doomed patient is unable to articulate except in a shrill, piping treble. With many, when near the last stages, all powers of speech are lost, and vainly do they endeavour to make known their wants by sounds which belong not to this earth of ours. Death steps in at last to relieve the poor crea- tures of their sufferings ; and to them, at least, it would seem that the visit of the grim tyrant must be welcome.” Mr. Kendall farther states that there were some 60 males, and more than that number of females, affected with the disease in the hospi- tal of San Lazaro, when he was there ; that he cannot say whether the disease is contagious or not; that there is little doubt of its being constitutional and hereditary, being never en- tirely eradicated from the blood. He thinks the climate has some effect in engendering and keeping alive the disease ; says that the com- mon belief among the lower classes is, that it is communicated by contact, and expresses the opinion that the only risk a person runs of taking it is from touching the person of one afflicted with it in its worst stages. It seems that when a person is known to be a leper in Mexico, he is at once sent to this hospital, where he re- mains till death, for we are told that “ none ever recover from the horrible disease” (p. 222; “ If all the Mexican inmates of San Lazaro,” says Mr. K., “ were afflicted with leprosy, and we were told that such was the case, there must be three or four different species of the disease. The faces of some of the lazarinos were covered with blotches and eruptions, while their hands and feet were unmarked. Others, again, had complexions exceedingly fair and unblemished, yet their feet and hands were distorted or decayed. Some of the vic- tims of the dreadful scourge were covered from head to foot with sores and ulcers hide- ous to look at; and then there were two or three cases where the patients presented no other marks of the disease than the loss of a nose. But the most singular case of all was that of the old Spaniard, whom I' have previ- ously mentioned as continually smoking his cigarittos. His flesh appeared to be entirely gone—dried up—his skin turned to a bluish purple — and his whole appearance was so strangely changed and distorted, that he more resembled an animated mummy than aught else I can compare him to. His senses he still re- tained, while his actions and conversation con- vinced us that he was a well-informed and gentlemanly man.”—(P. 241.) Leprosy in New Brunswick.—In the year 1844, the attention of the Canadian government was called to the existence of leprosy at Tracadie and Nequac, in the Province of New Bruns- wick, near the Bay of Chaleur ; and a commis- sion was accordingly appointed, consisting of Drs. Key, Skene, Toldarvy, and Gordon, to investigate its nature and origin. The follow- ing is extracted from their report to the Cana- dian Parliament: “ The disease is the Greek elephantiasis—the leprosy ; not the elephantia- sis of the Arabians, but the leprosy of the Mid- dle Ages ; the lepre tuberculeuse of the French, or tubercular leprosy, which raged over nearly every district of Europe from the tenth to the sixteenth century. It is the decided opinion of the gentlemen comprising the commission that the disease is contagious; and, so far as they could ascertain, no person in the above districts who contracted it is ever cured. It is also their opinion that it has no affinity to scrofula ; and the idea very prevalent that it is owing to the poor diet of the French settlers, and their filthy habits generally, is not correct, for they found it existing in some of the clean- est dwellings and most respectable families. It has spread very rapidly during the last year. They discovered upward of 20 cases, all of which can be traced up to one source. They have every reason to suppose that there were a still greater number ; but not having power to search, and the inhabitants showing a great disposition to withhold information, or to point out the parties labouring under the disease, they could not make so minute an inquiry as they otherwise would have done, or as they were desirous of doing.” Dr. Boyle, of St. Johns, has also investigated the disease (Land. Med. Gaz., 1844), of which he has given an in- teresting account. Dr. B. agrees with the com- mission that the disease is tubercular elephanti asis of modern pathologists ; the juzam of the Arabians, and the lepra Grce.corum of the Middle Ages ; but he regards the disease as non conta- gious, and goes into a long statement of Lets LEPROSY—Bibliography and References. 815 to prove this position. He, however, thinks the disease is hereditary, traces its existence back to 1827, numbering some 20 cases and 12 deaths since that period, although he is of opinion that it was introduced into the province much earlier. Dr. B. briefly describes a case of the disease, where “ the breath was extreme- ly offensive, the face, hands, and legs covered with blotches and tubercles of a livid, brownish colour, and some of them were in a state of ul- ceration.” We are not aware that the disease has ever been noticed to any extent in any part of the United States, although sporadic cases have been occasionally observed, as in a young girl a few years ago in the State of New-York, in whom no hereditary predisposition dxisted.— (Worcester, On Diseases of the Skin, p. 231, Philad., 1845.) In Norway, in the Gazette des Hopiteaux, for April 4, 1844, is a short account of a memoir presented to the Academy of Sciences, by M. Daniels sen, physician to St. George’s Hospi- tal at Bergen ; from which it appears that this disease has prevailed epidemically for half a century upon the coast of Norway, and that, out of 200,000 inhabitants, 1200 had been at- tacked. In the great number of autopics the author of the memoir has had occasion to make, it was found that the skin and cellular tissue, and walls of the sub-cutaneous veins, were one indurated mass, yellowish, and granulated. The same indication was found in the eyes, larynx, trachea, bronchial tubes, pleura, liver, spleen, intestines, and uterus; the lungs alone escaped. The disease uniformly terminated fatally, how- ever treated.*] Bibliog. and Refer.—Lucretius, De Rerum Natura, 1 iii.,et 1. iv.—Celsus, Medicina, 1. iii.,1. xxv.—Galen, Opera. De Arte Curat, ad Glauconem, 1. ii.; et De Compos. Medi- cam. Secund. Loca., 1. v.—(Galen states, that the disease was common in Alexandria, owing to the full and rich liv ing, and the heat of the climate. He recommends, in its early stages, a variety of tonics, stimulants, and alteratives.) —Aretceus, De Causis et Signis Morb., edit. Boerhaave, p. 69.—C. Plinii Sec., Hist. Mundi., 1. xxvi., 4 ; et 1. xxviii., 33-50.—Ccelius Aurelianus, De Morb. Acut. et. Chron., 4to. Amst., p. 492.—Aetius, Tetrab. iv., s. ii., c. 123.—Oribasius, Synops., 1. vii., c. 51. — Paulus JEginetm, De Re Medica, fol. Par , 1532, 1. iii., ch. i.—Avicenna, Canon. Medicinte, 1. iv., p. 130, fol. Venet., 1564.—Theodericus et Lanfran- cus, in Arte Chirurg. Scriptorum Collect., p. 175 et p. 207. Venet., 1546. — Gilberti Anglici, Compend. Medic, tam Morb. Univ. quam Partieul., &c. Vienna, 1510.—Joannis Anglici, Praxis Medica, Rosa Anglica dicta, p. 1076, edit. Schopffin, 1595.—B. Gordon, Lillium Medicinas, &c., in Op. Med., p. 49. Lugd., 1574. — Guy de Chauliac, Chirurg. Tractatus Septem (De Lepra). Venet., fol., 1470.—/. Fer- nelius, Universa Med., p. 579. Geneva, 1680. — Schenck, Observ. Med., &c., p.776.—Stemfels, De Elephantiasi Grae- corum, 8vo. Marb., 1662. — Zacutus Lusitanus, Pr. Med. Hist.,1. vi., n. i.—Prosper Alpinus, Medicina iEgyptiorum, 1. i., p. 56. (Describes the Elephantiasis of the Greeks, and the Eleph. of the Arabians.)—L. J. Debes, A Description of the Islands and Inhabitants of Feroe, &c. ; Englished by J. S., 12mo. Lond., 1676, p. 312.—Martin, Voyage to St. Kilda, 1698-1749, p. 140 ; and Phil. Trans., 1730.—Pontop- pidan, Nat. Hist, of Norway, &c., Trans. Lond., 1755, p. 261. —Turner, Treat, of Dis. Incident to the Skin. Lond., 1736, p. 2. —Lorry, Tract. De Morb. Cut., p. 376.—Plenck, Doct. de Morb. Cut., p. 67,— Sauvages, Nosolog. Method., t. v., p. 229. —Pococke, A Descript, of the East and other Countries, fol., 1753.—De Chamserue et Coquereau, Recherches sur l’Etat actuel de la L6pre en Europe, &c.; in Mem. de la Soc. Roy. de Med., t. v., p. 199. — T. Heberden, Med. Trans, of Roy. Coll, of Phys., vol. i., p. 35.—Tode, De Elephantiasi Norwegica. Haun., 1785.—F. Ruette, Essai sur l’Elephant. et les Mai. Lepreuses, 8vo. Par., 1802.—Casan, Mem. Soc. Med. d’Emulation, t. v.,p. 102.—T. Winterbottom, Account of the Native Africans around Sierra Leone, &c., vol. ii., p. 50, 8vo. Lond., 1803.—Adams, Observ. on Morbid Poisons, 4to. Lond., 1807, p. 265.—Alibert, Descrip, des Maladies de la Peau. Paris, 1806.—Jackson, Account of Morocco, 8vo, 1810. — T. Bateman, Practical Synopsis of Cut. Dis- eases, 8vo. Lond., 6th ed., p. 413. — Robinson, Transact, of Med. and Chirurg. Soc. of Lond., vol. x., p. 27.—Babing- ton, in Ibid., vol. i., p. 27. — Lawrence, in Ibid., vol. vi.— Southey, in Ibid., vol. vi.—W. Ainslie, Obs. on the Lepra Arabica, as it appears in India; Trans, of Roy. Asiatic Soc., vol. i.—H. H. Wilson, in Transact, of the Med. and Phys. Society of Calcutta, vol. i., p. 1 .—Wise, in Ibid., vol. vii., p. 156.—Pierquin, Journ. des Progres des Sc. Med., t. xi., p. 140. — M. Guide, Archives Gener. de M6d., t. xvii., p. 533.—L. A. Struve, Ueber die Auss&tzige Krankheit Hol- steins, 8vo. Alt., 1820. — H. Martius, De Lepra Taurica, 8vo. Novr., 1827.—Heineken, On the Leprosy of Madeira ; Edin. Med. and Surg. Journ., vol. xxvi.,p. 15.—H. Holland, in Ibid., vol. viii., p. 202. — Cazenave, Sur l’Elephant. de Grecs, Journ. Hebdoniod. de Med., t. iii., p. 146.—P. Rayer, Theor. and Pract. Treatise of the Dis. of the Skin, 2d ed.; Trans, by Willis, 8vo. Lond., 1835, p. 740. — /. Y. Simp- son, Not. of Leprosy and Leper Hospitals in Scotland and England, in Edin. Med. and Surg. Journ., vol. lvi., p. 301. — J. A. Raisin, Essai sur l’E16phantiasis des Grecs, 4to. Pans, 1829.—Joy, Cyclop, of Pract. Med., vol. i.— Von Vo- gel, Encyclop. Worterbueh, vol. x. Berl., 1834. (In most of recent works, the Synonymes and Bibliography apper- * [Dr. Mott, who examined recently for himself the Lepra of the Greeks, in Athens, thus speaks of a patient whom he was invited to visit: “ I examined him with great care and minuteness, heard the history of his symptoms, and saw the disease for myself, as it now affected his throat. I ascertained that the affection commenced, in its primary stage, in the same parts as those attacked by the syphilitic virus, and that the ulcerative appearances in each bore a striking resemblance, both in that stage and in the consti- tutional or secondary form, which latter truth I myself can attest to from the case under my inspection. The primary ulcerations, as well as those in the throat, were harder, and with edges more callous, elevated, and irregular, than is usually seen in common cases of lues ; but they were such as I have seen occasionally in the lues of our own country. The same character of ulceration was visible in the throat of this patient; and, immediately upon looking into it, I re- marked to Dr. R., that this was certainly a form of lues, to which opinion Dr. J. gave also his full concurrence. It passes through the same stages as ordinary lues, from the throat to the skin, and, lastly, to the bones. I am there- fore of the opinion, from what I saw, that the lepra of the Greeks is a more formidable, and apparently a more chronic disease, than modern syphilis, but legitimately descended from the same parentage. If the leprosy of the patriarchs of old was the same disease as the lepra of Greece, and which latter I afterward found, to my satisfaction, to be the same as the lepra of Egypt, it is my opinion that the an- cient leprosy is the great progenitor of them all, and that climate, habits of life, constitutions, and difference of race make all the modifications it has assumed in different coun- tries and ages. I come to this conclusion without any feel- ing or wish to remove the odium, which is unkindly thrown upon our country, of having given birth to so loathsome a malady. These convictions are the result of careful ob- servation and mature reflection during my jouriieyings in Europe and the East. We have no doubt, in our minds, that when the ancient lepra and modern lues shall be more closely studied and accurately compared, their identity will be made more and more manifest; and if the leprosy of the Scriptures be the same as the present leprosy of the East, the question is narrowed down to small limits, and the in- ference is legitimate and unavoidable. It may be cited, in evidence of their analogy, that Eastern nations hold a lep- rous person in the greatest detestation and abhorrence, in- somuch that they are made outcasts of society. They are placed in habitations by themselves alone, and forbidden to have intercourse with their neighbours, as is illustrated in some of the Eastern cities, where leprous houses are pointed out, undergoing as rigid a quarantine as if the disease were the true plague. And sometimes leprous subjects are driv- en outside the gates, and turned into the fields and mount- ains, as though they were beasts. One instance of this I saw afterward on the plains of Argos, in Greece, the poor victim oeing a man who was wandering alone in the fields, and obliged to seek shelter in the clefts of the rocks. One feature in the character of this disease, by which its iden- tity with lues is farther established, is in the similarity of the remedies for both, which are mercurial and arsenical. This I ascertained afterward to be the practice in Egypt as well as in Greece. The physicians in both informed me that, in the early stage of lepra, the mercurial treatment was successful, and that, in the confirmed or secondary stages, where debility and irritability existed, either from the continuance of the disease or too much mercurial prac- tice, the tonic treatment by arsenic was the most efficacious ; all of which is in general accordance with the experience of practitioners in the treatment of lues in our own coun- try.” The close relation existing between lepra and syphi- lis has been noticed by several writers, and it is very prob- able that in some instances they have been confounded.] 816 LEUCORRHCEA—Symptoms of. taining to the different forms of Elephantiasis and Lepra are confounded together. I may again state, that in the above article I have confined myself to the consideration of the Leprosy of the Middle Ages, which is identical with the Elephantiasis of the Greeks and the Lepra of the Arabians, a disease generally prevalent in Europe for some hundred years, and still met with in a few places, and in warm cli- mates ; that the Elephantiasis of the Arabians, Elephantia, Elephant Leg, Barbadoes Leg, Egyptian Sarcocele, &c„ is altogether different from tubercular leprosy ; and that the scaly lepra, the lepra of the Greeks, &c., is also distinct from both the foregoing maladies, and is merely a variety of psoriasis (which see). Doubtless, owing to the numerous causes above stated (Q 13, 28), cases of the last-named dis- ease were often aggravated, and others would assume so modified an appearance, that some difficulty, particularly in the early stages of the first of these maladies, might exist in forming a diagnosis; and this difficulty would be in- creased by the slow progress of all of them, and by the op- portunities of examining and observing them during their entire course, being frequently wanting.) [Am. Bibliog. and Refer.—Good’s Study of Medicine, Am. ed., by A. S. Doane, M.D., 1840. New-York, 2 vols. — Worcester, On Diseases of the Skin. Phil., 1845.—Caze- nave and Schiedel, On Cutaneous Diseases, Am. ed., by H. D. Bulkeley. New-York, 1846.—George W. Kendall, Nar- rative of the Santa F6 Expedition. New-York, 1844, 8vo. —Kidder, Travels in Brazil, 1844.—New-York Jour. Med. and Collateral Sci., vol. ii.—Report of Commission to in- vestigate the Origin and Nature of the Leprosy in New- Brunswick.—Valentine Mott, Travels in Europe and the East. New-York, 1842, 1 vol., p. 221. — Boyle, in Lond. Med. Gazette, 1843.—Maundrell, Travels.—Rayer, On Dis. of Skin, Am. ed., by John Bell. Phil., 1846.] LEUCORRHCEA. — Synon. Fluor Albus, Xev- Koppoia (from levnog, white, and peu, I flow); (6oof ywatKEtog, Auct. Grsec. Fluxio Vulva, Pliny. Ulcus Uteri, Sennert. Cachexia Ute- rina ; Menorrhagia Decolor, Sauvages. Men- orrhagia Alba, Cullen. Blenorrhcca Uteri vel Vagina ; Fluxio Vulva ; Fluor Muliebris ; Fluor Uterinus; Menstrua Alba; Catarrhus Genilalium, C. Vagina et Uteri, Auct. Var. Hysterorrhcca Mucosa, Swediaur. Medorrhaa Vagina et Uteri, Frank. Fleurs Blanches, Ca- tarrhe Uterin; Leucorrhee, Perte Blanche, Fr. Das Weisse; Weisser Fluss, Germ. Flusso Bianco, Ital. Weakness, White Discharge, the Whites. Classif.—1. Class; 4. Order {Cullen). 5. Class; 1. Order {Good). II. Class ; I. Or- der {Author). 1. Defin.—A light-coloured discharge from the female genitals, varying in hue from a whitish or colourless to a yellowish light green, or to a slight- ly red or brown; in consistence, from a limpid se- rum to a tenacious, ropy substance ; and in quan- tity, from a slight increase of the healthy secretion to several ounces in the twenty-four hours. 2. Various forms of this disease have been pointed out by writers, according to its pre- sumed seat or source, and to the several cir- cumstances connected with it. Most of the older writers treated it as a consequence of lo- cal relaxation, or of general debility. Dewees viewed it as generally proceeding from local inflammatory excitement; Pinel considered that it was sometimes accidental, constitution- al, and vicarious. Dr. Churchill has described it with reference to its seat, as vaginal and ute- rine. Dr. Ferguson has divided it into acute and chronic; and Dr. Ashwell into the com- mon, the inveterate, and the symptomatic. Sir C. M. Clarke arranged the varieties of leucor- rhcea chiefly with reference to the character of the discharge, believing that the appearances presented by it are indicative not only of its source, but also of the state of vascular action and of structural lesion in that source. A some- what similar mode was adopted by J. P. Frank ; but the arrangements of these two eminent physicians were formed more as a means of distinguishing the inflammatory and organic dis- eases of the female organs, than with reference to the functional disorders of these parts. 3. Leucorrhcea, in every form, and in most of the circumstances in which it occurs, is merely symptomatic, either of functional, in- flammatory, or organic diseases of the female organs, or of disorder of the general health. It is unnecessary, therefore, at this place, to attempt to give a full account of the several states in which it appears in practice, as its chief symptomatic forms are necessarily com- prised in the articles on the principal diseases of the vagina and uterus. 4. Leucorrhcea may occur at any period of life from earliest infancy to advanced old age ; but it is most frequent between the ages of 15 and 50. In childhood and early infancy dis- charges from the vagina and vulva are not in- frequent, and are commonly the consequence of irritation or inflammatory action ; the mu- cous membrane of the genitals partaking in the general disposition of mucous membranes to be irritated or inflamed at this period of life, and to furnish a copious mucous or muco-puriform secretion. About 45 years of age the disease becomes less frequent, and after 50 it is seldom observed, unless as a symptom of organic le- sions of the uterus. In childhood the discharge proceeds from the vagina and pudenda, and is a simple and primary disease; in old age it is chiefly from the uterus and os uteri, and is gen- erally symptomatic. During the period of ute- rine activity, it proceeds from either the vagina, the os uteri, or the internal surface of the uterus itself, or from any two, or all, of these situa- tions ; and is more frequently a consequence of pre-existing disorder than a primary affec- tion. Owing not only to the situation or source of the discharge, but also to the state of vascu- lar action and vital tone of the vessels which yield it, various appearances are presented by it; and hence, in the difficulty attending the in- vestigation of the exact states of disease pro- ducing it, the importance of determining the connexion of its several appearances with the particular morbid conditions upon which they respectively depend. The accomplishment of this object is not easy, nor probably can it be attained with great precision; still, if reached with even tolerable accuracy, it furnishes an important aid to the diagnosis, not only of the more primary states of this affection, but also of all the maladies of which this is symptomat- ic. Hence the attempts of J. P. Frank and of Sir C. M. Clarke to arrange uterine and vaginar diseases according to the appearances of the discharges attending them, have not been de- void of great practical utility. 5. It is most evident that, to ascertain the particular part or parts chiefly or solely furnish- ing the morbid secretion constituting leucor- rhcea, is of equal importance with a knowledge of the state of vascular action and vital tone in that part; and, consequently, that both these objects should be made the principal pathologi- cal points or facts to which medical treatment ought to be directed ; and, although both are attended with difficulties, still these difficulties should not prevent the examinations requisite to the attainment of satisfactory information. The scat or source of the discharge is therefore LEUCORRHCEA—Description of—Vaginal. 817 a matter of the first consideration, and hence becomes the most legitimate basis of an ar- rangement of its several forms. That the se- cretion is, in many instances, chiefly vaginal, is shown by the circumstance of pregnant fe- males being often the subjects of it; although, even in them, it may partly proceed from the mucous follicles of the os or cervix uteri. That, again, the discharge may proceed from the in- ner surface of the uterus itself, is shown in some cases of prolapsus uteri, and by a variety of circumstances about to be noticed (§ 35); and, as Dr. Ferguson observes, there is no rea- son for doubting that other causes of irritation than those dependant on uterine disorganiza- tion may likewise rouse the inner membrane of this viscus to unhealthy secretion. In se- vere forms of leucorrhcea, whether chronic or acute, the cervix uteri is rarely unaffected, be- ing generally softer, larger, and moister, and not infrequently more sensitive than natural. The portion, too, of the lining membrane ex- tending through the cervix into the orijicium in- ternum is especially formed for active secre- tion ; the palmae plicatse which radiate on it, and which become greatly developed in the progress of utero-gestation, and which pour forth such a quantity of mucus in the progress of labour, prove that it can be the seat of active secretion, and therefore of deviation of its nat- ural function. That the discharge may pro- ceed not only from the cavity of the uterus, but also even from the interior of the Fallopian tubes, appears to be shown by the histories of some cases, as more particularly mentioned by Frank ajid others. In the following account of leucorrhcea, I shall describe its forms with reference to their seats or sources, and to the grades of action characterizing them. 6. I. Leucorrhcea Vulwe.—Leucorrhcea In- fantilis.—Infantile Leucorrhcea.—i. Description. —A discharge occasionally proceeds from the vulva and orifice of the vagina. In children it proceeds from the general surface of the exter- nal genitals, and more rarely from the vagina, unless in delicate and relaxed children, subject to catarrhal and bronchial affections, attended by a copious defluxion, when it assumes a ca- tarrhal form, or in those affected with worms, or other causes of intestinal irritation. When this form occurs in adults its source is often more partial or limited. In both children and adults it may assume either an acute, or sub- acute inflammatory character, or a chronic state. In the former state, its commencement is evinced by itching or local uneasiness, and by scalding in passing water; and the surface of the vulva is somewhat swollen and red. This condition is soon followed by a colourless, thin, mucous discharge, which becomes more and more copious, thicker, and of a white or yellow hue. It is sometimes so acrid as to excoriate the surface, and even the skin at the margin of the vulva. There is little or no symptomatic fever. In delicate, sickly, and relaxed children, the symptoms are milder, and are more dis- posed to the chronic form, which, however, may supervene upon the acute or sub-acute attack. In chronic infantile leucorrhcea the discharge is more profuse, milky, or puriform, and is attend- ed by less pain, smarting, or inconvenience. In cachectic, plethoric, and scrofulous children ; in those confined in hospitals, or in crowded, ill-ventilated, and low apartments, or in the ill fed and dirty, the disease may assume a very serious and totally different form, or may give rise to a state of phagedenic ulceration or gan- grene, which is noticed in the article Vulva, Occasionally infantile leucorrhcea presents a catarrhal form, and is then sometimes associa- ted with slight bronchitic or catarrhal fever, or even with ozaena. In these cases, the secre- tion from the mucous surfaces generally con- sists, at first, of a thin or watery mucus, and is thicker and more glutinous as the affection be- comes more chronic. It is usually the result of irritation, and proceeds frequently from the va- gina as well as from the vulva. 7. ii. Treatment.—If the irritation be consid- erable, the parts should be fomented with a de- coction of marsh-mallow leaves, or with any other emollient decoction, three or four times a day. After each fomentation, the black wash, or a weak solution of the sulphate of zinc, or of the acetate of lead, may be applied. When the affection becomes chronic or obstinate, a lo- tion of nitrate of silver, of gr. vj. to xij. to the ounce of water, is the most efficacious. If the irritation extend up the vagina, a little of the lotion may be injected by means of a small syr- inge. The patient must be debarred from rub- bing, or having recourse to friction of the parts, and be kept quiet. Care ought to be taken that the urine be not retained too long from fear of the smarting felt when passing it; and when smarting is much complained of, the vulva may be fomented, or bathed with warm water or poppy decoction after each evacuation. Cool- ing, diaphoretic, and aperient medicines may be given occasionally. The diet should be light, and chiefly farinaceous, and the bed-clothes light If there be any tendency to adhesion of the la- bia vulva, lint and a little ointment may be placed between them. The parts ought to be duly examined, lest such adhesion should form. If they are early detected, they are readily de- stroyed by forcibly separating the labia. 8. ii. Leucorrhcea Vaginae.—Vaginal Leucor- rhxa.—i. Symptoms.—This form of the disease is sometimes acute, and very frequently chronic. —A. In the acute form, it is simple vaginitis, or inflammation of the mucous surface of the va- gina ; and, in the more severe forms, is with difficulty distinguished from specific inflamma- tion of the vulva and vagina (see Vagina and Vulva, Gonorrhoeal inflammation of).—a. The earliest symptoms are a sense of heat or sore- ness in the vagina, often with itching of the ex- ternal parts. To these are subsequently added pain or smarting, with a sensation of tightness as if the vagina were swollen. If the attack extend along the vagina, there is sometimes a feeling of weight or bearing down, or pains ex- tending down the thighs. The discharge, con- sisting of a thin, acrid, and colourless fluid, ap- pears soon after these symptoms, seldom later than a day or two ; but it soon becomes thick- er, whiter, or yellowish, more purulent, and re- sembling cream. As the dischargee increases, the uneasy symptoms abate ; and it frequently continues varying in quantity and appearance in a more chronic or sub-acute form. In the ear- ly part of the acute stage, the mucous mem- brane is swollen, and the canal of the vagina is diminished, and it is hot and tender; but these soon subside as the discharge becomes 818 LEUCORRHCEA—Acute—Chronic. copious. There is no breach of surface nor erosions of the membrane. In some cases, the labia and vulva are swollen, and more rarely the glands in the groin are enlarged. When the complaint is slighter, the local symptoms are less severe, and little or no constitutional disturbance may attend it; but the more se- vere attacks are often accompanied with slight rigours or chills, followed by pain in the back and loins, by languor, thirst, and quick pulse, and costiveness, with high-coloured urine, and smarting on passing it. The terminations of this state of the complaint are : 1. In the grad- ual subsidence of the symptoms and diminu- tion of the discharge ; 2. More frequently in chronic disorder, characterized chiefly by the continuance of the discharge, and of the lan- guor. 9. B. The diagnosis of this state of leucor- rhoea from gonorrhoea is frequently difficult, par- ticularly when the requisite examinations are not permitted. Sir C. M. Clarke seems to think it impossible in most cases. M. Ricord, however, states, that it is easily determined by the aid of the speculum uteri. Whenever the peculiar erosions or minute superficial ulcers of the mucous membrane covering the cervix uteri, which have been noticed by M. Ricord, are discovered, there can be no doubt of the gonorrhoeal origin of the disease. These ero- sions and small ulcers are met with, he states, in nineteen out of twenty cases of the gonor- rhoeal discharge. An urethral discharge is much more frequent in gonorrhoea than in simple acute leucorrhcea. M. Ricord states that, of two hundred cases of the former, eight in every twelve had the urethra affected. The glands of the groin are also much less frequent- ly enlarged in leucorrhcea than in gonorrhoea. In general, the symptoms are much more se- vere, the calls to pass water more frequent, and the pains attending it greater, the extension of '■ the disease to the uterus much more common, with the symptoms indicative of such exten- sion more acute, than in simple acute vaginal leucorrhcea.—(See art. Vagina, &c.) 10. C. Chronic leucorrhcea vagina — chronic vaginitis of Dr. Churchill—is a most common complaint. From the constitution and state of health of some females, and frequently owing to the continuance of the affection itself, it has been very generally viewed as a consequence of debility, local or general—of local relaxation. But a closer attention will often show that the local affection is often the result either of sim- ple or of inflammatory irritation, more espe- cially at its commencement. In many cases, also, it commences in the acute form already noticed, and passes into the chronic, the acute state being sometimes slight or of short dura- tion. 11. a. The symptoms of this form of leucor- rhcea are chiefly a more or less colourless or whitish and bland discharge from the vagina. In some cases, however, it is of a deeper hue, being greenish, yellowish, or brownish, and oc- casionally so acrid as to excoriate the edges of the vulva, and in some cases the insides of the thighs. There is scarcely any increase of heat, and little or no pain or tenderness. The ingui- nal glands are not enlarged. The patient oft- en complains of weakness and of languor, or weariness after exertion, particularly if the dis- charge be profuse. The countenance becomes pale, and, if the complaint be prolonged, weak- ness or aching of the loins, and various dyspep- tic symptoms are felt. When vaginal leucor- rhoea is neglected, it may, especially in its more acute states, extend to the os and cervix uteri, or even to the interior of the uterus. Ultimate- ly, it may be followed by prolapsus, or descent of the uterus, and increased constitutional dis- order. 12. b. Diagnosis. — Chronic vaginal leucor- rhcea is distinguished, 1st. From gonorrhoea, by the local irritation being much less in the for mer than in the latter; by the absence of sym- pathetic enlargement of the inguinal glands ; by the whitish or colourless appearance of the dis- charge ; by the absence of irritation or dis- charge from the urethra, and of scalding on passing urine ; and by the less frequent calls to pass it; 2d. From uterine leucorrhcea, by the absence of the more prominent and constant phenomena attending that form of the com- plaint, by its not being increased before or af- ter the menstrual period ; and by the much less severe constitutional disturbance, and much less marked sympathetic phenomena. 13. D. Causes of the Acute and Chronic vaginal Leucorrhcea.—a. The causes of the acute or in- flammatory state of this complaint are, chiefly, cold, violence, excessive indulgence ; the cir- cumstances connected with the transition from the virgin to the married state, rape, exertion soon after delivery, inflammation extending from the vulva or labia; high or rich living, in connexion with habitually sitting on hot cush- ions ; sitting on very cold seats, on stones, or on the ground, especially if accustomed to warm seats; irritation from foreign bodies or stimulating injections, or from inflammatory haemorrhoids, or other inflammatory diseases I of the rectum. This form of the complaint is I not frequent in unmarried and elderly females, and it is much favoured by the habits, modes of living, and disposition of the patient. 14. b. The causes of the chronic form of the complaint are both local and constitutional or general. The local causes are the acute state of the disease ; irritations of various kinds, as of a pessary, or of excessive sexual excitement; displacement of the womb ; frequent child-bear- ing, or abortions ; the irritation of worms in the rectum, haemorrhoidal or other affections of the rectum; the local application of cold when unaccustomed to it, or warm, or relaxing ablutions or fomentations ; sitting and riding on warm cushions, and excessive indulgence in warm bathing. The general and constitutional causes are chiefly full and rich living and a neg lect of exercise, favouring the determination of the circulating fluids to the genitals, as duly insisted upon by Sir C. M. Clarke ; the influ- ence of cold and vicissitudes of season and weather on the frame, but more especially of warm, humid, and miasmal climates, as evinced among Europeans residing in the East Indies, and in other warm and intertropical countries; the abuse of spirituous and fermented liquors, previous debility and debilitating diseases ; the excitement connected with hot and crowded rooms, with music, dancing, and mental im- pressions. The period of female life during which this form of the complaint is most com- mon is from the appearance to the termination LEUCORRHCEA—Chronic—Treatment. 819 of the menstrual epoch of life—the term of ute- rine activity. It may, however, occur either before or subsequently to this term. 15. E. Treatment.—a. In the acute state of vaginal leucorrhcea, local or general vascular depletion, according to the age, habit of body, and strength of the patient, may be prescribed. If the symptoms be acutely inflammatory, this will be the more requisite, and should be aided by fomentations, by vaginal injections of warm water, and by hip baths. Subsequently, injec- tions of a solution of acetate of lead or of sul- phate of zinc may be resorted to. The patient should preserve the horizontal position, and sleep on a cool mattress, with light bed-clothes ; and the bowels ought to be kept gently open by means of the cooling saline aperients. Refri- gerant diaphoretics may also be prescribed. The diet should be light and spare, and the bev- erages cooling. 16. b. The chronic state of vaginal leucor- rhcea very rarely requires even local depletion. Much more frequently tonics and astringents, either vegetable or mineral, are found neces- sary, and when the patient is debilitated or ca- chectic, they should not be neglected. The balsams, especially copaiva balsam, have been recommended by many. I have often given, with much advantage, the copaiva and other balsams in the form of pills with magnesia ; and if this combination acted upon the bowels, I have added either small doses of opium or of the compound ipecacuanha powder, or of the compound storax pill, with increased benefit. Dr. Dewees has employed the tincture of can- tharides : I have had no experience of it in this complaint. It may probably be advantageously conjoined with the tincture of the sesqui-chloride of iron, which I have often prescribed with ben- efit in this disorder. Dr. Blundell and others advise the cubcbs in tincture or powder, and the compound tincture of benzoin. These, and oth- er tonics usually prescribed, are of great ser- vice when the complaint is limited to the vagi- na, and when there is irritation about the ure- thra ; for the cubebs, benzoin, and even the balsams, operate chiefly upon the urinary passa- ges. In many cases, however, they are infe- rior to the preparations of cinchona conjoined with mineral acids, or the sulphate of quinine. When there are marked debility, relaxation, and pallor, the combination of the sulphate of iron, quinine, camphor, &c., as in the follow- ing pills, is very beneficial: No. 286. R Camphor® ra’s®, Ferri Sulphatis, Quininae Sulphatis, as 3j. ; Ext. Anthemidis, 3ij.; Balsami Peruvi- q. s. ut fiant Pi ltd®, xxxvj.; quarum capiat duas vel tres, bis terve quotidie. 17. Various local means have been resorted to with advantage ; and, when the uterus is al- together unaffected, and the system is not pre- disposed to suffer from the sudden suppression of the discharge, they may be prescribed, but with more caution than I have known them to have been prescribed by several practitioners. Of these the most generally efficacious are thedecoc- tion of oak bark, or of cinchona, or other astringent barks, with or without alum ; and solutions of the sulphate of zinc, or of alum, or of nitrate of silver, thrown up by means of a suitable female syringe. The strength of these astringent so- lutions, usually advised, is frequently too great at the commencement of the treatment. I be- lieve it to be more beneficial, as it is safer, to prescribe at first only one drachm of the first, half a drachm of the second, and a scruple of the third of these salts to eight ounces of wa- ter, and gradually to increase the strength of the solution, according to circumstances. These injections should be employed at first tepid, and the temperature may be gradually reduced. They should be administered slowly, while the patient is in the recumbent position, and twice daily. During the treatment, the cold shower bath, or the cold douche on the loins and hips, will be of service. The patient ought to take gentle and regular exercise in the open air, and attend to diet and to the state of the bow- els. 18. Swelling and painful affections of the joints have been mentioned by Dr. Jewell as having sometimes appeared after the sudden suppression of leucorrhcea by injections. I have met with still more serious, and even fatal con- sequences, resulting from the use of strong in- jections, particularly when the uterus has been affected. Some years ago, especially, such oc- currences were not infrequent, for the excel- lence of a practitioner was too often considered great, particularly by coarse or vulgar minds, in proportion to his boldness or temerity ; and even now, when the individual organs and mem- bers of the body are taken under the especial protection of their respective physicians—now, when there is a physician for the brain, another for the lungs, a third for the heart, a fourth for the liver, a fifth for the stomach, a sixth for the bowels, a seventh for the urinary organs, an eighth for the female organs, a ninth for the spine, and so on for every prominent viscus, feature, sense, and limb of the human micro- cosm—now that the division of labour and the numerical calculations, which are applicable to mechanics, to political economy, and statistics, have been transferred to medical practice by the small minds who are incapable of grasping anything beyond a few palpable entities or ob- vious truths, or of extending their views to the numerous connexions, combinations, and suc- cessive states of morbid action—now, when the scientific physician, who pursues his vocation with elevated ideas of its relations to all other branches of knowledge, and of its tendencies and objects, finds the very circumstances which improve his intellects, enlarge his views, and extend his mental vision to the more compre- hensive, remote, and influential agents, rela- tions, and results of disease, the strongest bar- riers he has to surmount in pursuing a success- ful career of practice—now, when ignorance, presumption, impertinence, absurdity, plausi- bility, and humbug play their several parts in forming the medical character, and in taking advantage of popular errors in the modes of ex- ercising it—and now, when cant, rant, and quackery in religion, politics, government, and morals have infected the public mind, given currency to worthless pretension, and extend- ed its influence to medical science—the re- flecting will not be surprised, nor will the judi- cious be disappointed, when they find physi- cians, whose minds are duly imbued with liter- ature and science, and who believe that the human economy, both in health and in disease, can be successfully studied only as a whole, and in all its parts, relations, and connexions, 820 LEUCORRHCEA—Uterine. altogether overwhelmed by the crowd of noisy pretenders who obstruct the paths of science, knowledge, and honesty. 19. III. Leucorrhcea from Inflammatory Irritation of the mucous Glands of the Os nd Cervix Uteri.—This variety of leucorrhcea was first distinguished and connected with its source by Sir C. M. Clarke. It is characterized by the white appearance of the discharge, by pain in the lowest part of the sacrum, and by the state of the os and cervix uteri. 20. A. The symptoms are aching or pain at the lower part of the sacrum, or at the os co- cygis, and behind the pubis, increased by cough- ing or straining, or other actions of the abdom- inal muscles, and by sexual intercourse. The bladder and rectum are often irritable ; and menstruation is occasionally difficult. The dis- charge, particularly in the more acute cases or early stage, is opaque, white, and resembling in consistence a mixture of starch and water with- out heat, or thin cream. It is readily washed from the finger after an examination, and is ca- pable of being diffused in water. It is often much thicker than cream, and very tenacious. In this case it does not flow off, but remains in the vagina until exertions to empty the rectum squeeze out, at the same time, the contents of the vagina. When it becomes more chronic, it is often connected with some degree of vaginal discharge, by which it is rendered more fluid; and it may be associated with uterine leucor- rhcea, when it will be attended by the charac- teristic signs (§ 27) of that variety. An inter- nal examination detects nothing unusual in the vagina, but the os and cervix uteri feel swollen, and are very painful when pressed. 21. Although irritation or inflammatory ac- tion of the glandular apparatus of these parts may generally be attended by a white discharge, still it must be admitted that a similar dis- charge sometimes attends other sexual diseas- es without the os and cervix uteri being mate- rially affected. During the earlier stages of this affection, constitutional symptoms are ei- ther slight or absent; but if the complaint con- tinue long, or if it be associated with discharge from the vagina or uterus, debility, pallor, and some degree of anaemia, difficult or scanty men- struation, costiveness, and various dyspeptic symptoms commonly result. Sir C. M. Clarke suspects that this state of disease, particularly when neglected, sometimes precedes the more serious organic or malignant lesions to which this part is liable. This is not improbable, es- pecially when the disease occurs, and proceeds unchecked, in faulty constitutions, and where there is a tendency to malignant or structural changes. The character of the discharge in connexion with the state of the parts just men- tioned forms the diagnosis of the complaint. 22. B. The causes of this variety are those already mentioned (t) 13), and more especially cold, irregular habits, excessive indulgences, especially after marriage, great muscular exer- tions, the suppression of the catamenia, men- tal excitement, high-seasoned food, late hours, balls, the other forms of leucorrhcea, &c. 23. C. Treatment.—During an early stage of the complaint, cupping on the loins or sacrum, abstracting blood according to the severity of the symptoms, and constitution, and habit of body of the patient, is generally requisite ; and a repetition of it may be necessaiy. If the cat- amenia be difficult or scanty, a numler of leech- es should be applied below each groiv. a day or two before the expected return of this evacua- tion. The hip bath, or fomentations to the lower parts of the abdomen and back, once or twice daily, will often afford additional relief. Injections of tepid water into the vagina three or four times a day, or of a tepid decoction of poppy heads, if pain continue, or if the bladder be irritable, and the horizontal position, are generally beneficial. The bowels should be kept open by gentle and cooling aperients, such as the tartrate of potash, the super-tartrate of potash with confection of senna, or castor oil. Active purging, especially by resinous purga- tives, ought to be avoided. 24. When this complaint becomes chronic, its removal is difficult, particularly if it be as- sociated, as it often is, with uterine or vaginal leucorrhcea. In these cases, the horizontal po- sition ; frequent vaginal injections of tepid, an- odyne, and gently astringent fluids ; attention to the secretions and excretions, and particu- larly to the state of the bladder ; regular, light, and spare diet, and alteratives suited to the pe- culiarities of the case, are usually required. I have seen benefit arise from the super-tartrate of potass, with precipitated sulphur, and either with confection of senna or with any aromatic sirup, taken every night, so as to procure one copious pultaceous evacuation in the morning. If the bladder be irritable, demulcents, with the compound tincture of camphor and liquor po- tassae, will be serviceable, particularly if aided by tepid anodyne injections. If tenesmus oc- cur, a small cupping on the sacrum, and a starch enema, with a little sirup of poppies, will be of service. In other respects, the treat- ment may be much the same as that advised for uterine leucorrhcea ($ 41). 25. IV. Uterine Leucorrhcea.—It is some- times difficult to determine whether the dis- charge from the female organs proceeds from the vagina, or from the uterus, or from both; still, a tolerably accurate inference may be drawn, and it is often of consequence, as re- spects the treatment, that a correct opinion should be formed as to this point. That the uterus often is the affected organ, has been proved by the quantity of whitish or colourless fluid found in it after death, the female having been subject to leucorrhcea during life. Blat- tin states that, in nine cases out of twenty- four that he examined, the discharge proceed- ed from the uterus. The older writers believed that the uterus was the source of it in com- mon with the vagina, without, however, sta- ting the symptoms which are proper to the af- fection of this organ. Many modern authors entertain a similar opinion. Baglivi, Friend,. Astruc, Manning, and Leake consider that the discharge proceeds chiefly from the ute- rus. Denman, Burns, and Hamilton distin- guish, although briefly and imperfectly, the uterine and vaginal leucorrhcea. Dr. Locock thinks it difficult to establish a distinction, and does not attempt it. Dr. Blundell treats of vaginal leucorrhcea only ; while Gardien, Ca- puron, Duges, Lisfranc, and Nauche consider the complaint as one chiefly of the uterus. Siebold, Joerg, and Churchill have descri- bed the uterine variety at due length, and have LEUCORRHCEA—Uterine. 821 insisted upon the importance of recognising the existence of the uterine affection. M. Marc d’Espine has given the results of his ex- aminations with the speculum in 193 cases, and they have been referred to by some very re- cent writers, but without remarking that these examinations were entirely of patients in a venereal hospital: a circumstance that entire- ly vitiates his data, if made the basis of infer- ences as to the female community in general. Bearing, however, in mind the description of persons thus examined, the results may be worth recording. In 23 of 193 cases, the ute- rine orifice was found dry ; in 40 there was only a drop of discharge in the orifice ; and in 130 the discharge wras abundant. The orifice itself was in some quite healthy and pale ; in others, red, or deep red; and in some deep red, granulated, and bloody. The following table exhibits the character of the discharge, and the state of the uterine orifice in 111 cases : only the mucous membrane of the womb vas- cular and secreting an increase of its natural, or a somewhat modified discharge. In others, ulcerations of a more or less depth, extent, vividity, and variety of appearance are met with; in many cases associated with general or partial swelling and redness of the neck, with granular tubercles or papules, and with more or less redness of the vagina, in which case the follicular discharge of that part is usually much increased. Which of these le- sions is the starting-point it is difficult, though practically not unimportant, to decide ; but it is perhaps sufficient to know that such is their mutual dependance on each other, that each, when met with, requires special attention be- fore coexisting ones can be removed. Thus, a muco-hysteritis may cease upon, or its cure re- sult in the disappearance of a congestion of the neck ; while the latter has equally been seen to subside upon the cure of an ulceration, or an ulceration to require the removal of one or both of the other morbid states, before it could be made to cicatrize. Such we believe to be, even in cases which present the appearance of great constitutional debility, the true pathology of leucorrhcea; and we flatter ourselves that we have, in the foregoing pages, drawn the at- tention of the profession to the fact, scattered about, we acknowledge, in many volumes, but not before insisted upon and illustrated with equal force and distinctness, of the dependance of leucorrhcea upon certain phlegmasial states of the vagina and uterus, of its being not a disease per se, but a mere symptom of disease in the parts by which it is secreted, and seldom, if ever, the result of simple atony of those parts, as has so long been surmised. Nor is the dis- charge alone, we apprehend, often, if ever, the sole cause of the debility wiiich confessedly so often attends it, but which depends rather upon the constitutional irritation and derangement of the general health, consequent upon the ex- istence of a chronic local phlegmasia. The er- ror which Broussais so ably exposed relatively to certain cases of dyspepsia has been extend- ed to the disease in question ; the morbid effects of chronic gastro-enteritis and muco-hysteritis, and, to a certain extent, their pathology, are analogous, and their cure depends alike upon a judicious employment of a suitable antiphlo- gistic treatment, and the avoidance of the nat- ural and artificial stimuli of the organs diseased. But, while we have questioned its frequency, and adduced abundant evidence to justify our incredulity, we have not wholly denied the rare but possible occasional indubitable occurrence of cases of either, dependant, if the reader will, upon a simple atony of the part, or an increase not appreciably morbid of the secretory irrita- tion, upon which the phenomena of either de- pend. The term ‘ weakness’ has long been a cloak for ignorance, and the more enlightened pathology of modern times has established that of all chronic fluxes upon a more rational and scientific basis. Few are not now known to depend upon a state of inflammation more or less acute : if there be other causes for the uterine, we have not encountered a case w'hich countenances the idea. The lesions of the va- gina and uterus, with which we have shown that leucorrhcea is so invariably connected, are not sufficiently appreciable and seldom curable Orifice healthy. Orifice reddish. Orifice deep red and granulated. Aqueous discharge .... 7 3 i Albuminous transparent dis- charge 30 6 6 Albuminous semi-transparent discharge streaked blue, gray, or yellow .... Opaque discharge streaked . 13 19 10 3 7 6 53 35 23 [Dr. W. C. Roberts, in the N. Y. Journ. of Med. and the Collat. Sciences, vol. iv., v., has, in a very able and comprehensive essay on the pathology of leucorrhcea, given a summary of the views of preceding writers in relation to its pathology, together with his own views, derived from a very extensive experience with the speculum. Dr. R. thus concludes his ob- servations : “ We have now presented to the reader fifty-nine authentic cases in which leu- corrhceal discharge depended upon organic le- sion of the womb, or vagina; it would have been easy to have increased the number, but this would be unnecessary, for unless it can be shown that, which is contradicted by the united testimony of all who have published the result of their observations, leucorrhcea is also fre- quently seen to exist in the absence of any ap- preciable morbid state, these are surely suffi- cient to establish the real and symptomatic na- ture of the flux in question. In forty-six out of these fifty-nine cases, it is distinctly stated that the neck of the uterus was either swelled, red, livid, or granular; in two or three only it presented a natural appearance as to size and colour, the redness being confined to the inter- nal lining membrane. In thirty-three out of the fifty-nine, ulcerations existed ; in forty, the dis- charge was distinctly to be seen escaping from the os uteri; in others, this is not noticed ; in five, the vagina was red ; and in two only was the discharge chiefly follicular. The last state- ment sets at rest the idea that leucorrhcea is, for the most part, a vaginal disease; whereas its almost constant connexion with an inflamed 3tate of the neck and internal mucous lining of the uterus and vagina is clearly demon- strated by evidence which we firmly believe cannot be shaken, and the truth of which far- ther observation wfill serve only to confirm. The progress and effects of the inflammation are not the same in all cases ; in some we find 822 LEUCORRHCEA—Utf. rine. without the aid of the speculum, an instrument as indispensable in the treatment of the dis- eases of these organs, as the stethoscope in those of the heart and lungs, and to the non-use of which the errors of our predecessors on the subject of the uterine catarrh are referable. It is not even now—for two very obvious reasons, the disagreeable nature of the investigation, and the natural repugnance of both physician and patient to its use—the custom to employ it in the treatment of leucorrhcea But if the physician can but become assured of its value and necessity in these cases, he will, in justice to his patient and himself, recommend and em- ploy it. Its use will then become custom, sur- prise at its proposal will soon cease to be felt; nay, surprise may even be expressed if the usual means of full investigation be not resort- ed to, and the sufferer with leucorrhcea will look to be examined with the speculum with as much certainty as the phthisical one does to be percussed and auscultated. The objections to its use must yield to the sense of its necessity and utility; and when conscientiously and prop- erly urged, there will be found, after all, few sensible and right-minded females who will ob- ject to its employment; when properly used, few will refuse to consent to a repetition. We trust that no other than a conscientious belief in both, founded upon our ideas of the nature and cure of the affection, and the opinion of others, impels our advocacy of it in the disease in question ; and whenever it shall come to be generally employed, much suffering will be speedily obviated, many errors in diagnosis corrected, many a barren woman will become the joyful mother of children, and many a case of ultimate degeneration into incurable malig- nity will be prevented.”] 26. That it is important to explain the differ- ences in the local and constitutional symptoms characterizing uterine and vaginal leucorrhcea cannot be questioned, and these have been well shown by Dr. Churchill. That the discharge may proceed from both the uterus and vagina in the same case, must be admitted ; and that the vagina is seldom exempt when the uterus is affected, the discharge from the latter gener- ally keeping up some degree of affection in the former, may also be conceded; still, a knowl- edge of the symptoms attending the affection of the uterus aids us remarkably in determin- ing whether or not this organ is the chief source of the complaint. 27. A. Symptoms.—Uterine leucorrhcea is a more or less profuse discharge of fluid from the internal surface of the uterus, varying in col- our ; and is neither accompanied nor followed, necessarily, by organic change. It may affect females of all ages, from the time of approach- ing puberty; and it may assume acute, sub-acute, and chronic forms; the first and second of these states occurring chiefly in the young, robust, or middle-aged. It may occur in every tem- perament and habit of body, but with varying local and constitutional phenomena. 28. a. Acute uterine leucorrhcea is not so rare an affection as Dr. Churchill supposes. I have seen several cases of it; and, in some, the symptoms have been so severe as to amount to inflammatory action, the disease being rath- er hysteritis, with copious discharge from the internal surface of the uterus, than simple ute- rine leucorrhcea. When gonorrhoea occurs in the female, it is very apt to extend to the ute- rus, and to simulate an extremely acute form of leucorrhcea, or to cause inflammation of the uterus. Acute uterine leucorrhoea is attended by considerable local suffering and constitu- tional disturbance; more or less pain or un- easiness is felt between the sacrum and pubis, or in the hypogastrium, and is increased upon firm pressure in the latter situation. The un- easiness extends to the perinaeum and vulva; and the patient complains of dragging or un- easiness in the loins, sacrum, hips, and thighs, sometimes with frequent desire to pass water, or with spasmodic retention of it. These symptoms are generally increased by standing, walking, or exertion, and are often accom- panied with hysterical symptoms, quickened pulse, and thirst. On examination per vagi- nam, the cervix uteri is sometimes tender to the touch, or slightly swollen. The discharge varies in quantity and appearance; it some- times is copious, and evacuated in considera- ble quantity, affording marked relief, when it becomes scanty or ceases for a time; and it afterward reaccumulates, and is discharged more abundantly. In these cases, the local and constitutional symptoms, varying much with the severity of the disease, and the state of the patient, indicate inflammatory irritation of, or vascular determination to, the internal surface of the uterus, with increased secretion in this situation. In some instances,' the secretion seems to accumulate in the uterine cavity, and occasions an increase of the symptoms, espe- cially of the uneasiness or pain in the vicinity of the uterus, and of the lassitude, malaise, and pains of the joints before its discharge. In some instances it has presented a puriform ap- pearance, but it varies in different cases, and even in the same case. 29. b. The sub-acute state is merely a milder form of the preceding, and differs from it only in the greater mildness of the symptoms. If either this or the more acute state be not cured, it gradually subsides into the chronic, present- ing, however, several exacerbations in its progress, particularly before or after the men- strual period, which it may in some cases even replace, with so marked an aggravation of all the symptoms as to amount to a form of in- flammation of the uterus described in the arti- cle on that organ. 30. c. Chronic uterine leucorrhoea is a very common complaint; and, although it occasion- ally follows the preceding states, it much more frequently commences in slight disorder, or with a mild state of the symptoms above enu- merated. As the complaint proceeds, languor, weakness in the loins, headache, aching in the joints after exertion, pallor of the countenance, with a darker shade of colour under the eyes and increased discharge from the genitals, es- pecially at intervals, or shortly before or for some time after menstruation, are commonly present. When it has become persistent, or so chronic as to affect the general health, and especially if it have superseded the catamenial evacuation, the local and general symptoms are much more severe. A constant aching or pain is felt between the pubis and sacrum, with a sense of dragging in the loins, or of weight and occasionally of bearing down in the pelvis. LEUCORRHCEA—Uterine—Diagnosis. 823 31. The patient now often complains of headache, of languor, and indisposition to ex- ertion, of exhaustion after slight exertion, and sometimes of vertigo and faintness, which, with the headache, are owing to debility and insufficient circulation in the brain. Pain is occasionally felt in the spine, or in the back of the head, and is unattended by intolerance of light and noise. Sympathetic pains are often felt in different parts. The tongue is loaded, sometimes dry, yellowish, pale, sodden, or flab- by, and often indented by the teeth. The ap- petite is impaired or capricious ; the bowels and liver become torpid or insufficiently active, the face pallid, the eyes sunken and surround- ed by dark circles, and eruptions of acne punc- tata appear on the forehead and face. At last the pulse is small, quick, and weak ; the sur- face is flabby and pale, the ankles swell, and the countenance is waxy, yellowish, or chlo- rotic. 32. On examination per vaginam, the body of the uterus feels somewhat enlarged. The os uteri is a little more open than in the healthy state ; but its sensibility is not materially in- creased. The French practitioners, and a few British, who delight in the parade of this mode of research, inform us that the speculum uteri shows the cervix uteri pale, slightly rose-col- our, deep-red, or spotted ; yet I suspect that few reflecting physicians will consider them- selves much enlightened by the discovery, or will be induced to prescribe according to the shade of colour thus detected. Yet, the great fuss, parade, and seeming pains evinced, with the apparent object of getting at the truth, es- pecially when it lies deep, are not without their influence upon the mind of the patient; and the knowledge supposed to be obtained thereby is considered great in proportion to the trouble and difficulty of procuring it. 33. The discharge varies much in quantity. It is sometimes profuse. In most instances it is colourless and semi-transparent; in others it is opaque, and presents either a yellowish, greenish, or brownish tinge. It varies in con- sistency, from a very thin or watery mucus, to a gelatinous mucus resembling the white of a raw egg, or to a curdled-like matter in a few instances (Hamilton, Nauche, &c.). It is usually bland ; but Dr. Churchill has observed it so acrid as to excoriate the labia and adjoin- ing skin. I have observed this acridity in two instances of the complaint occurring in con- nexion with the accession of the catamenia. 34. Chronic uterine leucorrhcea may continue for a very long period, and prove inveterate, however judicious the treatment may be Its duration will depend upon the constitution of the patient, and the causes which occasioned it. If those causes continue in operation during the treatment, as is very frequently the case, the complete removal of the complaint is not only difficult, but nearly impossible, until a change takes place in the patient’s habits and feelings. 35. B. Diagnosis.—a. The circumstances more especially diagnostic of uterine leucorrhcea are, as Dr. Churchill has justly shown, 1. The occurrence of the discharge in young, delicate females at one, two, or three of the monthly periods preceding the evolution of the catame- nia, these causes indicating incipient activity of the uterus, with deficient vascular determi- nation. 2. The discharge of whites during subsequent monthly periods, where menstrua- tion has been suppressed. 3. An increased discharge during two or three days previous to menstruation, and immediately after it, in those eases where leucorrhcea is more persistent ; in these, the leucorrhcea may gradually dimin- ish the catamenia, until it entirely supersedes, or becomes vicarious of it. 4. The occurrence of menorrhagia in connexion with leucorrhcea, the latter preceding or following, or both pre- ceding and following the former, sometimes in great abundance, and occasionally continuing during the intervals between the menorrhagia. 5. The discharge of whites about the cessation of the menses, and the substitution of it for the menstrual evacuation. 6. The appearance of leucorrhcea in place of the menses, in chlorotic females, as not infrequently observed. 7. The termination of abortions, or of the coloured discharge attending them, in leucorrhcea. 8. A similar transition of the lochia, after delivery, into the colourless secretion. 9. To these I may add, the copious discharge of the morbid secretions at intervals, and sometimes after an exacerbation of the local symptoms ; and, 10. The local and constitutional symptoms char- acterizing this form of the complaint, as above described. It should, however, be kept in rec- ollection that uterine and vaginal leucorrhcea both often coexist in the same case ; that the glandular irritation of the os and cervix uteri {(} 19) may be associated with either or with both ; and that, although vaginal leucorrhcea may often exist alone, uterine leucorrhcea, es- pecially in a chronic form, and when the fluid is at all acrid, will be accompanied with a dis- charge from the vagina, and occasionally even from the vulva also. 36. b. This- variety is with difficulty distin- guished from uterine gonorrhoea, unless the su- perficial erosions, described by M. Ricord, be present. Still, attention to the history of the case, and the greater severity of the symptoms than even in the acute state of the complaint, will indicate its nature. In two cases of ute- rine gonorrhoea, which were treated by me in 1839 and 1841, and which occurred in recent- ly married ladies, the symptoms were still more acute than those above described, and were consequent upon the affection of the vulva, urethra, and vagina. There were much heat, swelling, and pain in the parts, and in the re- gion of the uterus, the uterine symptoms being exacerbated at intervals, and followed by a co- pious discharge of yellowish, opaque, puriform matter, occasionally coloured with blood, and generally increased immediately after the ex- acerbations. The discharge assumed a green- ish hue after a time, and the disease subse- quently appeared in the usual form of chronic uterine leucorrhcea, presenting many of the features of gleet in the male. The severity, character, and history of the case, and what has already been advanced on the subject-, will generally disclose the nature of the complaint. 37. c. Inflammatory irritation of the glandu- lar apparatus of the os and cervix uteri is distin- guished from uterine leucorrhcea by the regu- lar white puriform discharge, and the tender- ness of the part on pressure, these character- istics being only occasional or accidental in the 824 LEUCORRHCEA—Uterine—Treatment. latter. The slightest attention to the history of the case will prevent the discharge of the contents of an abscess of the uterus, ovary, cel- lular tissue, or adjoining parts, by the vagina, from being mistaken for this complaint. 38. C The causes of uterine leucorrhcea are diversified, and are oftener inferred from va- rious circumstances than from direct testimo- ny or satisfactory proofs. They are constitu- tional, local, and mental; and individual caus- es belonging to these classes of influences may be variously combined in their operations in different cases. Delicate, susceptible, and scrofulous persons seem most predisposed to this complaint; and the inordinate indulgence of the emotions, especially of the desires, often concurs with other causes in producing it. Lo- cal excitement, venereal excesses, masturba- tion, and sedentary habits, or indolence, are certainly influential agents in developing it. Fatigue, over-exertion, cold, humid, and mias- matous localities, sedentary occupations, fre- quent abortions or child-bearing, undue or pro- longed suckling, the use of emmenagogues, or of stimulating injections, or of pessaries; a too rich, stimulating, full, or heating diet and regimen ; the suppression of other discharges ; the too frequent use of resinous purgatives, and the irritation of intestinal worms, may severally, or in various combinations, be con- cerned in producing this form of leucorrhcea. 39. D. The nature of uterine leucorrhcea can hardly be mistaken. The concomitant signs of debility lead many to infer that it is a dis- ease of debility, and proceeds entirely from re- laxation of the internal surface and parietes of the uterus. This may be the case, in some degree, especially after the complaint has con- tinued for a considerable time. Others, again, believe that the discharge is altogether owing to acute, sub-acute, or chronic inflammation of the internal surface of the womb, according to the forms it assumes, and that the local and constitutional symptoms are owing to these states of vascular action in the organ. Prob- ably there are many cases in which inflamma- tory action truly exists ; and others, in which debility, as respects the states of both the in- ternal surface, and of the parietes of the or- gan, performs its part. Still, I believe that too much is imputed exclusively to the one or the other ; and that a third state, not necessarily connected with either, although sometimes as- sociated with one or the other, is most fre- quently concerned in producing the discharge. If the circumstances connected with the oc- currence of the complaint be duly considered, there is much reason to infer that it is often owing to the vascular determination to the uterus and female organs, generally conse- quent upon the excitement or irritation of the nerves supplying these organs or parts; and that such excitement, and the vascular deter- mination consequent upon it, are in some ca- ses carried almost to the pitch of inflammatory action, as in the acute states; while in others, as in the more chronic, it is attended by im- paired tone of the extreme vessels in the in- ternal surface of the organ, and probably also, in some instances, with deficient tone of the parietes of the organ itself. The importance of entertaining correct views as to the nature of the individual cases occurring in practice is manifest; for upon these views must the treat- ment be altogether based. 40. E. Terminations.—When uterine leucor- rhcea is neglected, it may give rise to very serious diseases, both local and constitutional. Amenorrhoea, anasmia, chlorosis, sterility, phthi- sis, and even dropsy, are occasionally conse- quent upon neglected or protracted states of this affection. These contingencies should in- fluence our prognosis in many instances; but generally a favourable result may be expected in the less protracted cases, and when the ex- citing causes are avoided. 41. F. Treatment.—On this subject, the ob- servations of Dr. Churchill are extremely just, especially as regards the use of astringent in- jections, and agree with those which I have promulgated for many years.—a. In the acute and sub-acute states of the complaint, the local abstraction of blood by cupping on the sacrum or loins, or by applying a number of leeches below both groins, or to the vulva, [or os uteri,'] when the catamenia are scanty or suppressed, is generally requisite; and, in some cases, a repetition of the depletion is necessary. The hip bath, and injections of warm water per va- ginam, are subsequently of service. The bow els should be kept gently open by means of cooling aperients and laxatives, such as those mentioned above (§ 23); and small doses of camphor, of the liquor ammoniae acetatis and spiritus aetheris nitrici, to which small quanti- ties either of the vinum ipecacuanha! or of the liquor antimonii tartarisati may be added, ac- cording to circumstances, should be given every four or five hours. After the more acute symp- toms have been removed by these remedies, the application of a blister on the sacrum, as advised by Dr. Leake and Dr. Churchill, and the repetition of it oftener than once, if the case be obstinate, will be found of great ser- vice ; or either of the' liniments (Nos. 296, 298, 311) in the Appendix may be kept applied, on two or three folds of flannel, as an embrocation. 42. b. In the chronic state of uterine leucor- rhcea, blisters on the sacrum, or the terebinthi- nated embrocation on the sacrum, or loins, or on both ; the occasional recourse to an enema with about an ounce of the spirits of turpen- tine ; and the sulphate of quinine, with camphor and capsicum, in doses of about two or t hree grains of each, taken twice or thrice daily, are the means which I have found most beneficial. Dr. Churchill states that the medicines which he has found most useful are : 1st. The balsam of copaiba, in pills, or otherwise, increasing the dose from fifteen minims ; 2d. The sulphate of iron, with blue pill, or the compound rhubarb pill; 3d. Decoction of logwood ; and, 4th. The ergot of rye, in doses of five grains, three or four time a day. 43. The tincture of the sesqui-chloride of iron, with tincture of cantharides ; the sulphate of iron, with camphor and rhubarb; and the sul- phate of zinc, with aromatics, &c., have sever- ally been prescribed by me with advantage. Iodine has been advised by Brera, Gimelle, and Sablairolles, especially in very chronic and obstinate cases. My experience of this medicine leads me to recommend a trial of it when the disease is associated with scanty or difficult menstruation, and when the system presents a pallid, anaemic, or chlorotic appear- LEUCORRHCEA—Uterine—Treatment. 825 ance, and then the iodide of iron * and the prep- arations of guaiacum, will often be of service. The ergot of rye has been recommended by Roche, Dufrenois, Negri, Ryan, and Church- ill, and may be given in larger doses than those prescribed by the last of these writers, conjoined with some aromatic powder or spice. It is most serviceable in those cases which are connected with menorrhagia or excessive men- strual discharge, in which cases I have found the arsenical solution also productive of great benefit. Besides these, the ammonia-citrate, or the ammonia-tartrate of iron, the preparations of krameria, or of uva ursi, or of the pareira brava, or of the diosma crenata, [or pyrola umbellata,] may be employed, especially in the more obsti- nate cases. M. Nauche advises the use of aro- matics ; Dr. Hunt, of the capsicum; Drs. Fis- cher, Roberton, and Dewees, the tincture of cantharides; Hecker, the cascarilla bark; Lange, camphor with oil of amber and nitre ; Marcus, the aromatic sulphuric acid of Hallf.r ; Lett- som, the ammonio-chloride of iron, in the infusion of quassia ; Hufeland, the muriate of lime; Ranoe, cinchona with lime-water; Stoerck and Quarin, the conium, both by the mouth and in injections ; White, the willow bark; and Zacu- tus Lusitanus, the insertion of a seton, or issues. 44. An occasional recourse should be had to aperients of a stomachic and tonic kind, as the sulphate or super-sulphate of potash with rhu- barb, or the compound infusions of gentian and senna ; and the operation of these may be aid- ed by suitable enemata. Advantage will often accrue from the use of chalybeate mineral waters, [as those of Saratoga,] in connexion with change of air ; and from sponging the back, loins, and hips, and lower part of the abdomen with tepid or cold salt and water, or vinegar and water. Afterward the shower bath, the cold douche on the loins, or cold sea-water bathing will be of service. Dr. Leake advised tonic infusions in- ternally, blistering the sacrum, and the “ use of the Tunbridge, or Pyrmont water for common drink ; or the artificial Spa water, impregnated with iron and fixed air, as directed by Dr. Priestley.” If these occasioned costiveness, he prescribed senna tea, or imperial drink with manna. 45. If pain or local irritation exist, the prep- arations of opium, henbane, or conium may be conjoined with the remedies prescribed, or may be administered in enemata. If the acridity of the discharge occasion excoriation of the labia, or of parts in the vicinity, lotions contain- ing the acetate of lead, or sulphate of zinc, with vinum opii, may be used. The utmost care should be taken to wash away the morbid discharge by tepid injections, with or without small doses of anodynes, or the poppy decoc- tion ; yet no benefit will result, but, on the contrary, much risk may be incurred, in this variety of the disease, from employing astrin- gent or stimulating injections per vaginam. I have been called to cases where recourse to these had been followed by inflammation of the uterus, and by the appearance of disease in the lungs, and other ill consequences. 46. Strict attention ought to be directed to the states of the digestive functions, and partic- ularly of the bowels ; and derangements of the menstrual discharge should be ascertained and removed. 47. The diet and regimen always require regu- lation. I have met with cases, particularly in connexion with a too copious or too frequent menstrual discharge, which appeared to have been prolonged by a too full and stimulating diet, in connexion with other indulgences. In these cases, the quantity and quality of the food and drink of the patient should be strictly pre- scribed ; and a separate sleeping apartment, and cool but sufficient clothing of the loins, hips, and limbs, early hours, and removal from the dissipations of the metropolis, ought to be directed, and continued according to circum- stances.* [There is no disease in which treatment is more apt to be empirical than leucorrhcea. This arises from incorrect notions as to its pathology and true nature. The various forms of the malady vary very widely from each other in degree, and require corresponding variations in treatment. If the discharge is of a mucous, transparent character, it will yield to very sim- ple management, as astringent injections, rest, abstaining from sexual intercourse, &c. ; but if the disease is inflammatory, marked by a purulent discharge, hard pulse, increased heat about the genital organs, with swelling, or pain in the loins and hypogastric region, the anti- phlogistic treatment must be promptly resorted to, as general and local bleeding, by leeches to the vulva, or os uteri (Dr. Ashwell recom- mends scarifying the cervix with a lancet * [Few disorders of a more perplexing nature fall within the scope of the medical prescriber than those connected with the disturbed condition of the uterine function under the various forms of leucorrhcea. As a general rule, we may safely class them under the two heads of acute and chronic ; those associated more especially with the vagina, and those which involve the condition of the uterus itself. Vaginal discharges, by continuance of the infirmity, almost always, after some duration, involve the state of the uterus; and, in a medico-legal point of view, as well as in their re- sults upon the constitution at large, are to be deemed of se- rious import. When the discharge is of a puriform charac- ter, we have the strongest reason to believe in its acute or inflammatory nature. The principle arising from consider- ing these discharges either of a passive or chronic nature, or of an acute character, necessarily points out our best remedial measures. That the complaint is, in many in- stances, owing to the great vicissitudes of our climate, is a recognised fact; and the preposterous use of cold applica- tions must also be pronounced a frequent source of it. Nor are we to forget that the disorder is sometimes dependant upon a gonorrhoeal cause. This last form of the disease is ever to be treated in reference to its specific origin. The active treatment of the complaint, when of an inflammatory nature, must be urged upon the practitioner, consisting of repeated losses of blood by the arm and by local measures, together with saline purgatives, the infusion of senna, and the like. Among the most valuable local remedies for the inordinate discharges which mark leucorrhcea, the introduc- tion, lately, of tannin, gives promise of much benefit. One or two drachms of tannin, dissolved in sixteen ounces of pure water, is an admirable wash for the purposes indicated in this disease, and, as an injection, can often be advanta- geously used. American physicians, from the recommend- ation of Dr. Dewees, have made free use of the tincture of cantharides internally, with the view that by its genera] tonic and stimulant effects it would mitigate the evils of leu corrhcea, and restore the system to its ordinary functions It has unquestionably proved •serviceable in many instances: as a lotion, however, for the many annoyances which the female suffers from leucorrhcea, the tannin seems destined to hold a favourable place. According to Dr. Francis, it has many advantages over a great number of astringents for- merly much in use. M. Gibert, one of the physicians of the hospital of St. Louis, has very lately introduced the al- coholic extract of tannin as a new astringent vaginal injec- tion, for the cure of leucorrhceal discharges.] * This preparation and the iodide of sulphur were made by Mr. Murson, at my suggestion, as early as 182fi, and pre- scribed by me in various disease since that time. The Sirup is the best preparation of the iodide of iron, as all others arft readilv decomposed. 826 LICHENOUS RASHES—Description of. mounted on a piece of whalebone), together with emollient and soothing injections, and the other means usually recommended in such cases. In the treatment of leucorrhcea, especially when chronic, we have found an injection of the nitrate of silver very successful in arresting the discharge; also of tannin. Creasote may also be used with great advantage by mixing 20 drops of it with 3ij. of a solution of potash, 3ij. white sugar, rubbed together, with fviij. of water, for an injection, to be thrown up three times a day. We have also known an injec- tion of iodine succeed, after other remedies had failed. It should be employed by way of injec- tion, prepared by mixing 3iv. of iodine with 3j. of alcohol, and of water; one fourth part to be employed night and morning, using the compound tincture of the same article internal- ly. A bit of sponge soaked in this solution, and passed high up the vagina, to remain in contact with the os uteri over night, will often be followed by the best effects. A decoction or infusion of pyrola umbellata, diosma crenata, or the pareira brava, we have found almost spe- cific in correcting the unhealthy state of the vaginal secretions, and restoring healthy action. Dr. Kopp, in a recent number of Hecker’s Annalen, recommends the following mode of treating leucorrhcea, wThich he says he has fre- quently employed with advantage : A piece of sponge, of proper size to fill completely the va- gina, is to be dipped into the following solution, and introduced into it at night, before going to bed : Decoct. Ratanhia, fxii. ; Extr. Ratanhia, fss. ; Tinct. Catechu, 3jss.; Tinct. Kino, 3jss. M. Dr. Cless states that he cures almost all the cases of leucorrhcea that occur in his hospital, at Stutgard, with cubebs.] Bibliog. and Refer. — Hippocrates, Opera. Ed. Fees., p. 566, 637, 621. — Oribasius, Synopsis, 1. ix., c. 48, 49.— Avicenna, Canon., 1. iii., fen. 21, tr. 3, e. 23.—Primerosius, De Morb. Mulieb., 1. i., c. 8. — E. Jorden, A Rational Ac- count of the Natural Weaknesses of Women, 8vo. Lond., 1620.—T. Raynald, The Birthe of Mankinde. Lond., 1634. —Zacutus Lusitanus, Med. Pract. Hist., t. i., 1. iii., No. 11. —Zacchias, Qusest. Med. Leg.,1. ix., tit. iii., quaest. 5.—G. Charleton, De Causis Catameniorum et Uteri Rheumatismo (Leucorrhrea), 8vo. Lond., 1685. — Friend, Emmenologia, p. 105.—Morgagni, De Sed. et Cans. Morb., Epist., xlvii., art. 11, 25, 26.—Lange, Miscell. Veritates, p. 77.—Mauri- ceau, Malad. des Femmes, &c., t. i., p. 457; t. ii., p. 147.— Stoerck, Libellus de Cicuta, p. 107; et Ann. Med., vol. ii., p. 213.—/. Leake, On Dis. of Women, Vien., 1808.—A. Ramsay, in Edin. Med. and Surg. Journ., vol. viii.—D. Pring, An Essay on the Absorbents, compri- sing some Observat. on the relative Pathol, and Functions of the absorbent and secreting Systems, 8vo. Bath, 1813. —W. Goodlad, A Practical Essay on the Diseases of the Vessels and Glands of the Absorbent System, Svo. Lond., 1814.—Howsliip, Pract. Observat. in Surgery and Morbid Anatomy, Case 94.—G. Breschet, in Diet des Sc. M6d., t. xx., p. 196.—Allard, Du Si6ge de la Nature des Maladies, 8vo, 2 vols. Paris, 1821 ; et De 1’Inflammation des Vais- seaux Absorbants, 8vo. Paris, 1824 —Lippi, Journ. des Progres de Sciences M6dicales, t. i., p. 167 ; t. ii., p. 27 ; t. iii.,p. 108.—Rossi, in Ibid., t. ii., p. 20.—Lasserre, in Journ. Univers. de M6d., t. xxiv., p. 5.—Andral, in Archives G6u6r. de M6d., t. vi., p. 502 ; et Anat. Patholog., t ii.—Benedict, Remark, iiber die Krankh. der Brust und Achsel-Driisen, 4to. Breslau, 1825.—V. G. Becker, De Glandulis Thoracis Lymphaticis, atque Thymo, Specimen pathologicum, ?iVKTaivov(jTi Xoi/uktj) is distinguish- ed from measles (erepa Xenrij aal no/evy 2.ov- ULKTj). 7. However, measles were very generally con- founded with smallpox even as late as 1674. Among the last writers who committed this error were Lange and Diemerbroeck, while the distinction was first clearly made by Forestus (1597), Schenck (1600), Riverius (1655), and particularly by Sydenham (1676), and F. Hoff- mann (1718), who, with Huxham and Lepecque de la Cloture, have recorded the history of several epidemics, and added greatly to our knowledge of the disease. At the same time, it may be noticed that Morton and Watson confounded measles with scarlet fever, and view- ed the latter as a severe variqjy of the former disease ; and, as Dr. G. Burrows has remark- ed, it was not until the appearance of Dr. With- ering’s Essay on Scarlet Fever, in 1793, and of Dr. Willan’s Treatise on Cutaneous Diseases, that the profession was fully convinced of the distinct nature of the two diseases. 8. II. Description of Measles.—Instead of dividing this disease into different varieties or forms, as the Rubeolu vulgaris, the Rubeola ma- ligna, and the Rubeola sine catarrho, &c., I shall first describe the regular form of the disease, and next notice those modifications, complications, and irregularities which it presents, according to the influence of individual constitution, epidemic prevalence, and of climate. 9. i. The Regular Form of Measles.—Ru- beola vulgaris, Willan, Bateman, &c. Morbilli regularis, Sydenham. Rougeole vulgaire, Fr. The progress of the disease, in its regular and common form, is similar to that of all the erup- tive fevers, and consists of four well-marked stages, namely, 1st. The period of febrile commo- tion ; 2d. That of eruption; 3d. The stage of flo- rescence ; and, 4th. That of desquamation. 10. 1st. The period of febrile commotion, or of precursory fever, is that in w’hich the infection of the whole frame has commenced, and that febrile action appears, which produces, after a certain period, the cutaneous eruption. This stage usually commences with chills, horripila- tions, shudderings, or rigours, alternating with heat of skin, and accompanied by a turgidity, erethism, or catarrhal irritation of the mucous membranes, particularly those of the respirato- ry apparatus. The patient is affected with fre- quent sneezing, coryza, stuffing of the nose, sometimes with dryness and redness of the pi- tuitary membrane ; with heat, redness, turgid- ity, and watering of the eyes; sensibility to light, heaviness, or pain in the head, somno- lency in very young children, and in older sub- jects, wakefulness ; frightful dreams ; pain or aching in the back and loins ; soreness, pain, and tenderness at the epigastrium, and with slight hoarseness and dry cough. Sometimes the eyelids and sub-maxillary glands are slight- ly swollen. The appetite is diminished or abol- ished, while the desire for cold drinks is much increased. The tongue is white and loaded, and an unpleasant taste in the mouth is often complained of. There are frequently nausea, vomiting, and a lax or irregular state of the bowels. The febrile commotion rarely amounts to the production of convulsions or delirium; but generally more or less exasperation of fe- ver, preceded by chills and horripilations, and accompanied with a full, hard pulse, oppression at the chest, and difficulty of breathing occurs towards evening, and remits towards morning, when a slight moisture appears in the skin un- til the eruption appears. Instances, however, are not uncommon of so slight a grade of the disease as not to render it necessary for the patient to keep his bed; and yet, in some of those cases, the patient may have complained for several days of catarrhal fever. In the more severe cases, haemorrhage sometimes takes place from the nostrils, or a haemorrhagic discharge occurs from the uterus, in this stage with considerable relief. 11. 2d. Stage of Eruption.—During the third febrile exacerbation, generally about the fourth day from the first occurrence of horripilations, an eruption takes place first on the face, par- ticularly the cheeks, around the eyelids, nose, and ears ; and next on the neck, breast, arms, hands, and abdomen; and last on the lower 940 MEASLES—Modifications, Complications, etc. extremities, with more or less turgidity of the countenance, particularly of the eyelids. Some- times great restlessness, anxiety, convulsive movements, inequality of pulse, pain and sense of fulness in the head, slight delirium, or epi- staxis usher in the eruption, which is generally completed in twenty-four hours. At this pe- riod the tongue is red at its point and edges, loaded or furred at its base, and the fauces exhibit some obscure patches resembling the cutaneous eruption. The eruption is at first discrete and scanty, resembling the bites of fleas. The stigmata increase, are of a crimson or reddish colour, slightly elevated above the skin, and rough to the touch, particularly on the face, and early in the eruption. When ex- amined with a glass, they have a rounded, or, rather, an elliptic form, resembling linseed. When the papulae are fully formed they are of a lively red, but contain no fluid ; when press- ed by the finger they momentarily lose their colour, which returns rapidly upon removing the pressure; and their circumference is not defined, their colour being deepest in the cen- tre, and becoming paler until they insensibly pass into the natural tint of the skin. Wede- kind (Ueber die Masern. Roschlamb’s Maga- zin, iv., B, No. 6) observed an extremely fine hair, scarcely discernible by the unassisted eye, penetrating each of the morbillous papulae. If the eruption is very scanty, it is never equally diffused over the surface, but appears in clus- ters in different parts, separated from each oth- er by large patches of healthy skin. Although the papulae, or stigmata, may approximate near- ly to each other, and coalesce into patches, they never completely run into each other, par- ticularly in the early period of the eruption. In the more severe cases, however, especially in adult subjects, they often coalesce much more closely, the cutaneous surface assuming a deep red. The more acute the fever, the more co- pious is the eruption, which scarcely ever di- minishes the fever, but, on the contrary, is oft- en increased by it, until the period of desqua- mation. During the eruptive stage the tran- spiration and breath have a peculiar odour, which generally continues till the seventh day, and is at first of a slightly sweetish, and after- ward of an acidulous character, and has been likened by Heim to that given out by a recent- ly killed goose. 12. 3d. The Period of Florescence.—The erup- tion continues generally in full force for nearly three days, namely, from the fifth, when it is usually fully out, till the seventh, when it sub- sides ; but this stage presents no distinct marks from the foregoing, for the eruption on the face and neck generally declines on the sixth, while it is fully out on the body and limbs, or even only breaking out on the lower extremities. The stigmata coalesce more closely, the skin becomes more uniformly red, tense, or turgid, extremely hot and itching, and the tumefaction of the face and eyelids, particularly on the fourth and fifth day, is very marked. The tongue and fauces now evince an evident par- ticipation in the eruption. The fever and ca- tarrhal symptoms show scarcely any remission, but are even sometimes increased. Intoler- ance of light, dryness of the nostrils, hoarse- ness and dyspnoea, and a hoarse clangous or barking cough, at first dry, and afterward fre- quently followed by the expectoration of a thin mucus, containing dense, rounded, albuminous particles, continue during this period. Towards evening, the fever, restlessness, and heat of skin increase. Sometimes a slight diarrhoea occurs, from which the patient experiences some relief. The urine is generally of a deep colour, and scanty. 13. 4th. Period of Desquamation.—On the sev- enth and eighth days from the commencement of the first stage, the eruption declines on all the upper part of the body ; but the subsidence and desquamation of it have generally begun a day or two earlier on the face and neck, the turgidity of which is now much diminished. On the eighth and ninth days, and in the same order as the eruption appeared, it subsides, with desquamation of the cuticle ; and on the tenth and eleventh days it has entirely disap- peared, leaving in its place a furfuraceous des- quamation, passing off generally with an in- creased and troublesome itching, and a slight moisture on the surface. The more prominent and copious the eruption, the more marked the desquamation becomes. Generally, when the eruption is very slight, the skin continues un- changed. In the course of this stage, critical perspiration, a copious sediment in the urine, and free evacuation, frequently supervene and contribute to its felicitous termination. But the pectoral symptoms usually continue longer, and occasionally with increased severity, par- ticularly the cough, hoarseness, and the expec- toration already described. With the subsi- dence of these, the system returns to the healthy state. 14. ii. Modifications, Complications, and Irregularities of Measles.—There are va- rious circumstances which contribute to modify the progress and character of measles. Of these, the most important are the prevailing nature of the epidemic, the season of the year, the state of the atmosphere in respect of temperature and moisture, the nature of the locality, the ventilation of the place and apartments, the previous health of the patient, and his temper- ament and habit of body. But I believe that there are few causes proper to the individual that has greater influence on the character of the disease than the vital powers of the sys- tem, and the disposition which the patient may possess to affections of some vital or important organ. 15. A. Measles with predominance of Inflam- matory Character.—a. This form of the disease is generally ushered in with marked febrile symptoms of the inflammatory type ; full, strong, or oppressed and frequent pulse ; great heat of skin ; a phlogistic appearance of the blood drawn from a vein; severe catarrhal symptoms, with acute coryza; marked injec- tion and turgidity of the conjunctiva; watery discharge from the eyes ; constant cough ; with oppression at the chest, great difficulty ot respiration, bloody sputa, and other symptoms of inflammation of the mucous mer tbrane of the air passages and lungs, and occasionally with acute pain and other signs of pneumonia or pleuro-pneumonia. The eruption appears rap- idly and copiously, with convulsions in young children, and delirium in older patients, or, at least, with most severe pains in the head, after which a slight amelioration is sometimes ob- MEASLES—Modifications, Complications, etc. 941 served. The eruption is more intensely red, more prominent, and more closely coalescent, so as to occasion a nearly erysipelatous red- ness and tumefaction of the face and other parts, than in the common form of the disease. Desquamation also often takes place earlier, and is not infrequently complicated with, or followed by, marked inflammation of the lungs and bronchial membrane, or even by various modifications of croup. 16. This state of the disease is most frequent during the epidemics which occur in winter and spring; in persons of a robust, sanguine, and irritable temperament, and plethoric habit. It occurs sporadically in those who are exposed soon after infection to cold in any form, partic- ularly to a cold, dry air after the body has been heated; and in children who are teething, and Who have been highly or grossly fed, and kept in warm apartments, and are of an inflamma- tory and plethoric habit. 17. b. This form of measles is so very fre- quently complicated with serious inflammation of the air passages and lungs, and is so liable to kindle up those diseases towards its decline, or to dispose to them during convalescence, that strict attention should be directed to the cir- cumstance. 18. a. When extensive or severe bronchitis occurs during the course of this type of mea- sles, the patient is often suddenly attacked with great difficulty of breathing ; the face is pale, if it precede the eruption, but generally some- what livid, or of a deep crimson, if it occur du- ring the eruption. Sometimes the eruption ei- ther appears only partially, or recedes prema- turely; the lips are also livid; the chest and diaphragm, as evinced by the motions of the abdomen, labour much during respiration, and a sonorous, sibillous, and, lastly, a mucous rhonchus, is heard on auscultation. The coun- tenance becomes anxious; the expectoration is more or less abundant, and attended with se- vere paroxysms of cough; the pulse is quick, small, or oppressed ; and the skin either cool or warm in parts only. This state of disease is not merely a severe form of bronchitis, but an association of it with congestion of the lungs, to which a similar state of the brain is some- times superadded. The pulmonary affection, in this severe form, may soon terminate the life of the patient, chiefly in consequence of the effusion which takes place in the air passages, together with the loaded state of the vessels of the encephalon. 19. In the less severe forms of the complica- tion of bronchitis with measles, or when the bronchitis is not conjoined with congestion of the organ, the symptoms are less marked ; there is less urgent oppression at the chest, and the lividity of the countenance is generally ab- sent. But these less severe states of bronchi- tis not infrequently superinduce inflammation of the substance of part of the lungs or of a whole lobe. In this case the sputum becomes more purulent, more rounded, and sometimes streak- ed with blood ; respiration is puerile in the vi- cinity of the affected part, in which the respi- ratory murmur is either feebly heard, or is at- tended by crepitating rattle, or the sound is no longer detected in it, while the chest is dull, in this situation, upon percussion. At the same time, the respiratory motions are quick, labour- ed, unequal, and imperfect. 20. j3. Pleuritis may occur during the course of this type of measles, and the inflammatory action may either originate in, or may extend to the pleura from the affected part of the lungs. But in either case we seldom find in measles that the pleura becomes inflamed without a por- tion of the lungs participating in the diseased action. The presence of acute pain generally indicates this complication, with immobility of the ribs, quick inspiration, and slower expira- tion, and pain on percussion, which gives no farther information, unless effusion has taken place, when a dull sound will be emitted, and the cegophonous sound heard on auscultation. This form of complication not infrequently ter- minates in hydrothorax, particularly after the disappearance of the eruption. 21. y. Another severe and dangerous compli- cation, viz., croup, sometimes occurs in this form of measles. It generally appears during the stages of eruption and florescence, and more rarely subsequently. It is chiefly characterized by hoarseness and ringing, croupy cough, follow- ed by difficult and sibillous inspiration ; by sore- ness and tumefaction about the larynx and trachea; and by the expectoration, after the par- oxysms of strangulating cough, of a ropy, clear fluid, sometimes with membranous threads. It very seldom happens that the inflammation of the larynx and trachea, constituting the croupy complication, occurs without some de- gree of inflammatory action being extended to the bronchi, or even to a portion of that sub- stance of the lungs. When a fatal termination occurs in this state of disease, the air passages present more or less of the usual marks of in- flammatory action, and are loaded with a thick, tenacious mucus, or contain false membranes, or both. 22. B. Measles with Predominance of Gastric and Bilious Disorder.—a. This form was first de- scribed with accuracy, and the importance of attending to its character pointed out by Stoll. It is chiefly marked by accumulations of sordes in the stomach and bow’els ; by loaded tongue; pain and tenderness at the epigastrium, hypo- chondria, and bowels ; by morbid, bilious, and offensive alvine evacuations ; by the great se- verity of the cough ; by depression of the ener- gies of the frame; the slower and less abun- dant eruption on the skin ; by weakness and frequency of pulse ; and by severe pains in the loins, limbs, and forehead. It sometimes char- acterizes summer and autumnal epidemics, par- ticularly during or soon after warm and moist seasons ; and it occurs sporadically in weak children during the periods of the first and sec- ond dentition; in the imperfectly nourished, and in those who have had their bowels long neg- lected. 23. h. This form of measles is frequently com- plicated with irritation of the mucous surface of the stomach, or with disorder of the liver. But when this latter organ is principally attacked, it is more generally congested than otherwise affected. The complication of this modification of measles with gastric irritation is very fre- quent in children during the periods of dentition, and is generally indicated by nausea and vom iting, tenderness or pain, or heat at the epigas- trium ; an imperfect, impeded, or irregular state of the eruption, and its premature disappear- ance. Congestion of the liver is much more sel- 942 MEASLES—Modifications, Complications, etc. dom met with, and chiefly occurs in older sub- jects. It is generally attended by pain and ful- ness in the right hypochondrium, sallowness of the countenance, an irregular and morbid state of the alvine evacuations, and a dark, muddy state of the urine. 24. c. Diarrhoea is not an infrequent compli- cation in this form of measles. It may appear early in the disease, When this is the case the eruption is often delayed, or it is scanty, imper- fect, or irregular. It may also take place du- ring the period of desquamation, assuming the character at first of a salutary crisis; but, in consequence of error in diet, or exposure to cold, putting on a more serious appearance, or even passing into a state approaching to dysen- tery. When this occurs, the appearance of the evacuations, and the state of the cutaneous sur- face, require the attentive examination of the practitioner, as being the chief guides to this state of the disease, and to successful treat- ment. Dr. Abercrombie, of Cape Town, de- scribed to me an epidemic prevalence of mea- sles in the colony which presented much of this character; the complication with diarrhoea, or enteritis, or dysentery, or the supervention of these during the decline of the measles, or even some time after recovery from that disease, be- ing very frequent and uncommonly fatal. 25. C. Measles with Predominance of the Ner- vous Character.—In this form of the disease the patient is, from the commencement, much de- pressed in mind ; is severely affected with chills and rigours, which pass into a burning heat, with inquietude, general pain and lassitude, par- ticularly about the loins and limbs, with delir- ium or somnolency, leipothymia, harsh heat and dryness of the skin, and dry, loaded tongue. The eruption sometimes appears as early as the second or third day, frequently with convulsions, and rapidly extends to all parts of the body. The patches of the eruption are scarcely at all, or only slightly prominent; are paler than the regular disease, and more readily disappear. The febrile and nervous symptoms are never diminished, but, on the contrary, increased by the eruption, particularly if it disappear prema- turely, or is repelled by any cause. Sometimes, still more severe and frequently fatal symptoms accompany this form of the disease, such as dyspncea, dry cough, anxiety, oppression at the chest and prascordia, cardialga, dryness and trembling of the tongue, dryness and redness of the fauces, loss of voice, vomiting, loss of recollection, with stupor, starting of the ten- dons, tumefied abdomen, very quick, weak, soft, and open pulse, and a crude, scanty urine. The character of the disease so nearly approaches to the typhoid type of fever, that it has been termed by several authors typhoid measles. Critical evacuations sometimes occur towards its close, or abortive efforts at evacuation, oc- casioning fatal determination to some weak- ened organ, or subsequent visceral disease, which can be removed with great difficulty only. The cuticle is frequently not thrown off in this form of measles. 26. Measles with the nervous character oc- curs generally at the same season and in the same class of subjects as the foregoing variety (§ 12). It characterizes certain epidemics, par- ticularly those which occur at the same period as epidemic continued fever; and it evidently evinces a more marked determination of the febrile action towards the large nervous cen- tres, particularly the substance and membranes of the brain. This determination is often re- markably increased about the eruptive and sub- sequent stages, or upon the imperfect appear- ance of the eruption, or its repression. 27. D. Measles presenting a Malignant or Sep- tic Character.—Rubeola maligna; R. Putrida ; R Septica, Auct. var. To many of the symptoms which I have detailed, as marking the nervous form of measles (<$ 25), are generally superadd- ed, most commonly during the stages of erup- tion and florescence, or occasionally somewhat later, the eruption ofpetechiae, lividity and sore- ness of the fauces and throat generally ; an ex- udation, or more copious flux of dark decom- posed blood from the nostrils, mouth, or vagi- na : a profuse and exhausting diarrhoea ; dark, offensive motions ; dysenteric symptoms, and viscid perspirations. The measly eruption be- comes, either previously to or contemporane- ously with the above symptoms, discoloured, ol a deeper and darker red, or livid ; and the cu- ticle is readily rubbed off upon the decline or detumescence of the papulae. This form of measles presents a similar state to that of pur- pura haemorrhagica, or of land scurvy, compli- cated with the exanthematous fever. 28. Malignant measles occurs chiefly in hot, warm, moist, and miasmatous climates, in close or crowded localities ; and during hot and moist seasons, in cachectic habits, in the ill-fed, or in those in whom the energy of the digestive and assimilatory functions is greatly impaired, and who have been subjected to those agents which act most injuriously on the powers of life and the tonicity of the moving fibres, con- taminating the circulating fluids, and occasion- ing the liquescence of the soft solids of the body. I have seen it prevalent in the natives of warm climates, and in those who inhabit marshy, moist, and miasmatous districts, both in temperate and warm seasons. I have like- wise observed it in natives of some of the north- ern countries of Europe who have been imper- fectly fed, and whose only animal food consist- ed of fish, frequently stale, and eaten with little salt, or who have lived in ill-ventilated and low apartments. The nervous form of measles oc- curs most commonly in scattered or isolated cases, while the malignant variety more com monly presents an epidemic character, the for- mer more evidently depending upon individual predisposition ; the latter to more generally pre- vailing causes, as unwholesome food or modes of living, general scarcity of provisions, delete- rious miasms, and epidemic constitutions of the atmosphere. 29. E. Of certain irregularities often presented by Measles.—a. Sometimes the eruption is more languid, or retarded beyond the usual period. It may likewise be precocious, precipitous, or irreg- ular, as to the parts on which it appears, and the succession of its progress. The form and character of the eruption may differ greatly ; it may be very pale or very red, dark red, or even livid, as in the malignant form; it may like- wise be scarcely perceived rising above the rest of the cutaneous surface, nearly smooth, or it may be very prominent and rough to the touch, and discrete, or it may coalesce so close- ly as to appear confluent. As respects the pe- riod of its disappearance, this may be prema- ture, and the desquamation subsequently be ei- ther imperfect or altogether wanting. 30. a. Measles without the catarrhal symptoms —Morbilli sine catarrho auctorum—not infre- quently occur during the epidemic appearance of the disease ; or an eruption presenting all the characters of measles sometimes is met with, but without the usual catarrhal symp- toms, and without, or with slight febrile com- motion. This variety was first described by Willan, and as it does not protect the consti- tution from the regular form of measles, it is considered by Frank, Hildenbrand, and Will- iams as spurious, and as an eruption only re- sembling measles, and symptomatic of gastric disorder. Dr. G. Burrows, however, thinks that this objection cannot be admitted ; for, be- sides the opinion of Willan, Bateman, and others, that it is a distinct variety, the recur- rence of measles in the same person has been seen by these and other writers. In the most of the cases of this eruption that I have ob- served, the stages of the disease wanted the regularity of true measles, and the desquama- tion was not so marked or complete as in them. In many, also, of the imputed instances of a second attack of measles, some doubt may be entertained as to one or other having been the regular disease. I believe, however, that I have seen instances of an undoubted second attack.* 31. b. Measles without the Eruption—Morbil- lous Fever without the Exantheme.—Fcbris mor- billosa sine Exanthemate, Hildenbrand.—Sev- eral writers have contended that, during the epidemic prevalence of measles, some children may have all the catarrhal and febrile symp- toms of measles, and yet no eruption will ap- pear, such children notwithstanding being pro- tected against a subsequent attack. I have met with two or three instances, when measles was prevalent in a family, of one of the children having all the catarrhal and constitutional symptoms without any eruption appearing, and have attributed this to impaired vital power, to an anaemic state of the vascular sys- tem, and to impaired vascular action, probably also associated with predominant disorder of some internal viscus. I have seen other in- stances where the disease has advanced far, the febrile symptoms having continued for sev- eral days, when a scanty, imperfect, or evan- escent eruption has at length appeared after the exhibition of stimulants or tonics. 32. c. The connexion of hooping-cough with measles has frequently been remarked upon. Indeed, the occurrence of measles sometimes presents a very intimate association with per- tussis, the epidemic appearance of the one be- ing frequently followed by the other, and the attack of the one being often followed closely MEASLES—Terminations of. by the other in the same subject. Some phy- sicians, as De Haen and Macbride, conceive that they have seen measles associated with smallpox in the same person. But I agree with Reil and Hildenbrand in considering this opin- ion to have originated in mistake. 33. III. The Terminations of Measles.—i. Resolution or restoration to the healthy state usually takes place from the resistance which the vital energy opposes to the morbid changes characterizing the disease, and to the influence of this energy on those organs which are the emunctories of the frame. When the train of phenomena is not interfered with, the disease frequently, about the seventh or ninth day, presents some critical evacuation, which tends greatly to the restoration of the healthy func- tions, especially a copious and general perspi- ration ; a paler and more abundant secretion of urine, which deposites a copious sediment; di- arrhoea continuing for two or three days, but readily becoming hurtful if it be not judiciously managed ; a copious discharge of mucus, which often removes the remaining irritation of the bronchial surface with the hoarseness ; and the furfuraceous discharge and transpiration which takes place from the cutaneous surface after the exfoliation of the cuticle. 34. ii. The Sequelce of Measles.—A. Some- times not only the irregular and complicated states of measles, but even the more benign and regular form, leave after them, without any evident cause, various diseases which place the lives of patients in great hazard. The chief of these are pulmonary consumption, the result either of a chronic state of the bronchitis which had accompanied the measles, or of organic lesion of the substance of the lungs, the conse- quence of the complication of the disease with pneumonia, or with broncho-pneumonia, readily passing into chronic pneumonia, or of tubercles which had been developed during its progress and decline, or which had previously existed. It is by no means rare to observe both pneu- monia and pleuritis, or both conjoined, super- vene during the period of desquamation. The accession of the former especially is often ex- tremely furtive and latent. I have frequently seen patients brought to the Infirmary for Chil- dren with the most severe attacks of pneumo- nia, in an advanced stage, with all the symp- toms fully developed, following an apparently mild form of measles ; and other cases, which had manifestly been advancing for several days in a concealed manner, and gone on to serious organic change before the parents had been alarmed. These latter are very frequent du- ring some epidemics, and particularly after the inflammatory form of the disease, although they are not peculiar to this variety, but equal- ly consequent upon the regular, and some- times on the gastric states of the malady. In cases of this description the practitioner has often no opportunity of watching the accession of the local mischief, which may occur so early in the disease as to be a complication of it, or during the stage of desquamation. I have, however, observed it still more frequently—I may say in many hundred instances presented to me in the institution already referred to—at an indefinite, but no very reftiote period from the last stage, occurring generally during re- covery, either from an incautious exposure to 943 * [This form of measles occasionally prevails in this coun- try, and sometimes goes under the name of French measles. Besides lacking the catarrhal symptoms, the eruption ap- pears at an earlier period, and is diffused over the surface in specks instead of a succession of well-defined crescents ; it also is more transient, usually subsiding in 24 hours. It may exist at the same time with common measles, or sep- arately ; in some cases it has been succeeded by the former in a few days, showing that it affords no protection against an attack of catarrhal measles. Professor Chapman sup- poses that it is an efflorescence of another nature, depend- ant on some veiy different cause ; or that, if it is of a mor- billous character, it is illegitimate, and therefore truly called rubeola spuria.] 944 the air, or to cold, early in convalescence, or from an injudicious management of this pe- riod, which, in all exanthematous diseases, re- quires the particular care of the physician in order to prevent their dangerous sequelae : often more dangerous than even the original diseases themselves. Improper diet, prema- ture exposures to cold, and even atmospheri- cal vicissitudes, which cannot be sufficiently guarded against, will also frequently occasion the unfavourable consequences now pointed out. 35. B. The symptoms indicating the super- vention of disease of the lungs are often ex- tremely treacherous, particularly if the local mischief commences early in the disease, and if viewed superficially, or without the aid of percussion and auscultation. They chiefly con- sist of the persistence of cough, expectoration, frequency of pulse, and febrile exacerbations, after the disappearance of the eruption. Or, the different stages of the measles having been completed, febrile action is rekindled and ac- companied with oppression, weight or uneasi- ness in the chest, with a dry, spastic cough and difficulty of breathing, followed after a time with purulent expectoration, occasionally streaked with blood, evening exacerbation of fever, nightly perspirations, loss of flesh, &c. In those cases wdiich are characterized by a gradual or insensible concentration of diseased action in the lungs, particularly in the mucous surface of the bronchi and. air cells, the expec- toration which supervenes* in the latter stages gradually changes from a clear, whitish, thin fluid, containing numerous white albuminous specks or flocculi, to a thicker, more opaque, tenacious, and muco-purulent matter, till it at last becomes more decidedly purulent, the sputa being each distinct and rounded, less tena- cious, not running into each other, and form- ing a viscid, stringy substance, adhering close- ly to the sides of the vessel, but a yellowish, rounded mass, which imparts a whitish, turbid appearance to the water in which it is thrown, from mixing partly with this fluid. But these and other symptoms, although most certainly indicating serious disease of the lungs, give us no precise information as to the extent and na- ture of the existing lesion. This is only to be acquired from an attentive and repeated ex- amination of the chest by means of percussion and auscultation, and from weighing the evi- dence thus furnished us in connexion with the rational symptoms in the manner pointed out under the articles where these subjects more appropriately fall. The above remarks are equally applicable to the occurrence of pleuri- tis, either as a complication or as a sequela of measles. When pleuritis, or pleuro-pneumo- nitis, does occur in either of these ways, it is extremely prone to terminate in effusion of a serous fluid into the plurae, as adhesions are less readily formed in pleuritis when thus com- plicated than when occurring in an idiopathic form. 36. But effusion into the chest, and even into the pericardium, may be consequent upon mea- sles without any previous signs of inflamma- tory action. When these results supervene, the disordered state of the respiratory and oth- er functions, and particularly the information conveyed by percussion and auscultation of the MEASLES—Sequel,® of chest, will generally point out the nature and extent of mischief. Other dropsical effusions, particularly anasarca, hydrocephalus, and as- cites, occasionally are observed as sequelae of measles, and may be imputed either to increas- ed determination of the circulation to, with diminished tone of the extreme capillaries ter- minating in serous surfaces, or to congestion of the vessels, particularly those conveying the blood from the adjoining viscera and parts. As in anasarca, so also in the other forms of dropsy, the obstruction opposed to transpira- tion by the state of the cutaneous surface may determine an increased exhalation or secretion of serum into the cellular tissue underneath and into the shut cavities. The occurrence of anasarca after measles from granular, disease of the kidneys is seldom observed. 37. C. Enteritis, in some one or other of its forms, more commonly appearing as muco-en- teritis, or commencing in the mucous surface of the intestines, is a not infrequent sequela of measles, either upon the disappearance of the eruption or during convalescence, partic- ularly in some epidemics. In the remarkable epidemic which appeared at the Cape of Good Hope about 1838, where the disease had not existed- for thirty years, and which few under thirty years of age escaped, this sequela was much more fatal than the measles itself, al- though of a very severe form. (See art. In- testines, Inflammation of.) Diarrhoea, acute or chronic, the former being often inflammatory and passing into enteritis as just noticed, or lapsing into the chronic state, not infrequently with ulceration of the intestines, is often ob- served consecutively upon measles. 38. D. Ophthalmia of a chronic and obstinate character frequently follows the malady, par- ticularly in the fair and scrofulous diathesis. In addition to these, scrofulous sores and af- fections of various kinds; enlargements and inflammations of the lymphatic and mesenteric glands ; aphthae and ulcerations of the cheeks and gums ; furunculi and abscesses of the cel- lular tissue, and fluor albus, should also be ranged among the sequelae of measles. 39. E. When the disease occurs in females who have reached the period of puberty, it may be followed by various irregular forms or man- ifestations of hysteria, sometimes connected with disorder of the catamenia. Of these, hys terical or nervous cough, occasionally with aphonia, is one of the most common, and al- ways requires a treatment suited to its hys- terical character. 40. F. A more particular consideration of the above sequelae of measles is not consistent with my limits. The mere reference to them serves to illustrate the nature of the disease, while it warns the practitioner as to what may occur, and hence points out to him what should be guarded against. These sequelaj, more- over, show that the inflammatory character of measles is variously modified in respect of the degree of vital energy and nervous power with which the vascular system and the tissues generally are endowed ; that all the vital man- ifestations, and even the cohesion of the tex- tures, are seriously modified in its progress, particularly in certain of its types; and that while morbid action of an acute and febrile kind may exist, even in an extreme grade, it may be at the same time conjoined with great diminution of the nervous functions and vital energies. 41. iii. Not only may measles terminate in a return to health, and in other diseases tending gen- erally to disorganization, but they may termi- nate in a more immediate manner, in death. This seldom occurs sooner than the stages of efflo- rescence and desquamation ; but cases have occurred in which a fatal issue has taken place about the period of eruption, congestion of ei- ther the lungs or brain, or even both, occur- ring either alone or in conjunction with effu- sion of serum, &c., into the air cells and small bronchial tubes of the former, and in the ven- tricles and between the membranes of the lat- ter, and quickly arresting the functions of these vital organs. In the later stages of measles death generally occurs in a more gradual man- ner, and may be imputed: 1st. To inflammato- ry disorganization, commencing and rapidly ad- vancing in some vital organ, either as a com- plication or as a consequence of the general febrile commotion and constitutional affection constituting the disease. In these cases the eruption may be extremely abundant, prema- ture in its appearance and decline ; but it is much more commonly either late, extremely scanty, irregular in its course, or even scarce- ly appearing. 2d. A fatal result may be occa- sioned by the extreme degree of general adyna- mia, or depressed state of the vital energies, owing to which reaction cannot take place suf- ficient to restore the different functions of the ceconomy to their natural state ; or the vital manifestations of the different organs are in- capable of sustaining the struggle with, and re- moving the morbid impression made upon the nervous energies, and through them upon the different emunctories, secretions, and circula- ting fluids, by the exciting cause of the disease, aided by the different concurrent influences of individual predisposition and pre-existing dis- order. 3d. A fatal result may occur in any of the advanced stages of the disease from the combination of these two principal pathologi- cal states, either of them existing in a more marked degree than the other, in different ca- ses, in different epidemics, and in different seasons. 42. iv. Appearances .observed in Fatal Ca- ses of Measles.—These vary according to the nature of the prevailing epidemic, the season of the year, the severity of the. attack, and the individual predisposition and state of health at the period of seizure. The lesions detected after death have generally a strict reference to the particular type of the disease, and to the complications which had existed in its course. The regular and uncomplicated measles never terminates fatally unless serious or dangerous visceral disease occurs on its decline, and ends unfavourably. It is different, however, with the other types or states of the disease.—a. In fatal instances of inflammatory measles, the lungs always present more or less change. The mucous surface of the air passages is vas- cular, of a reddish or dark-red colour, generally in patches of a small size, somewhat softened and turgid, and covered with either a mucous, muco-puriform, or viscid matter. In those ca- ses which have presented signs of the croupy or bronchitic complication, the above appear- MEASLES—Appearances observeb in Fatal Cases. ances are very marked about the larynx, epi- glottis, and trachea, and are sometimes accom- panied either with infiltration and injection of the sub-mucous tissue, or with a thick, whitish, albuminous exudation, approaching in parts to an imperfectly formed membrane ; but this lat- ter is, as far as my observations have gone, ex- tremely rare. The above changes are more commonly observed in the large and small bronchi, where the accumulation of viscid mu- cus, containing whiter and denser specks of an albuminous appearance, is sometimes very great. Accompanying these states of the air passages the lungs are often congested with a dark, frequently fluid, or semi-fluid blood, a similar congestion likewise existing in the veins and sinuses of the encephalon. After the more decidedly 'pneumonic complication, se- rous, or sero-sanguineous infiltration of the air cells and connecting cellular tissue, hepatiza- tion or condensation of portions of the lungs, purulent infiltration of parts of this organ, or the formation of small purulent collections with disorganization of the immediately surrounding structure, and, lastly, inflammation of the pleu- ra, are the lesions which usually present them- selves. When pleuritic symptoms occur during the last stages of the disease and terminate fa- tally, effusion of a turbid serum to a greater or less extent, injection and softening of parts of the pleura, and more or less lesion of the sub- jacent lung, are usually observed. 43. b. In the nervous type of the disease, the brain is generally much more vascular than natural, and occasionally somewhat softer ; the veins and sinuses are congested, and serum, in various quantities, is frequently found in the ventricles and between the membranes. The pia mater is also generally more than usually vascular, and the arachnoid more or less opaque. These lesions vary greatly in degree. Some- times they are most remarkable on the surface of the hemispheres ; but I have observed them most frequently about the base of the brain. The extent of morbid change has frequently no relation to the severity of the nervous type during the progress of the disease. In some cases these appearances are very slight, and yet the character of the disease has been mark- ed and severe. In other cases the lesions have been considerable, yet the nervous symptoms have not been proportionately great. It seems as if the manner in which the energies of life are influenced has an intimate relation to the intensity of disease and the manifestations of the nervous functions in its progress. 44. c. In the gastric and bilious type of the disease, the morbid appearances are generally most marked in the mucous surface of the stomach, intestines, and oesophagus, and con- sist chiefly of inflammatory injection, in patches or small grouped specks, and of softening or loss of cohesion of the mucous membrane, sometimes with injection and slight infiltration of serum in the sub-mucous cellular tissue. The liver does not often present much appear- ance of disease—seldom more than slight in- jection or congestion of the portal and hepatic veins—the biliary derangement, when it accom- panies the disease, being more functional than inflammatory. 45. d. I have had occasion to observe a few inspections of fatal malignant measles but only 945 946 MEASLES—Diagnosis. three in this country where this character was marked. The most remarkable features in these inspections were the softness of the tis- sues and the facility with which they might be torn—characters in which even the heart itself participated. The serous cavities sometimes contained a small quantity of serous fluid of either a turbid or sanguineous appearance. I have observed this kind of effusion in the peri- cardium, but more frequently in the pleura. The lungs were generally congested, and the mucous surface of the bronchi, as well as some parts of that of the digestive canal, were of a darker colour, even without any very marked injection of the vessels farther than engorge- ment of the small veins, than in other cases of the disease. The bronchial mucous surface presented, in parts, small livid or purple ecchy- moses, similar marks also sometimes appear- ing in the fauces, stomach, and cascum. 46. The veins and sinuses of the brain were generally engorged with a dark, semi-fluid blood. The auricles and large veins contained blood in a similar state. The surface of the body was livid in parts, mottled, and dotted with petechiae of a dark colour, approaching to the characters of purpura haemorrhagica. [Blood in Measles.—Andral and Gavarret found that in the measles the fibrin never ex- ceeded, nor did it ever fall much below Leca- nu’s average (3 parts in 1000); ranging in adults from 2\ to 3J. This mean is found at the com- mencement of the disease ; but after the erup- tion appears, and in the adynamic form of the disease, there is a tendency to a diminution of this principle. The proportion of blood corpus- cles, however, is augmented in measles from 129 in 1000, the natural ratio, to 137, 140, and 146. It will be observed that in the phlegmasia, the quantity ef fibrin is materially increased from 3 up to 10 parts in 1000, while the propor- tion of globules is not increased. Measles, therefore, should be ranked with the pyrexia, so far, at least, as the state of the blood is con- cerned. (See Pathologie Hamatologique, Paris, 1843, Or Am. Trans., 1844; also Simon's Ani- mal Chemistry, Am. ed., p. 255.)] 47. v. Tissues most uniformly affected in Mea- sles.—The structures specifically affected by this disease are the rete vasculosa of the skin, the mucous membranes, particularly those li- ning the air passages, and, in a lesser degree, those of the fauces and stomach. The redness observed in the mouth and throat during the stages of eruption and florescence is seldom so intense as in scarlatina. The other lesions of structure observed after measles may partly be attributed to the interruption of those functions performed by the cutaneous and mucous sur- faces, and to the consequences thereby pro- duced on other organs associated with them in action, together with the influence of the effi- cient cause of the disease on the nervous and vascular system, on the circulating fluids, and, indeed, on all the vital manifestations, and even on the organization of the frame. These latter, or more extreme changes, however, are chiefly manifested in the more' severe or malig- nant cases, and are not dissimilar from those which take place in the advanced course of low or adynamic fevers, whether exanthematic or simply continued. 48. IV. Diagnosis.—An exact knowledge of the symptoms and course of the disease in each of its sta'ges, and in all the states and forms it may assume, having, at the same time, regard to its origin, its causes, and the character oi the reigning epidemic, will generally enable us to distinguish it from all other maladies of a similar kind.—a. Miliary fever will seldom be confounded with measles, as its phlyctense, containing a serous or whitish fluid, scarcely ever appear on the face, and are always accom- panied by perspirations of an acid and strong odour.—b. Urticaria is distinguished from this disease by the itching attending it, by the lar- ger and more elevated papulae appearing and disappearing without any order, and by its more fugacious character. — c. The exantheme fre- quently accompanying true or contagious typhus, particularly as described in the article Fever (§ 500-503), has a close resemblance to the de- clining eruption of measles. It is, however, readily distinguished by the history of both dis- eases, unless when the measles assume the nervous character. In this case the difficulty of diagnosis is much increased. But the more protracted stages of typhus, the profound typho- mania, and the persistence of the eruption long beyond the period of its disappearance in mea- sles, with various other subordinate features, will generally point out its nature to the atten- tive observer.—d. The early stages of smallpox may also be mistaken for measles; but the marked catarrhal symptoms ushering in the latter, the troublesome cough, the small size of the stigmata, their superficial, slight, and less circumscribed character, and the absence of hardness, will readily distinguish them from the incipient eruption of smallpox.—e. The dif- fused, comparatively smooth, light, scarlet red- ness, the severe affection of the fauces, the early appearance at once over all parts of the body, and its occasional sudden subsidence and return, the burning heat and dryness of the eyes, and the tendency to affection of the di- gestive mucous surface, mark scarlet fever, with which, however, measles have many points of resemblance, fully pointed out under that dis- ease. It has been remarked by Ziegler, and my own experience confirms the justice of the observation, that while measles evince a dis- position to affect the respiratory apparatus, scarlet fever has a manifest tendency to disor- der the cellular tissue. I may add to this, that this latter disease is more intimately associa- ted with a disordered state of the digestive mucous surface, and that this surface is more liable to be diseased in the severe forms of the malady, or after the sudden subsidence of the eruption, than is usually observed to occur in measles.—f. As to rubeola, or that intermediate disease between measles and scarlet fever, I will not here point out its distinguishing char- acters from either one or the other, as this sub- ject is more fully considered in the article Ru- beola.—g. Roseola is often distinguished with some difficulty from measles ; but it may gen- erally be recognised from the circumstance of its being generally sympathetic of dentition, dyspepsia, and a disordered state of the digest ive organs. It is very seldom preceded by any very marked fever, or depression of the volun- tary powers and vital actions, and is not ac- companied by the catarrhal symptoms charac terizing measles. It does not superinduce the morbid affections so frequently observed after this disease. 49. V. Prognosis.—The prognosis in mea- sles is, in many respects, dependant on the type and complication of the disease. Measles is generally less dangerous than the smallpox and scarlet fever. The benign or common form is scarcely attended with any danger, unless as respects its sequelae, or when officiously inter- fered with. The gastric form of the disease is more serious, but this seldom presents much danger if it be judiciously managed. The in- flammatory state should lead us to give a cau- tious opinion of the result, particularly if it be complicated with croup, bronchitis, pneumo- nia, pleuritis, or haemoptysis. Of these, croup, pneumonia, and haemoptysis, especially the last, are very dangerous complications. I have met with several cases of haemoptysis in the differ- ent stages of measles, but the larger proportion of them have terminated fatally sooner or later, under treatment varied according to the fea- tures of each case. The nervous and adynamic or malignant forms of the disease are seldom devoid of danger, particularly the latter. 50. Much, also, depends upon the character of the reigning epidemic, which usually, indeed, assumes some one of the varieties into which I have divided the disease. Some epidemics are so mild as scarcely to cause any apprehension as to the result. Others are so severe as to lead us to dread either the immediate or more remote consequences. Percival states that 91 died out of 3807 cases. Watson had, in the London Foundling Hospital, 1 death in 10 cases, and in another year, 1 in 3. In 1793, 6 cases died out of 69 ; and in 1794, none died of 28 cases in this institution. In 1800, out of 66, 4 died. These results confirm the calcu- lation of Home, who estimated the deaths at 1 in 12. The seasons have also some influence, but chiefly in sporadic cases ; for, during the epidemic prevalence of the disease, their ten- dency is lost in the more predominating char- acter it then assumes. Winter, however, is a less favourable season for the disease than summer and autumn.* 51. a. A premature or retarded eruption gen- erally indicates a severe disease, and one dis- posed to an irregular form and complicated state. An obstinate, severe, and hoarse cough, accompanied with difficulty of breathing, and much febrile action, prolonged beyond the pe- riod of desquamation, evinces a serious affection of the lungs, and danger. Tumefaction of coun- tenance ; a pale, yellowish eruption, intermin- MEASLES—Prognosis—Causes. 947 gled with petechiae ; copious perspirations with- out relief of the symptoms, but indicating re- laxation of the tissues and of the tone of the extreme vessels ; profuse diarrhcea; haemor- rhages, particularly those from the air passages and fauces; livid petechiae; a dark or livid state of the eruption ; gangrenous spots or escars ; very great debility or exhaustion ; a very frequent, very soft, open, or compressi- ble pulse, or an irregular or intermittent pulse; and the presence of nervous symptoms in a marked degree, particularly spasms or convul- sions, are severally most unfavourable symptoms. The disease is generally more severe in chil- dren during dentition, and in young persons near the period of puberty ; also in infants during the first or second or third month. Con- vulsions preceding the eruption, especially du- ring dentition, are unfavourable signs. Adults who have a tendency to pulmonary diseases, or who have previously been affected with them; those of a phthisical or scrofulous diath- esis ; persons addicted to the abuse of ine- briating liquors, and females in the pregnant or puerperal states, generally experience the dis- ease in a severe form. However, the measles are far less dangerous to pregnant women than either smallpox or scarlet fever. 52. The sudden disappearance of the erup- tion, followed by symptoms of internal disease, or by aggravation of pre-existing visceral dis- order, is generally followed by an unfavourable termination. The danger is also great in pro- portion to the extent and confluence of the eruption, and the violence of the attendant fe- ver. The later the eruption is in supervening upon the fever, the better; the earlier, the worse, Very great lassitude, torpor, and rheumatic- pains of the limbs, if experienced long before the eruption, indicate a disease of great se- verity. Difficult dentition, and hooping-cough, concurring with measles, place the patient in danger. A fatal issue, within the course of the disease, occurs most frequently on the ninth and tenth days. It has been supposed by some writers that measles have become more severe since the introduction of vaccine inocu- lation ; but I agree with Hildenbrand in con- sidering this to be devoid of foundation. 53. b. The favourable indications which occur during the disease are, a moderate eruption with a mitigation of the fever ; a disposition to an equable moisture on the skin ; a moderate or slight cough, with a mucous and easy ex- pectoration ; a free and unembarrassed respi- ration ; a free state of the bowels, and mod- erate relaxation of them towards the close of the disease ; hypostatic urine ; a regular suc- cession of the changes of the eruption ; and no appearance of any irregularity or complication with visceral affection, the existence of which, as I have already shown, often occasions a fatal result at a more or less remote period, owing to the tendency to disorganization being greater in the local affections occurring than when ta- king place primarily. 54. VT. Causes.—The infectious nature of measles is sufficiently demonstrated, and re- quires neither proof nor comment.—a. The dis- tance to which the emanation from the body of an infected person may infect a sound one has not been shown, nor, indeed, is it capable of satisfactory demonstration ; for it must depend * [The deaths from measles in the city of New-York, ac- cording to the reports of the city inspector, from Jan. 1,1819, to Jan., 1835, inclusive (16 years), was 1387, ranging from one up to 290 annually. In some years it has assumed a very malignant and fatal character, but generally it is a mild and manageable disease. In Philadelphia, during a series of 20 years, from Jan. 1, 1807, to Jan. 1, 1827, there were reported 667 deaths from measles. In 7 years there were no deaths reported by this disease ; in 1823 there were 156 deaths by it. It appears that by far the greatest mor- tality from this complaint occurs between the first and fifth years ; after this period but 81, out of the above number of 667 deaths, happened. In Massachusetts (4th Ann. Report relating to the Registry and Returns of Births, Marriages, and Deaths, 1845) there were reported for the whole state (Boston excluded) 86 deaths from measles in 1842; 30 in 1843; 32 in 1844; 44 in 1845; which gives the following ratio to 10,000 deaths by all specified causes: 1842, 140; 1843, 42 ; 1844, 45 ; 1845, 54. It is to be recollected that the reports of deaths in this state are as yet very incomplete, but are becoming more complete every year.] 948 MEASLES—Causes, etc. upon the stage and virulence of the disease, and the susceptibility of those exposed to the emanation. It is probable that the infectious effluvium commences to emanate from the sub- ject of the disease from the first appearance of the eruptive fever, and that it increases in ac- tivity until the period of desquamation, after which it declines ; but it has not been shown satisfactorily when all power of infection ceases. That the infectious effluvium is formed as early as during the primary fever, and before as well as after the appearance of the eruption, has been proved by several occurrences by which exposure to infection has been limited to cer- tain periods of the malady. 55. b. As in other infectious maladies, so in this, the infection is etexnded and the disease perpetuated, even after periods of its apparent cessation or disappearance, by fomites, or by the imbibition and retention, for a considerable period, of the miasm given out by the infected. Dr. Williams adduces an instance of this, and similar instances on a smaller scale, as respects the results, must have occurred to every phy- sician. A boy from the Foundling Hospital visited at a house where a child was ill of mea- sles. The boy returned in the evening, and mixed with his fellows as usual; but in the course of fourteen days he and sixty boys were ill of the disease. The experiments of Home, Speranza, and others have furnished numer- ous other proofs of the propagation of the dis- ease by fomites. 56. c. Although the chief modes in which the malady is disseminated are emanations pro- ceeding directly from the sick, and emanations absorbed and retained for a time by woollen or porous bodies, and afterward given out, still it may be spread by contagion and inoculation. Home, Vogel, Wachsel, Brown, Monro, and Tissot have proved the contagious nature of measles by inoculation, either with the blood, or with the serum taken from the vesicles which are occasionally intermixed with the eruption. It was supposed by some of the phy- sicians just mentioned that a mild foim of the disease was produced by inoculation ; but the experiments made by Cullen, Rosenstein, Girtanner, and Vaidy have not confirmed this opinion ; and the inoculation of measles has even partially adopted. The latest trial seems to have been made by Speranza in 1822, who inoculated seven persons, who had the disease regularly and mildly. 57. d. The latent period, or the time which elapses from the impression of the morbid efflu- vium on the sound constitution until the appear- ance of the eruption, varies from six to twenty- one days. In the cases of the inoculated dis- ease, the eruption appeared on the sixth and seventh days. (See art. Infection, § 31.) 58. e. The morbid seminium or poison of measles may coexist with some other morbid poisons, as observed by various pathologists. Macbride states that he occasionally saw mea- sles and smallpox in the same patient at the same time, and that the combination was gen- erally fatal. The coexistence of these mala- dies, either taking the precedence, has been noticed also by De Haen, Vogel, Horn, Pinel, Bateman, and Willan. The coexistence of cowpox and measles, and of hooping-cough and measles, is not infrequent. 59. /. The morbillous miasm, having pro- duced its specific effects, leaves the frame ex- empted from a second attack. But this ex- emption is not universal. It is so general, however, as to induce such experienced ob- servers as Willan and Rosenstein to believe in its universality; while the exceptions to this law are so rare as to be observed only by few, and, probably, in certain epidemics only. Sec- ond attacks have been recorded byBuRSERius, Roberdien, Home, Baillie, Webster, and ob- served also by the author. It has been fully ascertained that the spurious disease, which has been termed “ Morbilli sine catarrho," does not protect the system from true measles ; but it has not been shown that those cases of mor- billous fever, unattended by eruptions (-‘v-<^»-*v_«v-* rf-.WJOMOCOCC^ClU'^WWMOO Years. I I I 1 1 1 Reported by w M. Petrequin. » CO 1 1 1 1 1 1 At Marseilles and 0 Toulon. a | | WtOUWMMM 1 tO 1 ►-* 1 fcO to h* OJ p-* t— -4 ►— £> 1 By M. Bucliacourt gj at Lyons. © 1 | | 1 | »-• Ui to •— GO CD CO OS O OS rf». C* 1 At Lyons. jg 1111 CO 00 Oi OKI 2 00 05 W I ►— At Paris. I 1 1 1 *i3S3338S£Sl 1 At Manchester. g 1 1 to 1 00 © !2 to GO CO | | I At Goettingen. * tO CO h3 •—* | CO 00 to © -1 OI CO to >-* Oil C^!0^-^^»^C0mW^CX)^Om Total, 1604. 10. From the foregoing table it will be seen that menstruation generally commences be- tween the ages of twelve and nineteen, and more frequently at the age of fifteen than at any other. Although it is not always, at its commencement, correlative with other signs of puberty still, it must be viewed as generally connected with and depending upon the chan- ges taking place in the ovaria and uterus at this period, and as being determined by the increas- ed development and activity of the nervous system of organic life endowing the uterine system. That the ovaries exert an influence in determining the occurrence of menstruation, was supposed by Friend and many more re- cent writers, and is not improbable. The well- known case published by Mr. Pott, and cases of disease of the ovaria which have occurred to Dr. Montgomery and in my own practice (see the case about to be alluded to), almost dem- onstrate this influence. Dr. Power attributed menstruation to the action of the ovaries. He conceived that gestation is the natural condi- tion of the female organs ; that a female men- struates because she does not conceive ; that pertain changes take place in the ovarian vesi- cles preparatory to the transmission of the ovum, and that parallel changes are taking place in the uterus, which may issue in the formation of the decidua ; but that, if the stim- ulus of impregnation be denied, the increased action of the uterus is not sufficient to produce that effect, although it is sufficient to cause the effusion of a fluid, which is the menstrual fluid. MENSTRUATION—Phenomena of. 961 However this may be, there can be no doubt that the accession of the catamenia is the con- sequence of a periodical excitement, or irrita- tion of the nerves of the uterine organs acting upon the vascular system of these organs, and determining an increased afflux of blood to them; and hence, that it is somewhat analo- gous to the condition in the lower animals usu- ally denominated that of “ heat.” An opportu- nity was afforded to Dr. Hooper of examining the organs of a female who was instantane- ously killed by accident during the menstrual period. The uterus was swollen and vascular; its structure less dense than usual, and its in- ternal membrane injected, floccy, and bedewed with menstrual fluid. The ovaries and Fallo- pian tubes were also swollen and very vascu- lar. Other facts and considerations might be adduced to prove that menstruation is the re- sult of increased nervous and vascular activity of the uterine organs; and this view is that most accordant with the phenomena which this function evinces during disease. [It is now generally acknowledged that men- struation, as well as conception, is dependant on the existence and influence of the ovaries. The ovarian vesicle was first discovered by De Graap, from whom it received its name; but no important inference was derived from this discovery, until Purkinje, in 1825, found this vesicle in the unimpregnated yolk. Since then we have been favoured with the observa- tions ofMM. Caste, Wagner, Schwann, Whar- ton Jones, Barry, Bischoff, Gendrin, Raci- borski, Lee, Negrier, Boismont, Girdwood, and others, and which have established, beyond all reasonable doubt, that menstruation is the consequence of the periodical maturation and rupture of a Graafian vesicle, with the escape of an ovum from the ovary into the Fallopian tube, which is washed away by the menstrual blood. It is based on the physiological law of the sex, that an embryonic germ is developed and brought to perfection at stated intervals, corresponding nearly with the revolution of the lunar period of twenty-eight days each, one ovum being ripened every month. “The substance of the ovary,” says Dr. Meigs (Am. ed. of Colombat, p. 460), “ or its stroma, is found to contain a vast multitude of small points, disseminated w’ithin its structure. Each of these points, discoverable only by the aid of a microscope, is supposed to be a rudi- mental germ, ready to commence its work of development whenever the proper time may ar- rive, in its series or turn; and it proceeds in that work by such degrees, that at least one such will be brought to complete maturity, as before said, once a month, as long as the men- strual age lasts, and while the woman enjoys good health. Now, as the microscopic ovum is contained within a double capsule, called the Graafian vesicle, it happens that the contain- ing vesicle expands, and grows with great ra- pidity during the latter part of the process ; it continues to rise from the central or internal parts of the ovary towards the surface, distends the stroma, puts the tunica albuginia on the stretch, and, finally, bursts outward, dischar- ging its fluid, and the ovum in that fluid, with its accompanying retinacular or granular matter, into the cavity of the belly, or, in case of im- pregnation, into the fimbria of the Fallopian tube, by which it is conducted to and lodged in the womb, to constitute the ovum of a gra- vid uterus. Now it clearly appears, from the showing of Robert Lee, of London, M. Ne- grter, of Angus, M. Gendrin, of Paris, and M. Raciborsici, of the same city, and many oth- ers, that if a woman die in menstruating, or soon afterward, there is found on the sur- face of the ovary a bloody and ragged opening, leading into a small pit or crypt, in which is fre- quently found a small clot of blood, and which crypt once contained the fluid, the granules, and the ovum of the now broken Graafian ves- icle. It also appears, where the rupture has recently taken place, the entire ovary is found reddened and turgid, from the hyperaemia indu- ced in it by the development of the vesicle, just as the gum of a young child, over a large jaw tooth, is found to be reddened and engor- ged from a hyperaemic irritation arising from the pressure of the still uncut tooth. “ Different observers report that they have found the ovary of the same side, the Fallopi- an tube, and the uterus of a bright red colour in patients dying suddenly during their men- struation ; and they declare it to be an invari- able rule to find the evidence of a recent rup- ture in all such persons, while the numerous pits, depressions, and cicatriculae to be noticed upon the surface of every ovary of females be- tween fifteen and forty-five years of age are regarded as the vestiges of these periodical dis- charges. Stated developments and bursting of the Graafian vesicle may be confidently looked for on one or other of the two ovaries. So firmly does M. Raciborski seem to regard this doc- trine as established, that he calls it a regular ponte, or laying process, whose appearances and laws, as far as ascertained, he has published in his recent work, De la Pubcrte, &c.,” &c.—{hoc cit.) For an able resume of what is known on this subject, the reader is referred to an article by Dr. Purple, of New-York, in the sixth vol- ume of the New-York Journal of Medicine and the Collateral Sciences, p. 229, entitled, “ Men- struation, its true Nature and Office, with a Re- view of the Evidence of its Vesicular Origin, with illustrative Cases.'7 See, also, the Brit, and For. Med. Review, vol. xvii., 1844; R. Lee’s “ Mid- wifery Raciborski, in Gaz. des Hopitaux, vol. iv., 1842; Land. Med. Gaz., 1844 (cases by Ritchie) ; and New- York Med. Gaz. (case by Dr. Post).] 11. The symptoms indicating the first accession of the catamenia are not always present or con- stant ; but generally, for some days previous to the accession of the discharge, headache, heav- iness, languor, pains in the back, loins, and down the thighs, are complained of, with indis- position to exertion. There is a peculiar dark tint of the countenance, particularly under the eyes ; and occasionally uneasiness or a sense of constriction in the throat, or about the thyroid gland. The cutaneous perspiration has often a faint or sickly odour, and the smell of the breath is peculiar. The mamma? are enlarged and painful, or tender. The appetite is fastidi- ous and capricious, and digestion impaired. These symptoms continue one, two, or three days, and subside as the menses appear. At the commencement of this function, the sec- ond, third, or even the fourth period may not be attended by any discharge; it sometimes MENSTRUATION—Management of. 962 thus recurring irregularly at first, even in healthy females. The period continues from three to six days, and returns every twenty- eight days, excepting during gestation and lac- tation. 12. In order that this function should be duly established and sustained, the following condi- tions are requisite : 1st. A healthy development of the female organs of generation; 2d. A cer- tain degree of vigour or organic energy of these organs ; 3d. The absence of such lesions as im- pair the influence of the ovaries, or interrupt the functions of the uterus ; 4th. A certain de- gree of constitutional power. Upon these the healthy or regular state of the menstrual dis- charge chiefly depends. 13. The duration of the function of menstru- ation is very generally thirty years, but more fre- quently above than under this term. The peri- ods of commencement have been shown above. Those at which the function ceases have been commonly stated at an earlier age than is gen- erally observed in this country. Menstruation has been said to cease at about the forty-fifth year; but, judging from my own inquiries, I believe that the period between forty-five and fifty is the common period with healthy females. In warm climates this function may cease be- tween thirty-nine and forty-five years ; but in temperate climates it disappears more frequent- ly after than before the forty-fifth year—at least in England. Mr. Roberton states, that of seventy-seven females, ten ceased to menstru- ate at forty-eight years ; seven at forty-nine ; twenty-six at fifty ; two at fifty-one ; and seven at fifty-two ; the catamenia thus disappearing in fifty-five out of seventy-seven, from the years forty-eight to fifty-two inclusive. 14. II. Management of the Menstrual Pe- riod.—i. During the presence of the catamenia, the female frame betrays increased suscepti- bility and excitability; and this period is usu- ally viewed by females themselves as one of greater delicacy and liability to be affected by injurious agents and mental emotions. It is of much importance to obtain satisfactory in- formation as to the regularity and states of this evacuation in all cases in which the health and disorders of females are concerned, and there- fore the inquiries of the physician respecting it should be careful and precise.—a. When the female enjoys good health, and the discharge is regular and natural in every respect, all that is required, during its continuance, is the avoid- ance of all influences, physical and moral, which may powerfully affect the body and mind. These may either suppress, interrupt, or in- crease the discharge, and either contemporane- ously or consecutively produce other very seri- ous or even dangerous results. Sudden frights, fits of anger, and all powerful mental emotions may have an injurious effect upon this dis- charge. Blood-letting, emetics, purgatives, em- menagogues, active diuretics, the more power- ful diffusive stimulants, and astringents ought not to be resorted to at this period, as they may morbidly increase the discharge, or even alto- gether arrest it. Cold or warm bathing, hip and foot baths should also be discontinued du- ring this period, especially when it is healthy nr natural. Care ought also to be taken not to expose the feet to wet or cold; and to avoid sitting upon stone, cold, or damp seats, or upon the ground. Excessive exertion of every kind; long walks, long rides on horseback, or on rough roads, and prolonged dancing or stand- ing ought also to be avoided, as tending to produce not merely an increased discharge, but even prolapsus uteri, particularly in married females. Females subject to leucorrhcea ought not to have recourse to vaginal injections du- ring or shortly before this period. Dr. Locock remarks, that either “by accident or by criminal impatience, sexual intercourse has sometimes been permitted during this period ; and, al- though not constantly, yet such conduct has been frequently followed by the most serious effects—generally by profuse haemorrhage ; at other times by a sudden suppression of the dis- charge ; to which have succeeded fever, delir- ium, obstinate hysteria, confirmed mania, and even catalepsy.” 15. ii. On the first appearance of the menstrual period there is generally little farther required, as respects the healthy young female, than great care in avoiding the injurious physical and moral influences now mentioned; and even when the second, third, or fourth periods for the recurrence of the discharge are passed over, but little may be necessary if no farther disor- der be manifest. If, however, the female be delicate, or is much confined in-doors, or if the bowels be habitually costive, the preparations of iron or of iodine, with emmenagogue purga- tives, as aloes with myrrh, &c., may be ad- ministered, and regular exercise in the open air enjoined. A smart walk should be taken daily before breakfast, and be repeated twice in the course of the day. Confinement to close or crowded apartments, and in close or crowd ed streets ; and, still more, numbers sleeping in small, low, damp, crowded, or ill-ventilatea rooms ; and deprivation of air and exercise— of the free use of the limbs in an open and healthy atmosphere, are the chief causes of the disorders of menstruation in cities and large or manufacturing towns. To these causes may be added want of sufficient sleep, prolonged mental attention and exertion, and whatever tends to impede the functions of respiration, digestion, assimilation, and muscular action. Hence all these injurious agents ought to be especially avoided at the epoch of female pu- berty. 16. iii. The period of the final cessation of the menses is variable; and even in healthy females the change may be attended by phenomena re- quiring discrimination on the part of the physi- cian. This period is also one which often ex- cites the fears of females. In a few cases, the uterine functions acquire an increased activity shortly before their final cessation, so that fe- males who have not had children for years, or who have been barren hitherto, have unexpect- edly become pregnant. More frequently, how- ever, females mistake the symptoms often at- tending the cessation of the menses for those of pregnancy. The passing over of the men- strual period, swelling and pain of the breasts, the sickness and disorder of the stomach, and capricious state of the appetite, the increase in size, and the movements occasioned by flatu- lence of the bowels often accompanying this epoch, sometimes induce a belief in the mind of even an experienced female that she is preg- nant ; and her exact state can be determined only by an examination per vaginam, by time, or by the exhibition of purgatives and carmin- atives. 17. Menstruation rarely ceases at once, when the usual age at which it disappears is arrived at, unless some accidental circumstance, as fright, exposure to cold, an acute illness, &c., occurs and occasions it. More commonly, the change is gradual, and is attended by irregular- ities as to the intervals between the periods, the duration of the period, and the abundance or scantiness of the evacuation. Sometimes the discharge returns every two weeks, then ceases for several weeks, or even months, and afterward recurs for a few periods as regularly as ever, and then altogether ceases. Many fe- males of delicate constitution, who have com- plained much during the earlier epochs of their existence, or who, up to the period of this change, have been liable to hysterical and ner- vous ailments, have subsequently enjoyed a much better state of health, and lived long and healthily, when this change has been brought about carefully and fortunately. During the functional activity of the uterine organs, and while these organs are highly susceptible of ir- ritation, many of the disorders depending upon irritation of them are more or less frequently experienced; but when these organs undergo the change characterizing this epoch of life, the susceptibility of irritation subsides, and gradu- ally disappears; and, consequently, the disor- ders which thus originate are no longer felt. 18. On the other hand, when disease already exists in some organ, or even when a predis- position to disease exists, the cessation of the menses generally aids in aggravating the for- mer, or in developing the latter. A disorder, or even an organic lesion, which may have been so slight, or so little advanced, as to escape detection as long as the menstrual discharge has continued, and has proved a periodical der- ivation from the affected organ, and a recur- ring evacuation of the vascular system, will no longer thus remain latent or continue station- ary, but will assume an active and rapid form. The maladies which most commonly become thus developed are the various organic and ma- lignant diseases of the uterus and mamma ; gout, apoplexy, and paralysis ; organic diseas- es of the liver ; dropsies ; structural changes of the lungs; cutaneous eruptions ; ulcers of the lower extremities; heemorrhoidal affec- tions ; epilepsy, hysteria, and mental disorder, &c. In many cases, leucorrhoea occurs, and continues long at this epoch, and powerfully tends to prevent the vascular fulness which might develop or aggravate these or other diseases. In some instances, haemorrhoids su- pervene, and have the same effect; and even the appearance of cutaneous eruptions, or ul- cers on the extremities, exert some degree of derivation from an organ disposed to serious disease. 19. iv. The medical management of impending disease at this epoch is of great importance, and the earliest indications of disorder should be carefully watched and duly estimated. Signs of vascular fulness, of local congestions, and of oppression of any organ ought to be met with local depletions, which should be repeated according to the circumstances or urgency of particular cases. Vascular fulness or visceral MENSTRUATION, DELAYED—Diagnosis. oppletion or obstruction are the chief patholo- gical conditions at this period of life ; and al- though local bleedings are necessary to remove impending mischief, still, diet and regimen are the means on which we should chiefly depend for the permanent removal of the evil. A reg- ular state of the bowels ; the occasional exhi- bition of a mercurial to promote the biliary se- cretion ; a light, farinaceous, and vegetable diet, or a very moderate use of animal food; and regular exercise in the open air, are means which are applicable to all cases characterized by vascular fulness or congestions. When dis- ease of some internal organ is actually present, and when the more acute or active state has been subdued by vascular depletions and other appropriate means, perpetual blisters, setons, and issues will prove of service in removing the remaining irritation, and in preventing a recurrence of vascular determination to, or con- gestion of, the affected organ. 20. In all cases, the treatment should mainly depend upon the states of the vascular system, in connexion with those of the chief viscera; nevertheless, the nervous manifestations re- quire attention. If the nervous system be mor- bidly susceptible or sensitive, the vascular sys- tem being neither too full nor oppressed, means should be used to impart energy to it, and there- by, as well as by other agents, to remove this condition. If it be connected, as is sometimes the case, with a deficiency of blood, or of haematozine, the ferrugineous tonics should be prescribed ; and if painful or convulsive disor- ders be associated with this state of the vascu- lar system, narcotics, anodynes, and antispas- modics may be conjoined with these. In most cases of sudden seizure attended by convul- sions— whether epileptic or hysterical — al- though following the cessation of the menses, antispasmodics and anodynes constitute a prin- cipal part of the treatment; and even local de- pletions should be cautiously and sparingly em- ployed, unless the signs of general or local ful- ness be quite conclusive, and then they ought to be resorted to in conjunction with the rem- edies just mentioned. III. Absent, Suspended or Suppressed, and Vicarious Menstruation.—Synon. Amenor- rhoea (from a, priv., gyveq, the menses, and fieu, I flow), Vogel, Cullen, Parr, Young, Pi- nel, &c. Emansio mensium, retensio mensi- um, Auct. Paramenia obstructionis, Good. Ischomenia, Swediaur. Meneschesis, Plouc- quet. Defectus menslruorum, suppressio men- sium, Auct. var. Manque des regies, sup- pression de rigles, Fr. Mangel des monatblut- fluss, Germ. Suppressions dei menstrui, ame- norea, Ital. Obstruction. Classif.—IV. Class, V. Order {Cullen), V. Class, I. Order {Good). I. Class, II. Order {Author). 21. Defin.—Absence of the menstrual dis- charge at the period of life when it is usually reg- ularly established, or the suspension or suppres- sion of it after it had recurred regularly for some time. 22. This subject may be considered under three distinct heads: 1st. Absence and reten- tion of the menses; 2d. Suppression of the menses; and, 3d. The complication or associ- ation of either of these with some other disor- der or malady. 963 964 MENSTRUATION, DELAYED—Diagnosis. :. Absent and Retained Menses. — Synon- Emansio mensium ; relentio mcnsium; delayed menstruation ; retained menses; obstructed men- struation. 23. Defin.—A delay in the first appearance of the menses, owing to functional disorder or to or- ganic change. 24. The menstrual discharge may be delayed or absent, owing to functional inactivity or dis- order ; or it may be obstructed or retained by or- ganic change. Hence, amenorrhcea presents two forms, the distinction between which should be preserved; the one being simple and func- tional, the other structural and obstructive. 25. A. Simple or Functional Amenorrhcea. —Emansio Mcnsium; Delayed Menstruation.— The differences in the age at which menstrua- tion commences have already been noticed. In some of those instances in which it has not appeared until three or four or more years after the usual period, in w’hich it has been delayed merely, the amenorrhcea being simple, or un- complicated with organic change or mechani- cal obstruction, it will be found that the retard- ation has occurred in one or other of the fol- lowing states : a. The development and action of the uterine system are not correlative with the growth and health of the body.—b. The development of both the uterine organs and the whole frame is apparently natural.—c. The ute- rine functions are insufficient to produce a col- oured discharge, uterine leucorrhcea being sub- stituted.—a. Some of the cases of simple amen- orrhcea are actually instances of protracted puberty, the whole frame betraying imperfect growth ; but care should be taken to ascertain the nature of the case, and the absence or pres- ence of malformation or obstruction of the kind about to be noticed (§ 39). Siebold and Churchill distinguish two principal conditions of the system in this form of amenorrhcea, viz., a plethoric state conjoined with rigidity of fibre and robust health ; and somewhat of deficiency of blood, or laxity of fibre, associated with pal- lor, and a weak or delicate constitution. In both, an apparent attempt at menstruation oc- curs occasionally, or even monthly, and is char- acterized by pains in the back and loins ; by weight in the lower part of the abdomen ; by aching in the tops of the thighs, with lassitude and uneasiness; and sometimes by constric- tion about the thyroid gland. After two or three days these symptoms cease, without any menstrual evacuation, or merely with leucor- rhceal discharge, and are often succeeded by severe headaches, with intolerance of light and sound. In the more plethoric cases these suf- ferings are severe, and occur occasionally be- tween the efforts at menstruation, and are at- tended by flushings and throbbings of the face and head ; quick, full pulse, thirst, and gener- al febrile action. In the pale and delicate, there is little or no fever, and the symptoms are slighter and more chronic. As these dis- orders continue or occur, the functions of the digestive organs languish ; the bow'els become irregular ; the countenance pale ; the strength reduced; and the breathing short; and the general health gradually declines. Various hysterical symptoms, or even severe hysterical paroxysms, particularly in the more plethoric leases, occasionally appear; and severe attacks of disease of vital organs are apt to occur, from the influence even of their less energetic ex- citing causes. Nauche met with two instances of fatal disease of the brain in this state ot menstrual obstruction. I have seen a similar instance, attended by epileptic convulsions, and terminating in fatal coma ; also cases of pneumonia, and of congestion of the lungs, in similar circumstances ; but most frequently, particularly in the more delicate class of cases, this form of amenorrhcea assumes the com- plicated state about to be noticed, and the pa- tient passes into chlorosis or into tubercular consumption ; or becomes first chlorotic, and subsequently consumptive. In a few cases, however, diarrhoea or some discharge occurs and protects for a time the patient from the more dangerous consequences of the obstruc- tion ; or some evacuation takes place, from time to time, which proves vicarious of the menses, as will be noticed in the sequel. 26. Dr. Churchill states that he has re- peatedly examined the uterus of patients la- bouring under amenorrhcea; the cervix uteri has generally been small, and more pointed than usual during the interval; but in all these cases a small-sized bougie could be introduced into the cavity without pain or difficulty. Du- ring the abortive efforts at menstrual discharge an enlargement of the cervix takes place, par- ticularly in those cases which are attended at this period with some leucorrhoeal discharge. 27. b. The diagnosis of simple amenorrhcea has reference chiefly to its simple or uncom- plicated state. 1st. To the absence of mal- formation and mechanical obstruction. 2d. To the existence of some other disorder or mala- dy, which may have preceded or caused this condition, or which may be complicated with it. If there be periodical exacerbations (which do not always attend simple amenorrhcea, but generally that caused by mechanical obstruc- tion), an examination will readily detect the existence of an obstructive cause. When these exacerbations are evinced, and no local impediment exists, the form of the disorder now being discussed may be inferred to exist; and this inference will be confirmed if they be attended by a colourless discharge, or leucor- rhoea. 28. c. The prognosis of this form of amenor- rhcea should be stated with caution or reserva- tion in respect of the ultimate result, particu- larly where it is unattended by periodic efforts (<) 25), or leucorrhoeal discharge during these efforts. The more immediate consequences are those complications presented by the disor- der as it becomes prolonged ; as chlorosis and disorder of the general health ; continued leu- corrhoea ; sterility, at least during this state of the uterine organs; tubercular consumption, va- rious nervous ailments, anaemia, scrofulous dis- eases of the glands or joints, organic lesions ot the heart, epilepsy, hysteria, &c. The more acute, but rarer consequences, of simple amen- orrhcea, are inflammations of, or effusions on, the brain and its membranes ; haemorrhagic attacks; inflammations or congestions of the lungs, &c., as noticed above ($ 25). 29. d. The causes of amenorrhcea have been generally considered to be indolence and sed- entary lives; gross diet, luxurious habits, hot rooms, soft beds, and too much sleep : causes which may have some influence in producing MENSTRUATION, DELAYED—Treatment 965 the complaint in some constitutions, but which are often less influential than others that have been entirely overlooked, more especially sleep- ing in close and crowded rooms ; want of ex- ercise in the open air; constant mental exer- tion and occupation at the period of approach- ing puberty, to the neglect of the physical aids of bodily development; early masturbation, and all over-exciting and debilitating and exhaust- ing influences; the vicious system of modern and fashionable education ; the occupations of the poorer classes during the period of puberty, especially employments in warm-, ill-ventilated, and crowded rooms and factories ; insufficient sleep, prolonged exertion and attention, before and during the period of commencing menstru- ation ; residence in cold, damp, and malarial localities, or low cellars; prolonged exposure to cold, and insufficient clothing ; nostalgia and depressing mental emotions. 30. e. The pathological conditions to which amenorrhcea has been attributed are chiefly theoretical—entities of the imagination, such as spasm of the extreme vessels; torpor of the vessels; engorgements of the vessels, &c. The true condition is most probably an imper- fect development, or impaired energy, or both states conjoined, of the uterine organs [espe- cially the ovaries], arising from causes which impair or exhaust the organic nervous ener- gies during the progress of growth, or from circumstances which determine these energies to the brain. Those causes of simple amenor- rhcea which are characterized by vascular pleth- ora furnish no argument against this view ; as this state of the vascular system may exist in connexion with inactivity of the uterine organs.* 31. /. Treatment.—It is obvious that the management of amenorrhcea should be based upon the pathological condition of particular cases as far as it is manifested, and be directed with reference to the abortive efforts which may periodically occur. If the obstruction be attended by general vascular fulness and ro- bust health, local or even general bleeding, but chiefly the former, may be prescribed ; and preferably at the commencement of, or a day or two before the periodic effort, or recurrence of the leucorrhoeal discharge accompanying it. In London and large towns, local bleeding only is required, general blood-letting almost never, or only when the complexion is florid, the habit plethoric, and the fibre rigid. It has been rec- ommended, particularly by obstetric writers, to apply leeches to the vulva in these cases, and to take blood by cupping on the loins. Gener- ally, however, the application of leeches to the insides and tops of the thighs, just below the groins, is to be preferred, both as being more agreeable to young females than the other modes, and as being equally efficacious. In- deed, cupping on the loins is not to be confided in for simple amenorrhcea ; and it may even be injurious, although prescribed for inflammatory states of the uterine organs. I have seen it cause suppression of the menses when thus employed. 32. Next to local blood-letting, in the more plethoric cases, active purging by means of cal- omel, aloes, extract of colocynth, &c., with as- afcetida, myrrh, &c., is the most efficient rem- edy, particularly when persisted in for some days before, and even during the periodic ef- forts. In the intervals between these, the em- menagogue purgatives may be given with the stimulating emmenagogues, or with the bibo- rate of soda ; and the patient should live part- ly, or chiefly, on fish and shell-fish, take regu- lar and active exercise in the open air, and use the hip bath, especially at the periods ad- verted to. Having removed vascular fulness by these means, and the catamenia not yet appear- ing, the treatment may be conducted in many respects as may be appropriately directed for cases characterized by delicacy of constitution, or impaired organic nervous energy, connected with deficiency of blood, or of haematozine. 33. For this latter class of patients, the cha- lybeate preparations, particularly the compound steel mixture (Griffith’s) ; the tinctura ferri sesqui-chloridi, or the vinjum ferri with tinctu- ra lyttae ; the carbonate of iron, in the form of electuary, with confection of scammony and confection of black pepper ; the compound steel pill with the aloes and myrrh pill; the iodide of iron ; the tincture of iodine, or the iodide of po- tassium with tonics; chalybeate mineral wa- ters ; the tinctura lyttae, or tincture of capsi- cum with tonic infusions ; or pills consisting of ox-gall, asafcetida, myrrh, and capsicum, will severally be employed with frequent, although not with constant advantage. Dr. Locock rec- ommends pills consisting of myrrh, aloes, sul- phate of iron, and oil of savin, a combination often prescribed by the celebrated Dr. Gregory. 34. Dr. Bardsley prescribed strychnine, com- mencing with doses of one twelfth to one fourth of a grain, twice or thrice a day, that may be slightly increased after a time, or given some- what more frequently. Headache or twitch- ings of the muscles require the suspension of it. Nauche also employed it successfully, but gave it in larger doses. The cases, however, in which it was most beneficial were those of suppression of the menses. I have preferred the extract of nux vomica in combination with aloes, commencing with half a grain of the for- mer, twice or thrice daily. It manifestly acts, as Dr. Bardsley contends, by stimulating the uterine organs and improving the tone and vig- our of the system. Aconite has been likewise tried, and apparently with advantage, by some German and French physicians. I have pre- scribed the alcoholic extract of aconite with decided benefit. Besides these, various othei remedies have been recommended, particularly the balsams and turpentines, melampodium, savin, cantharides, asafcetida, conium, the ergot of rye, &c. This last has been favourably no- ticed by Dewees, Locock, Roche, Nauche, and * [M. Colombat has arranged the causes of primitive constitutional amenorrhcea under two heads, predisponent and occasional; the former including, 1st. Tne sanguine temperament, which is manifested by a plethoric condition, and by excessive fulness of the vessels, determining loeai congestions in different organs; and, 2d. The lymphatic temperament, characterized by a condition of general debil- ity, and by a want of activity in the circulatory system. Several of the causes of amenorrhcea alleged by our author are, perhaps, more often the occasion of menorrhagia than retention of the menstrual flow. We shall generally be able to trace this accident to some defect in the primitive consti- tution of the female ; or, in its absence, to debilitating in- fluences, as insufficient nourishment, want of exercise in the open air, abuse of sanguine evacuations, leucorrhoea, and other causes which impoverish the blood, the depress- ing passions, &c. If a state of plethora lead to the same result, it may be, as M. Colombat has suggested, that the blood, too rich in fibrin, opposes the periodical exhalation which constitutes menstruation.J 966 MENSTRUATION, OBSTRUCTED—Pathology. Pauly. During the use of these medicines, and particularly of the chalybeate preparations, a full dose of calomel with aloes should be giv- en once in the week at bedtime, and be follow- ed by the compound decoction and tincture of aloes in the morning. The ammoniated tincture of guaiacum has been much used for this com- plaint, and has been very favourably noticed by Dr. Hannay and others. 35. Various stimulating enemata have been advised, particularly those with spirits of tur- pentine, asafectida, aloes, rue, savin (see F. 130, 131, 134, 135, 141, 150). Dr. Shonlf.in pre- scribes an enema with aloes to be thrown up at the period when the effort at menstruation takes place. At that time, two or even more of the above substances may be employed with advantage, as proved by some cases in my own practice. 36. The local excitement of the uterine organs by means of medicated bougies and injections was recommended by the ancients and by the older writers, and has been advised by some modern authors. Lavagna prescribed a few drops of the liquor ammoniae in an ounce or two of milk to be thrown into the vagina, and several physicians have tried this practice. Dr. Blundell has noticed it favourably. The in- jection of a few drops of eau de Cologne in warm milk was a domestic practice in this complaint in some parts of the Continent. The safety of the practice entirely depends upon the particular circumstances of the case in which it is resorted to. There can be no doubt of the practice being hazardous, if it be not cautious- ly employed ; inflammation not only of the va- gina, but of the uterus also, being likely to fol- low the use of a too strong injection. 37. It has been attempted to excite the ute- rine organs sympathetically by irritating the mamma. Dr. Loudon applied leeches to the mammae with this view. Siebold recommends warm fomentations ; Sir James Murray, ex- hausting glasses ; and several writers, blisters, stimulating plasters, sinapisms, &c., to the breasts, with the same intention. I have pre- scribed blisters, sinapisms, and issues to the in- sides and tops of the thighs ; frictions to the loins and back, with stimulating and rubefa- cient liniments ; and embrocations of a similar nature applied more constantly in the same situations with marked advantage. Electricity and galvanism, directed across the uterine or- gans, have been advised by Thomann, Alber- ti, Birch, Capuron, Ritter, Marcus, Aldini, Nauche, Siebold, and many others. The hip bath, or mustard hip bath, and mustard pediluvia, are generally of service about the accession of the periodic efforts at menstruation. If these efforts are attended by leucorrhoea, the treat- ment does not require any material change from that above advised ; but if the colourless discharge continues or appears in the inter- vals, it then becomes an important complica- tion, which will be noticed hereafter. Of other means which have been tried in this form of obstruction, notice will be taken in the sequel, as being equally appropriate to suppression, as to absence, retardation, or deficiency of the menses. 38. The diet and regimen should have strict reference to the pathological states of each case. In the plethoric, the diet should be spare, and consist chiefly of salt-water fish and ve- getables. In the delicate, weak, and chlorotic, the diet ought to be nutritious, digestible, and sufficient in quantity to supply the deficiencies in the blood and frame generally, new eggs, mutton, game, and wine being allowed. Reg- ular exercise on foot or on horseback, and the more active amusements and exercises, should also be indulged in, especially in the open air. 39. B. Amenorrhcea from Congenital Mal- formation and Organic Lesion. — Obstructed Menstruation; Retained Menses.—The follow- ing malformations and organic lesions may oc- casion amenorrhcea : 1st. The ovaria may be wanting or diseased. 2d. The uterus may be absent. 3d. Both the ovaria and uterus may be wanting. 4th. These organs being present, the canal of the cervix uteri may be nearly or altogether obliterated. 5th. A false membrane may cover the os uteri. 6th. The vagina may be wanting. 7th. The vagina may have had its canal obliterated, or the orifice closed by adhesion of the lower portion and labia. 8th. The hymen may be imperforate. The most ot these lesions are congenital; others are the consequences of disease previous to full puberty. 40. a. Of the congenital lesions some affect the character and development of the whole frame: others have no such effect.—a. Defi- ciency of the ovaria is attended by a more or less masculine development of the body at and after the period of puberty. The mammae and external genitals are not fully developed ; the sexual propensities are not manifested ; the voice is harsher and deeper than usual; and a beard is observed on the upper lip. The gener- al health may not be affected. 41. b. Absence or malformation of the uterus has been noticed by Siebold, Lauth, Andral, Chaussier, Stein, and others. If the ovaria exist in cases of absence of the uterus, the general development of the body may not be affected ; but if they be also wanting, in addi- tion to the masculine character, or mixture of masculine with feminine peculiarities, the va- gina, on examination, will be found to termi- nate in a cul de sac, the cervix and os uteri will not be detected, or not be developed, and the uterus will not be felt from the rectum. In these cases, also, the general health may be little affected. 42. c. When the vagina is wanting, both the ovaria and the uterus being present, the men- strual secretion may take place, its exit only being prevented, producing distention, some- times to an alarming extent, of the uterus. The fulness in the hypogastrium is augmented at monthly periods, and the general health is very much affected. The outward signs of fe- male puberty are present; but the vulva or ex- ternal parts present no vaginal canal, or mere- ly a commencement of it. In these cases, the patient loses her complexion, becomes pale, delicate, and thin. She complains of pains in the back, loins, and hips ; of distention of the hypogastrium, and of a sense of weight and bearing down. These symptoms are increased every month. The abdomen increases in size, and the density of the swelling is shown by percussion. The distention of the uterus may proceed to rupture of its parietes and to the escape of the contents into the peritoneum, fol- lowed by rapidly fatal peritonitis; but more fre- MENSTRUATION, OBSTRUCTED—Trea tment 967 quently death takes place from the general dis- order, with prominent affection of some vital organ, before rupture takes places. 43. d. Imperforate hymen may be attended by many of the symptoms accompanying the early stages of absence of the vagina ; but even if the cause of disorder be not attended to, the distention of the vagina may rupture the hy- men before fatal injury be produced. In this case, as well as in the others, careful exami- nations, which ought always to be made, will show the nature of the mischief, and the mode of its removal. 44. f3. The organic lesions occasioning amenor- rheea are as follows : a. Disease of the Ovaries. —Dr. Churchill states, that Dr. Montgomery met with a case of a female with an obscure abdominal affection, who had menstruated for a time, and amenorrheea occurred. On ex- amination after death, it was found that there was only one ovarium, and that one had be- come completely disorganized. A delicate fe- male was attended by several practitioners in succession, and, lastly, by Dr. Farre and the author. Puberty was imperfectly developed, and the menses had not appeared at the usual term. She subsequently died of acute febrile phthisis. The uterus was found extremely small, and the ovaria remarkably atrophied, and converted into a dense fibro-cartilaginous sub- stance. The inspection was made in my pres- ence by two gentlemen who had attended my lectures at the Middlesex Hospital. [Dr. Pott has given the history of a case in which both ovaries were removed, and in con- sequence of the operation menstruation en- tirely disappeared, although previously to the extirpation puberty existed, and the function had been well performed. Dr. Ashwell also describes a case (in Diseases of Females, p. 49, Am. ed.) of complete scirrus of the ovaries, at- tended by a similar result.] 45. b. The canal of the cervix uteri may have become impervious, or the os uteri may be covered by a false membrane. Cases of this kind are not so rare as was formerly supposed. These le- sions, however, are more frequently a cause of suppression than of retention or primary ab- sence of the menses. Instances illustrative of these have been furnished by Rathieu, Dus- saussoy, Osiander, and Storr ; but their im- portance, from their frequency, was especially insisted upon by Dr. Mackintosh. They are usu- ally the consequences of inflammation, which also may occasion accretion of the sides of the vagina, and obliteration of the canal. Indeed, cases of congenital obliteration of the canal may have arisen from the same cause during, or soon after foetal existence. It is obvious that, in those circumstances, the symptoms of the accumulation of the menstrual secretion in the cavity of the uterus will be much the same as those accompanying absence of the vagina (() 42), but they may not become so extreme, as an attentive examination will show the na- ture of these cases, and a carefully conducted operation may remove the cause before they become urgent or dangerous.* 46. The labia or lower part of the vagina, or both, may have become adherent at any period be- fore puberty, but most frequently before nine or ten years of age. This lesion may follow inflammation of the vulva, or vagina, occurring either primarily or as a simple disease, or as a complication or consequence of exanthematous or other fevers. In these circumstances the menstrual discharge may burst the obstruction, but much more frequently its accumulation is attended by similar phenomena to those which arise from retention caused by imperforate vagina or imperforate hymen (§ 42, 43). 47. y. The prognosis and termination of this form of amenorrheea entirely depend upon the evidence furnished as to the nature of the mal- formation or organic lesion. When there is reason to infer the absence of the ovaria or uterus, or both, no immediate risk of life may be dreaded, although pectoral or other disease is apt to supervene and carry off the patient. If, however, these organs are present, apd the. discharge accumulates in the uterus, the result will entirely depend upon the nature of the ob- struction, and the possibility of removing it be- fore the general health suffers so severely as to prevent recovery. All these cases, how- ever, are attended by various contingencies, even after the immediate cause of obstruction is removed, that forbid a confident, or other than a cautious prognosis ; and these contin- gencies relate not only to the state and liability to disorder of the sexual organs, but also to the condition and predisposition to disease in the lungs and other organs. 48. S. Treatment.—It is obvious that where the uterus and ovaria are malformed and dis- organized, [or congenitally absent,] no means can be of service. But where the obstruction is seated in the canal of the cervix, in the os uteri, in the vagina, or vulva, well-devised methods may remove it. Even when it is caused by congenital absence of the vagina, the case may be highly dangerous ; but it is not hopeless, as shown by one in which M. Amussat (GazetteMedicale, Dec., 1835) operated. He suc- ceeded in making a passage through the cellu- lar tissue interposed between the urethra and rectum, until he reached the tumour in the pel- vis formed by the distended uterus, and punc- tured it; he afterward established an artificial vagina and os uteri, and ultimately restored the patient to health. 49. When the obstruction consists of occlu- sion Of the cervix uteri, or os uteri, from either of the changes noticed above (<) 45), an artifi- cial opening should be made by a trocar, or by a similar instrument to that employed by Mr. Stafford for dividing strictures of the urethra. If the membrane covering the os uteri be thin, or internal to the orifice, it may be punctured by a strong probe. When the vagina cannot be perforated, as in M. Amussat’s case, the uterus may be punctured from the rectum, and cnmscribed fluctuation in the anterior portion of the abdo- men, extending about one inch above the umbilicus: on introducing the finger into the vagina, the os tines was found wanting, the lower and central portion of the cervix being quite smooth and uniform on its surface. By means of a speculum the cervix uteri was brought into view, and penetrated by a trocar at its lower and central portion, when about three pints of blood were discharged from the uterine cavity. Pregnancy followed in a short time afterward, and in due time she was delivered of a healthy child. Similar cases are also mentioned in some of our medical ioumals.J * [Dr. G. S. Bedford, of New-York, has given us the history of a very interesting case of retention of the menses from a closure of the cervix uteri (A Pract. Treat, on Mid- wifery, by M. Chailly, Am. ed. New-York, 1844), in a young married woman, 27 years of age, and who had never menstruated. In this case there was an indistinct and cir- 968 MENSTRUATION, SUPPRESSED—Pathology of. its contents evacuated. In cases requiring these operations, both external and internal means should be used to prevent or remove in- flammatory action, as fomentations, poultices, laxatives, anodynes, and refrigerants. 50. If the vagina or labia have become uni- ted, the adhesion may be ruptured by forcible separation ; but if this be insufficient, such an operation as the case may suggest should be attempted. Where the hymen is imperforate, the difficulty is much less, and is readily re- moved. 51. When the menstrual discharge is accu- mulated in the uterus, and has only been ob- structed mechanically, the removal of the ob- struction is followed by the escape of a dark, thick, treacle-like fluid, which continues to run for some days as the uterus slowly contracts. Dr. Churchill recommends the vagina to be syringed in these cases with warm water, and a broad binder to be applied around the abdo- men. Care should be taken to preserve the passage open, and to promote the evacuation at the usual periods, until it is regularly estab- lished. Exercise in the open air, a regular state of the bowels, chalybeate medicines, and the usual means of promoting the general health, are the most appropriate to these cases. 52. In some cases, where the menstrual se- cretion has been accumulating in the uterus or vagina, or in both, the absorption of the more watery parts has left the accumulated matter not only thick, but grumous and gritty ; and the internal surface of these organs has become inflamed and ulcerated, and their parietes thick- ened ; very serious, difficult, and chronic dis- ease of the uterus and its appendages thus be- coming disclosed by, and following, the remo- val of the accumulated matter. ii. Suppression of the Menses. — Suppressio mensium; Amenorrhcea suppressa; Suppressed menstruation. 53. Defin.—Disappearance of the menses, af- ter having been established for a longer or shorter period, independently of pregnancy or of their ulti- mate cessation. 54. Suppression of the menses may take place suddenly or gradually. It may occur du- ring the period of menstruation; or the dis- charge may not appear either at or after the usual period. It may disappear gradually, each successive discharge being either more scanty or longer deferred. Thus, the suppression may be acute or chronic, although cases will often occur to which the one term may be as applica- ble as the other. 55. A. Acute suppression of the menses is gen- erally caused by exposure to cold, or by wet feet, bodily shock, or by violent mental emo- tions either just previous to or during the men- strual discharge. The depressing passions, anxiety, insufficient clothing, and want or mis- ery may also produce it. Fevers, and acute diseases occurring shortly before the period, and sexual intercourse during it, will often have the same effect. 56. The phenomena or consequences of sud- den suppression vary with the habit of body and temperament of the patient. In plethoric and robust females, fever, hot skin, headache, full, or hard, or bounding pulse, &c., are pro- duced ; and, not infrequently, most severe at- tacks of disease, according to the predisposition of the different organs, are the results. Haem- orrhages, inflammations, apoplexy, epilepsy, palsy, leucorrhoea, &c., are often thus occa- sioned. Females of a less plethoric habit of body, or of the nervous temperament, are lia- ble to be seized with hysterical convulsions or spasms ; or with hysterical affections of vari- ous kinds, these latter often changing their seats and forms, with neuralgic pains in differ- ent situations; with syncope, or with palpita- tions ; with aphonia, or with nervous cough; with vertigo, or with headaches; with nausea or vomiting; with pains in the back, sides, or abdomen ; with retention of urine, or with par- tial palsy or paraplegia ; or with any of the af- fections mentioned in the articles Hysteria and Neuralgia. 57. B. Chronic suppression of the menses is commonly a consequence of the acute, or of general debility of health. It may also proceed from disease of the ovaria or uterus ; or from the gradual development of organic change in some remote or vital organ, as the lungs, liver, stomach, head, or kidneys. This form of sup- pression may be gradual as to quantity, or the discharge may become pale by degrees, or it may appear after longer intervals, being also more scanty until it ceases altogether; or it may be variously irregular and uncertain, or painful, or difficult, and then disappear. In some instances it ceases, and leucorrhoea takes its place. It may even alternate with leucor- rhoea. It may follow low, typhoid, or adynam- ic fevers, or other diseases which diminish the quantity or impair the quality of the blood, or in which large quantities of blood have been lost. I have met with many cases in which it continued long after recovery from continued fe- vers, the evacuation having been regular up to nearly the attack of fever, but not returning un- til many months after recovery from it. 58. The attendant and consequent phenom- ena of chronic catamenial suppression are, im- pairment of the general health, disorders of the digestive organs, diseases of the lungs, cutane- ous eruptions ; various nervous, or hysterical, or painful affections; chlorosis or anaemia ; partial attacks of palsy, curvatures of the spine ; obstinate constipation and faecal accumulations in the large bowels, disorders of the excretion of urine, &c. 59. C. The diagnosis of suppressed catame- nia is of much importance. It is necessary to ascertain, 1st, whether or not the patient be pregnant; and, 2d, if the patient be not preg- nant, whether or not the affections or diseases associated with the suppression be the causes or the consequences of it. 60. a. Pregnancy cannot be inferred to be the cause when the suppression takes place sud- denly, or from any of the more energetic causes producing it, during the period of the discharge. The arrest of menstruation by conception is generally unattended by other unpleasant symp- toms, but it is commonly followed by morning sickness, by alteration of the volume of the breasts, and of the sebaceous glands and colour of the areolae. The difficulty of distinguishing between pregnancy and morbid suppression of the menses occurs chiefly in unmarried females, but only during the earlier months of utero- gestation; and even during these months, an examination of the mammae, of the abdomen, MENSTRUATION, SUPPRESSED—Prognosis—Treatment. 969 ana per vaginam, will disclose the nature of the case. Instances, however, may occur of pregnancy with a periodic coloured discharge from the vagina ; and this may be as abundant during two, three, or more periods as usually experienced by the patient. In these cases, the evacuation generally possesses a haemor- rhagic character, and either proceeds only from the os or cervix uteri, or from a minute separa- tion of that portion of the ovum near the cervix. 61. b. In most cases of acute disease appear- ing in connexion with acute suppression of the catamenia there will be no difficulty in deter- mining the exact relation in which the one may stand to the other; but, in cases of chronic or organic diseases occurring in connexion with chronic suppression, it is often difficult to infer whether the former or the latter has preceded the other. Most frequently, however, and par- ticularly as respects pulmonary disease, the suppression is the consequence of such disease, although various concurring causes may assist, particularly if it have taken place somewhat suddenly. Still, disease of the lungs, or of the brain, or of any organ, may follow suppressed menses, according to the predisposition of these organs, at periods more or less remote from the suppression. 62. The affections themselves, which appear consequently upon suppression of the menses, require to be distinguished from each other, especially those which are truly inflammatory from those which are nervous or spasmodic, or consist chiefly of altered sensibility. What I have stated in the articles Hysteria and Neu- ralgia will assist the diagnosis ; and generally it will be found that, when the disease is in- flammatory, the local and constitutional symp- toms nearly correspond with each other, and with the state of the organic functions ; but when the affection is nervous, although the pain and distress may equal, or even exceed that caused by inflammation, the constitutional disorder will be slight, the pulse and the organ- ic functions being but little disturbed. 63. D. Prognosis.—The opinion as to the consequences and ultimate results of suppres- sion of the menses will necessarily depend upon the nature of the causes, physical and patholo- gical, which have occasioned it, and upon the ef- fects of the suppression in those organs which most frequently sympathize with the genital or- gans, more especially the lungs, brain, and vas- cular system. The prognosis, therefore, de- pends chiefly upon the antecedent disorder or consequent malady which may present itself; the suppression, however, being a circumstance rendering an opinion of these still more unfa- vourable than it might otherwise be ; although, in itself, and devoid of all complication, it may be only a passing or contingent disorder, which nature alone may remove, or which a judicious exercise of art may assist her in overcoming. 64. E. Treatment.—a. The acute form of sup- pression of the menses may be inferred, from what has been stated above, to be more amena- ble to treatment than the chronic. The means usually employed to recall the discharge are more especially indicated for it ; but these should be selected with reference not only to the cause of suppression, but also to the ante- cedent state of health, and the associated or consequent disorders. In many cases, the hip bath, warm mustard pediluvia, and warm drinks upon getting into bed, if employed immediately upon the occurrence of suppression, will re- move it. If fever, or local inflammations, or congestions follow, bleeding, especially by leeches applied below the groins; the more emmenagogue purgatives, particularly calomel with aloes, &c., the spirits of turpentine in en- emata, and diaphoretics with diuretics, are re- quisite. If the suppression be followed by se- vere cerebral symptoms, as phrenitis, coma, apoplexy, epilepsy, &c., as occasionally observ- ed, the derivative bleeding should be carried as far as the circumstances of the case will sug- gest, and be aided by other derivative means, and by cold applications to the head, &c. In other and less urgent cases purgatives should be prescribed, so as to excite, and determine the circulation to, the pelvic viscera, without producing copious discharges, which, if produ- ced, may be injurious by deriving the current of circulation from the uterine organs. 65. If, however, the suppression occasion, as not infrequently observed, inflammation of the uterus or of the ovaria, or of both—consequen- ces which are often overlooked, particularly when slight or sub-acute, or when occurring in unmarried females—vascular depletions, cool- ing diaphoretics and aperients, derivatives, and the other means advised for inflammations of the ovaria or of the uterus are requisite. 66. In most instances, the chief efforts to restore the catamenia should be made shortly before the approach of the next period. Leech- es may then be applied to the groins ; a/id the hip bath, or pediluvia; warm clothing, espe- cially around the hips and thighs ; and emmen- agogue purgatives, may also be prescribed. The following have proved efficacious in many instances : No. 291. R Hydrarg-. Chlovidi, gr. xii.; Aloes Socot., 3j.; Pulv. Capsici, 3],; Olei Juniperi Sabinaj, q. s. M. Fiant Pilulse xij., quarum capiat duas omni nocte. No. 292. R Sodae Biboratis, Jss.; Aloes Socot., Pulv. Capsici, 5a, 3j. ; Olei Lavand., q. s. M. Fiant Pilulae xviij., quarum capiat duas ter quotidie. 67. While evacuations are required in con- nexion with such means as may excite the ute- rine discharge when suppression occurs in strong or plethoric females, or occasions acute disease of some important organ, as the brain, lungs, liver, or uterine organs themselves, oth- er means are often necessary, when the sup- pression takes place in spare, delicate, or ner- vous females. It should not be overlooked, however, that local inflammations or conges- tions may occur in these persons in such cir- cumstances, and require a somewhat similar, although less energetic practice ; but more fre- quently suppression in them demands a re- course to antispasmodics in conjunction with narcotics. The external and internal deriva- tives, the emmenagogue purgatives and ene- mata already mentioned, and, in many instan- ces, the application of leeches below the groins at the proper period, should be prescribed ; but, in addition to these, antispasmodics, such as ammonia, asafcetida, castor, camphor, madder, capsicum, rue, savin, &e\, variously conjoined with each other, and with conium, or stramo- nium, or belladonna, digitalis, &c., maybe pre scribed, particularly when much pain is com- plained of, or spasms occur, in consequence of the suppression. In some of these cases, the 970 MENSTRUATION, SUPPRESSED—Complicated Amenorrhcea. suppression is favoured by poor or deficient blood ; and in these the preparations of iron should be combined with one or more of the above antispasmodics and narcotics. 68. b. The treatment of chronic suppression of the menses should also be dependant upon the cause, and upon antecedent and consecutive disorder. If it proceed from progressive or- ganic disease in the lungs, liver, or other or- gans, the treatment should be mainly directed to the diseased part; although, even in these circumstances, local depletions in the situation already stated, and other derivative means, may be employed with benefit. When it is caused by repeated or severe inflammations of the ova- ria or uterus, the means should have reference to these. The ovaria, however, may be so changed by inflammation as to be incapable of exciting the vascular activity of the uterus so as to produce the menstrual discharge; but these changes are rather inferred from the his- tory of former disorders than manifested by ex- isting phenomena. When the uterus is affect- ed so as to obstruct the discharge, or to cause its retention, without preventing its production altogether, the nature of the lesion may be as- certained, and a remedy be found. Inflamma- tion may close the cervix uteri, or cover the os uteri with a false membrane, or may even ob- literate the vagina, as noticed above. In these circumstances, the means already indicated (§ 49) should be resorted to. 69. Even when the obstruction cannot be re- ferred to organic disease of the ovaria or of the uterus, there may be still great congestion of these organs ; requiring local depletions for its removal. Many of these cases present indica- tions of debility, and are attended, moreover, by leucorrhcea, which may be either periodic or more or less continued, this discharge being often considered as a consequence of debility merely. But the local congestion may be con- siderable nevertheless ; and although the gen- eral pallor and state of the circulation may in- dicate some degree of anaemia, the uterine or- gans may contain an undue proportion of blood. In these cases, the employment of stimulating injections per vaginam, as advised by the an- cients, and revived by some moderns, might convert suppression from congestion into ac- tual inflammation of the uterine organs; and in those cases where the congestion and sup- pression are associated with leucorrhcea, a re- course to astringent injections, in order to re- move the latter, may be followed by the same bad consequences, if local depletions, and other suitable means directed to the removal of the congestion, have not preceded such injections. 70. When uterine congestion or inflamma- tory action is not present, or has been removed, the treatment should depend much upon the states of the vascular system, and of organic nervous power. If the former be not plethoric, and if the latter be much impaired, the prepar- ations of iron, with iodine, or other appropriate medicines ; the ammoniated tincture of guaia- cum, the stimulating antispasmodics, and ex- ternal and internal derivatives, are generally serviceable. 71. iii. Complicated Amenorrhcea.—I have already noticed (§ 57) some of the most impor- tant associations of amenorrhcea, and shown that the obstruction, particularly when taking place slowly, or becoming chronic, is often ow- ing either to debility or some constitutional in- firmity, or to the gradual development of some organic malady, as of the lungs, brain, liver, &c. The complications most frequently ob servea are, haemorrhage from various parts, in fiammations, phthisis, epilepsy, hysteria, chlorosis anaemia, palsy, retention of urine, chorea, culane ous eruptions, diarrhoea, and various disorders of the digestive organs. These require a few re marks. 72. A. Among the most important of these are vicarious haemorrhagic discharges from some organ or part, or vicarious menstruation, as it has been commonly, but incorrectly, termed. These discharges, occurring during suppression, have been thus termed owing to their recurrence; but, although recurring, they are not always strictly periodic, or of monthly appearance. Writers have been more desirous of recording cases of this description, than of observing carefully the procession of the morbid states constituting them; and several have viewed the haemorrhagic discharge as an eruption of the menses in some singular locality in place of from the uterus, instead of observing the se- quence of morbid actions, and the relations be- tween the contingent or vicarious discharge and the suppression. Thus haematemesis is a not infrequent form of the vicarious discharge, and is usually attributed to a periodic determi- nation of blood to the villous surface of the stomach, instead of the uterus ; but, without denying that such is sometimes the case, I have met with instances which have led me to infer that hepatic or portal obstruction has ta- ken place in plethoric persons, and given rise to haemorrhage from the stomach, which either has anticipated and substituted the catamenia, or has occurred in connexion with suppression, and often in consequence of the operation of the same causes as have produced suppression. The same remarks apply equally to the substi- tution of a haemorrhoidal discharge. 73. The causes of suppression, also, particu- larly those which determine the flux of blood from the lower portion of the body to the head, not infrequently induce epistaxis, or even haem- orrhagic discharges from the ears, eyes, &c., especially in those who are constitutionally or otherwise disposed to epistaxis, or haemorrha- ges from these parts. In these cases, the ir- regular distribution of blood—the diminished determination of it to some parts, and its accu- mulation in others—is followed by its discharge from these tissues of the congested organ or part, which most readily admit of its escape. The circumstance of these vicarious discharges generally following, and but rarely anticipating, the precise period at which menstruation should have occurred, sufficiently indicates the nature of these occurrences. Besides the situations al- ready mentioned, haemorrhagic discharges may recur in connexion with amenorrhcea, from the bronchi or lungs, the gums, the fauces, the mammae, the urinary bladder, the bowels, from ulcers in any situation, from varicose veins, &c. Of the associations of amenorrhcea with inflammations, or with phthisis, which are of fre- quent occurrence, either preceding the other, no farther notice need be here taken, than that the former are more obstinate and untavoura- 1 ble wffien thus allied, and that the latter pro- MENSTRUATION, SUPPRESSED—Complicated Amenorrhcea. 971 ceeds much more rapidly to its usual termina- tion when it is thus complicated. 74. B. Epilepsy is generally consecutive of acute amenorrheea whei# observed in connex- ion with it; but the numerous and varying forms of hysteria, whether assuming a spas- modic or a neuralgic or painful form, may either precede or follow the suppression. The same remark may be extended to chlorosis, cho- rea, and ancemia, either of which is often thus associated, and more or less intimately depend- ant upon amenorrheea. The different forms of palsy are rarely seen connected with suppres- sion otherwise than as a consequence of it. I attended, a few years ago, with Mr. Flockton, a young lady who was afflicted with prolonged amenorrheea, followed by paraplegia, retention of urine, diarrhoea, and occasional attacks of vomiting, with which the diarrhoea often alter- nated. She had been many months in this state, and a great diversity of treatment had been employed without avail. The disease was ultimately removed by means which will be noticed in the sequel. Disorders of the di- gestive and cutaneous eruptions are too varied in their characters to require notice in connex- ion with amenorrheea. 75. C. The prognosis in complicated amenor- rheea depends upon the nature of the associated disease. It has generally been considered that the hcemorrhage which often occurs vicariously in some cases of this description is not attend- ed by any risk, and is not followed by other dis- ease, or even by much functional disorder. But, although this may be true in the majority of cases, more particularly as respects epistax- is, haemorrhoids, haematemesis, &c., it by no means generally obtains, especially as regards haemoptysis, and hardly as respects haemateme- sis. Haemoptysis should always be viewed in an unfavourable light, and its dependance as much upon incipient tubercles, or congestive inflammation of the lungs, or both, as upon amenorrheea, ought to be inferred. The prog- nosis in the other associations of suppression depends as much upon circumstances peculiar to the patient as upon the particular complica- tion present, and requires no farther notice than has been taken above ($ 73, 74). 76. j0. The treatment of the complicated ob- struction should be directed with the same in- tentions as have been already stated. In the acute complications, particularly those with haemorrhagic, apoplectic, epileptic, and inflam- matory seizures, in plethoric habits, general and local blood-letting, emmenagogue cathartics, diaphoretics, &c., are requisite; and when the other complications occur in these habits of body, a similar treatment, especially local blood- letting in the situation above pointed out, should be prescribed, and be aided with the other means already noticed, according to the particular as- sociations observed. 77. In the more chronic complications, the means should be adapted to the peculiarities of such cases, which are too numerous to admit of even a partial notice. The most of those, however, will allow of a trial of the means al- ready advised for delayed and suppressed men- struation ; and, although the exact recognition of the complication present should determine tne mode of treatment, still that which is more immediately directed to. the obstruction should not be neglected. The exhibition of the spir- its of turpentine in alterative or purgative do- ses, according to circumstances ; a mild course of mercury, or of iodine, or of both, or of iodine and iron; a recourse to digitalis, conium, stra- monium, belladonna, madder, rue, savin, &c., are the most deserving of notice. Where the obstruction is connected with spasmodic or painful disorders, turpentine, iron, stramonium, belladonna, opium, hydrocyanic acid, ammonia, &c., are severally useful. When it is related to chlorosis, chorea, or anaemia, the prepara- tions of iron are particularly indicated, and the aid of aloetic and warm purgatives required.* * IGalvano-electricity, or electro-magnetism, deserves more particular mention as an emmenagogue remedy. We have succeeded in some chronic cases of amenorrheea, that had resisted all other means, by daily sending a current of electricity through the uterus, or by inserting one conductor in a tub of warm water, in which the feet were immersed, and applying the other over the cervical vertebra, thus transmitting the fluid through the spinal axis. Dr. AsH- well states, that Dr. Golding Bird has recently em- ployed the same remedy with extraordinary success in the treatment of out patients at Guy’s Hospital (London). In some of the cases, where, after the condition of the aliment- ary canal had become healthy, the amenorrheea continued with slight pallor and weakness, electric shocks passed through the loins quickly induced menstruation. In oth- ers, its continued repetition three or four times a week led to a similar result; and instances were not wanting where a shock suddenly produced the flow. It is, however, a pow- erful remedy, and should be employed cautiously, lest it may depress the nervous system, and thus protract the dis- ease ; when moderately applied, it often rouses into activity the energy of torpid organs and parts; but, when used in excess, it may altogether destroy their excitability. It should not be employed in cases of local congestion or gen- eral plethora, or during pregnancy, and it should seldom be used alone. An injection of ammonia after the following formula will often succeed, if followed by a pungent sensa- tion of heat, tingling, and some pain in the vagina : R Liq. Ammon, fort., 3j. vel 3jss.; Lactis tepid, Jxvi. ; M.ft. In- jectio vaginalis, a third part to be passed into the vagina three times daily. Its use should be commenced three days prior to the expected period, and the patient, after each in- jection, should apply a napkin to the vulva so firmly as to cause the injected fluid to be retained for ten or fifteen min- utes. It is, however, not a safe remedy where there is uterine congestion, as inflammation of the cervix uteri and upper part of the vagina is apt to follow. It is adapted only to cases of torpor, unattended with congestion or acute ir- ritation. The strong mustard hip bath, used twice a day, the patient remaining in it for nearly an hour each time, at a temperature of 96° or 98°, is an effectual auxiliary reme- dy. The reader cannot be cautioned too much against in- jecting stimulating fluids into the uterine cavity, as recom mended by some writers, as peritoneal inflammation is very apt to follow. Dr. Ashwell highly recommends pulver- ized mustard, in doses of 8, 10, and 12 grs. in camphor julep prior to the menstrual period. Stimulating injections into the rectum, composed of 10 grs. of aloes with Jj. of muci- lage, two or three times a day, will often prove a successful remedy. Warm frictions, stimulating embrocations, as the flesh-brush to the hypogastric and lumbar regions, are also to be employed night and morning. The above are the most important of the direct emmenagogues, so called ; of the in- direct, or those producing their effect through the medium of the system, mercury is by far the most important. Dr. Ashwell cautions against using it in slight cases, or where there is extreme exhaustion, a predominant irritability, or a tendency to phthisical or strumous disease ; but in obsti- nate amenorrheea, where other treatment has failed, where there is chronic inflammation or permanent congestion, and any evidence of incipient structural change, he thinks there is no remedy comparable with this, in which opinion our experience leads us to coincide. If the pulse becomes more rapid and less strong under its influence, or if constitutional irritation and weakness daily increase, if there be cough or diarrhoea, these not having previously existed, its use should be immediately discontinued ; but where it is doing good, the tongue becomes clean, moist, and of a healthy colour; digestion improves, and there is some return of healthy ap- petite ; the complexion loses its dingy icterode hue, and be- comes more clear; and the general condition of the patient is greatly improved. Dr. Ashwell thinks that the mer- curial effect should be carried so far as to produce soreness of the gums and moderate salivation, and that these should be kept up for twelve or sixteen weeks. We regard strych- nine and savin as very certain emmenagogues, when prop- erly administered, but it requires judgment in selecting the 972 MENSTRUATION, DIFFICULT—Description. IY. Difficult Menstruation.—Syn. Dysmen- orrhea, Vogel, Sagar. Dysmenia, Swediaur. Menorrhagia difficilis, M. Stillatitia, Amcnor- rhena dijficilis, Amen, partialis, Auct. Para- menia difiicilis, Good. Menstrua difficilia ; M. Dolorosa. Bcschwcrliche monatliche reinigung, Germ. Menstruation difficile, Fr. Menstrua- zione difficile, Ital. Painful menstruation. 78. Defin.—Menstruation preceded and accom- panied by acute pain in the abdomen and hypogas- trium, and often in the back or mamma, the dis- charge being frequently scanty, or presenting mor- bid appearances. 79. This form of uterine disorder is of fre- quent occurrence, and is not only productive of extreme suffering, but often of very serious con- sequences. Dr. Ashwell remarks, that it oft- en prevents conception ; and, if pregnancy has occurred during its continuance, there is risk of abortion. Although, in itself, it is not a fatal malady, yet malignant diseases have followed its protracted existence; and it is generally very difficult of cure. 80. i. Causes.—Both married and single fe- males, the latter more particularly, are liable to it. Dysmenorrhcea may occur in all tempera- ments and habits of body ; but more frequent- ly in women of irritable, hysterical, and ner- vous temperaments, and of spare, strumous, and phthisical constitutions than in others. It is probably somewhat favoured by indolence and full or rich living. The most common exciting causes are, exposure to cold in any form during menstruation ; sudden fright, or shock, or vio- lent mental emotions or disappointed affections, especially when occurring at this period; ex- posures to cold soon after parturition or abor- tions, &c. Indeed, the same causes which oc- casion suppression of the menses, or inflamma- tion of the uterus, may occasion dysmenorrhcea. 81. Difficult menstruation may occur at any period, and is rarely confined to one or two pe- riods. It may be traced back in some cases to the very commencement of the epoch. The amount and character of the pain may vary much It may be moderate, and last but a few hours each time, or it may be so severe as to amount to extreme torture, and to occasion faintings or severe retchings; and even to render the patient a permanent invalid. The pain may also be neuralgic or inflammatory in its charac- ter. Owing to these variations, dysmenorrhcea has been divided by Dr. Churchill into, 1st, the neuralgic; 2d, the inflammatory; and, 3d, the mechanical or obstructive. M. Roche has treated of it as idiopathic and symptomatic, the latter generally depending upon inflammatory action in the uterus. Mad. Boivin and M. Duges have viewed it as commonly proceeding from inflammation. Dr. Ashwell has arran- ged the forms of amenorrhcea into, 1st. The ir- ritable or neuralgic ; 2d. The plethoric; 3d. The congestive; and, 4th. The obstructive. The chief objection to this division is that the second and third must be necessarily alike; for, if a pletho- ric and a congested state of an organ hardly ad- mits of being distinguished from each other, in respect of their physical conditions, how can they be recognised by aid merely of their phys- iological phenomena 1 It would be better, there- fore, to consider the second variety as one of congestion which may sometimes go on to, or be attended by an inflammatory state of the in- ternal surface of the uterus, which state, how- ever, may also exist in the first variety, the neu- ralgic character, however, predominating, and distinguishing it. 82. ii. Description.—A. Neuralgic or irritable dysmenorrhcea occurs chiefly in unmarried fe- males, and in the married who have not borne children. Although it may appear at any peri- od of the menstrual age, it is most common about the thirtieth year. It is generally ob- served in nervous or hysterical and irritable temperaments, and in spare and delicate habits of body. The monthly paroxysms of pain have all the characteristics of neuralgia. They are often preceded or followed by headache. The pain often commences in the region of the sa- crum, and extends around the lower part of the abdomen and down the thighs. The suffering is often very great; in some cases it is con- stant, in others it is remittent. As it contin- ues, a forcing or bearing down sensation is oc- casionally present, and aggravates the distress; and in some instances the torture is so extreme that the patient rolls about on the abdomen, en- deavouring to procure ease from pressure ; or is afflicted with constant retchings. These suf- ferings may endure for only a few hours, or they may continue a day or two before the dis- charge commences. This is usually scanty at first, or in slight gushes ; and the quantity va- ries in different persons, or even in the same person at different periods. It is often altogeth- er scanty, rarely too much. It is frequently natural in appearance ; but it is also often pale, or mixed with small clots, or with shreds, or with a bran-like matter. More rarely it con- tains shreds of membrane, as observed by Mor- gagni, Denman, Burns, Blundell, and others. 83. The cervix uteri undergoes the usual change at this painful period ; it becomes swol- len and softer, with an increase of heat; and the os uteri is somewhat more open than in the interval. As the discharge proceeds, the pain subsides gradually, but not so quickly as in the inflammatory variety; and as it disap- pears, neuralgic pains are sometimes felt in other parts. The pulse is seldom affected du- ring the attack, farther than being weaker than usual; and febrile symptoms are rarely observ- ed. In a few cases, the bowels are irregular during the period. Although the health may not suffer in the interval, yet in the severer cases, or when the complaint has been neg- lected, the patient complains of headaches, of pains in the back, which are increased by stand- ing or walking, and of various disorders of the digestive organs, consequent upon the general impairment of health, arising from protracted sufferings. 84. The membranous shreds passed in some of these cases, evidently consist of plast ic lymph thrown out in the cavity of the womb. In a few cases, this substance has been voided nearly entire as moulded upon the internal sur- face of the uterus, and has given rise to sus- picions of pregnancy, its expulsion being at- tended by violent forcing pains. It is dis- charged, in some instances, during several suc- cases to which they are best adapted. The preparations of io&ine and iron, especially combined with aloes, will often succeed, even in very obstinate cases. The mineral waters of Saratoga, containing, as they do, both these metals, will frequently bring on the menstrual flow when all other means have been tried in vain,] MENSTRUATION, DIFFICULT—Description. 973 cessive periods, in others only occasionally. Dr. Denman supposed that females could not conceive who voided these membranes ; and such is the case in the great majority of instances, although Dr. Blundell and Dr. Churchill believe that conception is possible. 85. B. Congestive and Inflammatory Dysmen- orrhcea.—In some cases the patient complains of lumbar pain, of a sense of weight and of bearing down in the pelvis for two or three days before the expected return of the menses. Frequent micturition, constipation of the bow- els, severe pain in the region of the uterus, restlessness, and violent forcing supervene. The patient is not feverish, but the pulse is often quick and irritable. The skin is gener- ally perspirable. A sense of exhaustion, with anxious, pallid countenance, is usually felt as the affection proceeds. After some hours, or even after a day or two, the attempts to mic- turate, or the severe forcing pains, extending sometimes through the abdomen, from the loins, hypogastrium, and hips, are followed by the expulsion of coagula, or occasionally of portions of membrane, the discharge being gen- erally scanty, or in irregular gushes, and at in- tervals sometimes almost colourless. The for- cing pains often resemble those of labour, but the suffering is generally more constant than in it. Sometimes the uterine pain is attended by a sensation as if the pelvis contained some foreign bo*dy that should come away ; and in these cases considerable masses of coagula, or of albuminous concretions or membrane, have been passed, affording much relief. This con- gestive form of dysmenorrhcea, when severe or prolonged, is often followed, for some days, or even for the greater part of the interval, by leu- corrhcea, which tends farther to weaken the patient, and to superinduce more extensive dis- ease. 86. In some females, particularly in the plethoric and in the sanguine temperament, the disorder assumes a more inflammatory form; or the whole frame exhibits more or less in- flammatory or febrile commotion. It usually occurs earlier in life than the neuralgic form, chiefly in the unmarried or in those who have had children. It is commonly caused by cold, particularly when applied to the feet, thighs, and hips, as when seated on cold or damp seats. It may also proceed from some sudden shock or constitutional disturbance, and may assume various grades of severity. In its slightest states, it not infrequently affects plethoric and robust young females from the first menstrual period until marriage. 87. It usually commences with chills or slight rigours, followed by flushing, feverishness, and headache, a few days before the appearance of the catamenia; with these the patient com- plains of pains in the back and hypogastrium, of aching in the limbs and lassitude ; of intoler- ance of light and sound, and fever. The skin is hot, the pulse full and frequent, the bowels constipated, and the mammae painful and some- what swollen (Dewees) ; but the febrile com- motion is rarely so high as to cause temporary or night delirium. These symptoms subside as the discharge proceeds, especially when it is abundant. When it is scanty, they often con- tinue in a less degree, or become aggravated for a time as it disappears; but it is generally more abundant in this than in the other states of the disease. It may be accompanied with the membranous shreds or exudations, as in the other varieties. 88. During the intervals the general health may not be materially affected, although head- aches are not infrequent, and leucorrhoea is often constant. The severity of the attacks is not so regular in intensity as in the neuralgic form, and sometimes a period or two elapses with little suffering. On examining per vagi- nam during the severity of the pains in the con- gestive or inflammatory states, evidence of en- gorgement of the uterus is generally furnished, with swelling and increased heat of the cervex uteri, but there is no external tenderness on pressure. 89. All the forms of dysmenorrhcea, when very severe, generally prevent conception ; but the slighter degrees of the complaint will not have this effect. In one of the severest and most obstinate cases for which I have been con- sulted, the patient had a family after marriage. 90. C. Obstructive Dysmenorrhcea.—Dysmenor- rhcea from mechanical obstruction consists of a narrowing or stricture of some part of the canal of the cervix uteri. This variety of dysmenor- rhcea was noticed by several continental au- thors of the last century, and was enumerated by M. Capuron as one of the chief states of the disease ; but Dr. Mackintosh was the first to insist on its frequency, and importance, and Drs. Churchill and Ashwell have directed their attention to it; but they believe that ca- ses of this kind are rare, and that the stricture is only a part of the complaint, and often ex- erts no influence upon it, inasmuch as the dila- tation of the stricture was not, in most of their cases, followed by an alleviation of suffering. It is natural to infer that, if the stricture had been the real cause of the disease, an accumu- lation of the menstrual fluid would have taken place in the cavity of the uterus ; but this ap- pears not to have been the case. Although an infrequent cause of dysmenorrhcea, it is of suf- ficient importance to determine its existence in all doubtful and obstinate cases. 91. iii. Diagnosis of Dysmenorrhcea.—This complaint is readily distinguished; it is only when it is accompanied with the discharge of an albuminous exudation or false membrane moulded within the uterus, resembling the de- cidual nidamentum of the ovum, that a distinc- tion is required. The duration of the com- plaint, the state of the menstrual discharge on former occasions, the length of interval from the previous period, and the physical charac- ters of the substance voided, are sufficient to determine the nature of the case. Dr. Mont- gomery has very accurately described this sub- stance, and has confirmed the account former- ly given of it by Morgagni. He states that it differs from the true decidua in not being in- tended to become a medium of nutrition for the ovum; hence it is not furnished with a struc- ture such as would be necessary for this of- fice. It is thin, and unsubstantial in texture; of a dirty white or yellowish colour after the agitation of it in w’ater; and is devoid of the soft, rich, and pulpy appearance and vascular colour, and of the numerous foramina for the reception of the nutrient vessels from the ute- rus, characterizing the true decidua; it is also 974 MENSTRUATION, DIFFICULT—Treatment. destitute of the little cotyledonous sacculi es- n sential to the latter structure. No trace of the is transparent membranes of an ovum can be dis- a covered within it or attached to it; and should n it happen to come away entire, in the form of e a hollow triangular bag, it never contains a du- t plicature of itself, forming an inner pouch or re- n flex layer, as in the case of the natural decid- 1 ual envelopes of the ovum. o 92. iv. Complications of Dysmenorrhea.—Most s of the complications presented by suppressed n are also observed associated with painful men- a struation ; and of these, hysteria and disorders c of the digestive organs are among the most i frequent. I have met with instances of a dis- s charge of membranes from the uterus during a dysmenorrhcea associated with painful dis- i charges of similar membranes from the intes- e tines, and with the severer forms of hysteria f and spinal irritation. Leucorrhcea is an equal- I ly common complication with hysteria, %nd is t often only a part of the uterine disorder caus- i ing dysmenorrhcea. Neuralgic and other ner- 1 vous complaints are not infrequently associated i with it; but the observations I have offered on ( the complications of amenorrhcea ($ 71, et seq.) 1 are equally applicable to those of dysmenor- ' rhcea. < 93. v. Prognosis.—Dysmenorrhcea is danger- \ ous only as respects its consequences when neg- I lected, and when it is complicated with some ( pectoral or other serious disease. Although it i be obstinate, severe, and prolonged, as long as ; the general health does not suffer, and no oth- er local malady appears, its chief importance consists in the distress it occasions, and the effect it may have upon the generative func- tion ; for, although a female may conceive who is suffering any of the forms of the mala- dy, even in their severest states, as when at- tended by the expulsion of albuminous exuda- tions, still this is an infrequent occurrence, sterility being a much more common result. Generally, however, the disease is cured by medical treatment, or by marriage, and child- bearing ; and it necessarily disappears at the change of life. The possibility of its being fol- lowed, particularly when it continues up to, or past the fortieth year, by organic, or even by malignant disease of the uterus, especially of the cervix and os uteri, ought not to be over- looked ; and this contingency is, perhaps, more likely to occur in the neuralgic than in the in- flammatory form. The mechanical state of the disease may be viewed as more unfavourable than the others; as the removal of the stric- ture is not always attended by a removal of the malady. Dr. Mackintosh, however, states that he cured twenty-four cases out of twenty-sev- en, and that of the twenty-four, eleven after- ward had children. This rate of success has not been confirmed by the experience of other physicians. 94. vi. Pathology.—The questions most agita- ted in respect of the nature of dysmenorrhcea are, whether it depends or not solely upon irri- tation or altered nervous sensibility, or solely upon inflammatory action—whether it is mere- ly neuralgic or entirely inflammatory. That a degree of inflammatory irritation exists in the internal surface of the uterus, even in the neu- ralgic form of the disease, is proved by the for- mation and expulsion of a false membrane in nany cases of that form. That this membrane s produced by a similar state of inflammatory iction to that which sometimes occurs in other nucous surfaces, and gives rise to a similar 3Xudation, is most probable, notwithstanding the absence of general inflammatory phenome- na and the neuralgic character of the pain. The absence of these phenomena is evidently owing to the nervous temperament, and dispo- sition to morbid or exalted sensibility, in con- nexion with the state of the vascular system, and probably, also, to the nature of the more common exciting causes. In these cases, the inflammatory irritation existing in the internal surface of the uterus excites, or is attended by an inordinate manifestation of morbid sensibil- ity, although it is insufficient to develop gen- eral vascular reaction, owing to the general de- ficiency of blood in the vascular system, and hence the neuralgic character prevails. In those cases which are manifestly congestive or inflammatory, the nervous susceptibility being less, while vascular fulness and disposition to increased action are much greater, these latter conditions are more prominent. That the al- buminous exudations, voided in the different varieties of the disease, are the results of states of local action similar to those which some- times take place in other mucous surfaces, may be inferred not only from their similarity of characters, but also from other phenomena, more particularly from the violence wf the pain attending their detachment from the surface on which they are formed, as evinced by their for- mation in the bowels (see art. Intestines, $ 52) as in the uterus. In two of the complicated cases alluded to above (§ 92), one of which was seen also by Sir B. Brodie and the late Dr. Da- vis, the other by Dr. Ashwell, in consultation, the albuminous exudation or membrane was voided from both the intestines and uterus, with violent suffering referrible to both these situations, and with severe and obstinate sym- pathetic disorders of an hysterical and neural- gic nature. 95. vii. Treatment.—The indications of cure are the same in all the forms of this malady: these are, 1st. To alleviate the suffering at the menstrual period; and, 2d. To restore during the intervals the healthy condition of the organ. A. The first of these intentions is, however, to be fulfilled by somewhat different means, in the several forms of the disease. 96. a. The neuralgic variety, as I have already stated (<) 82), ought not be viewed as being en- tirely devoid of a local inflammatory character, at least in many cases, or in those attended by the production of an albuminous exudation, be- cause the symptomatic phenomena of inflam- mation are not manifested. Therefore, unless there be manifest deficiency of blood in the vas- cular system, leeches should be applied below the groins, as above advised (§ 67), and be fol- lowed by fomentations with hot sponges. After the bleeding has ceased, the warm bath, or warm hip bath, and the anodynes about to be advised, may be resorted to, and even repeated. Where local bleeding is not indicated, and after it has been employed, opiates, or henbane, or bella- donna, or stramonium, conium conjoined with camphor, asafcetida or other antispasmodics, are generally beneficial. I have prescribed the following with advantage: No. 203. It Sod® Biboratis, 3ij.; Extr. Conii, Jss.; Extr. S»ramoni: (vel Extr. Alcoholici Aconiti), gr. iij.; Pulv. Capsioi. gr. vj.; Olei Juniperi, q. s. M. Fiat massa lequalis quarn divide in pilulas xviii., e quibus capiat duas, tertiis ve! quartis horis, ad tertiam vel quartam vicem. No. 294. ft Pilulie Galbani Comp., 3ss. ; Extr. Hyoscy- ami, 3j.; Sod® Biboratis, 3ss. ; Extr. Belladonna;, gr. iv.; Olei Juniperi, q. s. M. Fiant pilulae xx., quarum capiat duas, tertiis vel quartis horis. No. 295. ft Camphor® ras;e, 3j.; tere cum Mucilag. Aoaci®, 3iij., et adde Aquae flor. Auranti, fvjss. ; Soda; Bi- boratis, 3ij.; Spirit. dEtheris Nit., 3iij. ; Spirit. Juniperi Comp., 3iij. ; Tinct. Hyoscyami, xij. M. Fiat mist, cujus capiat coch. ij., larga, secundis vel tertiis horis. 97. The narcotics just mentioned may be prescribed in the form of suppository, or in ene- mata; but they ought not also to be given by the mouth when thus employed, nor should they be prescribed in large doses in enemata, as serious effects may follow. In those cases which are attended by a sensation of a substance pressing down in the pelvis, as if requiring to be brought away, the ergot of rye and the bi- borate of potash will often afford relief, partic- ularly when there are coagula, or albuminous exudations in the uterus, or passing the cervix. Injections, per vaginam, of the warm decoction of poppies, or of warm water, containing the ex- tract ofconium or of hyoscyamus, several times a day ; and hot fomentations of the same kind over the pubes and hypogastrium will frequently be of service. Plasters containing the extract of conium, or of belladonna, or of aconitum, and camphor, may afterward be placed upon the sacrum, or over the hypogastrium, in the more severe and obstinate cases. 98. b. The congestive and inflammatory states of dysmenorrhcea require, with very few excep- tions, either general or local bleeding, or even both, as early as the attack comes under treat- ment. Leeches applied to the thighs are pref- erable to cupping on the loins in these cases; for I have known instances of suppression of the menses caused by the latter. The bleeding, however, should not be too profuse, as it may thereby interfere with the catamenial discharge; it may, however, be repeated at the return of the period, according to the peculiarities of the case. After vascular depletions, cooling diaph- oretics, conjoined with narcotics, are gener- ally beneficial; particularly the liquor ammoniae acetatis, with camphor, spiritus aetheris nitrici, and any of the narcotics already noticed. Warm poppy fomentations, the warm bath, and the other means already noticed ($ 97), will also be frequently of service. The bowels should be kept gently open by means of cooling laxatives. 99. ti. During the intervals between the men- strual period, the treatment should be varied conformably not only with the varieties above distinguished, but also with the circumstances of the case.—a. In the neuralgic form, much at- tention should be paid to the state of the digest- ive functions, and to diet and regimen. The biliary secretions ought to be promoted by blue pill, or the hydrarg. cum creta, taken alternate nights ; and by a stomachic aperient, the fal- lowing morning or night. After the abdominal secretions and excretions have been improved, chalybeate preparations or mineral waters may be tried, and be aided by residence in a pure air; by exercise on horseback, or by regular walking exercise, taken moderately, twice or thrice daily; and by warm salt water baths, followed by cold salt water bathing or the daily use of shower baths. MENSTRUATION, DIFFICULT—Treatment. 100. The several preparations of iron have been advised in this complaint. The iodide of iron is one of the most efficacious. It may be given in the sirup of sarsa. Dr. Louock advises the vinum ferri with the spiritus setheris sulph. comp. The mistura ferri comp, and the alka- line combinations of iron are also very service- able. Dr. Dewees makes favourable mention of the tinctura lyttae, and more especially of the tinctura guaiaci and tinctura guaiaci ammoni- ata; and Dr. Chapman advises the decoctum senegae. Dr. Churchill recommends blisters (to the sacrum, or a caustic issue in the same situation. I have prescribed pea issues in the insides of the thighs with success. 101. The more obstinate cases, and those es- pecially which are attended by the expulsion of albuminous exudations, may resist most of the means now mentioned; particularly when the malady is perpetuated by persistence in one of its most common exciting causes, namely, mas- turbation. In these circumstances, Plummer’s pill, or the blue pill, may be given every night, alone or with soap and ipecacuanha, until the gums are affected ; or the spirits of turpentine, in the dose of about one drachm, may be taken at night and upon waking in the morning, on the surface of a cup of milk, or in any other vehicle, for some days before the next menstru- al period. Injections, per vaginam, of warm water containing a little of the biborate of soda, especially when the period of the catamenia approaches; the same substance taken inter- nally, alone, or conjoined with any of the more congruous medicines already noticed, or with the supertartrate of potash, when the bowels require to be kept freely open ; and warm pe- diluvia, hip baths, or the warm bath, continued or repeated according to circumstances, may farther be resorted to. 102. b. In the congestive and inflammatory states of dysmenorrhcea, spare diet, regular and active exercise, particularly on foot and in the open air, with attention to the state of the bowels, should be especially insisted on. If the case prove obstinate, or continue, not- withstanding the more active means advised for the treatment during the menstrual period (§ 98), it will be necessary to have recourse either to the means already advised for the more severe cases attended by the discharge of albuminous exudations (<) 101), or to a mild mercurial every night, the supertartrate of pot- ash with biborate of soda being taken in the morning. In some cases of this state of the disease, the iodide of potassium and the liquor potassae, given in suitable vehicles, have proved efficacious. Of the local application of iodine advised by some recent writers, in some obsti- nate cases of dysmenorrhcea, I have no expe- rience ; and I know of no circumstance that can render it appropriate. On the approach of the next menstrual period, leeches applied be- low the groins, and the means advised above ($ 101), should be resorted to. If the bowels be confined, the remedies just mentioned, or the biborate of soda with aloes, may be prescri- bed. In cases of this kind, as well as in sup- pression of the menses, Dr. Mead had great faith in hellebore given until a free operation was effected on the bowels. 103. C. The mechanical or obstructive variety of dysmenorrhcea has been remedied by the in- 975 976 MENSTRUATION, EXCESSIVE—Definition. troduction of bougies, which, however, require both care and dexterity to prevent injurious consequences. As the removal of the stric- ture is not necessarily followed by the cure of the complaint, the medical treatment recom- mended should also be employed according to the circumstances of the case.* V. Excessive Menstruation. Synon. Menor- rhagia (from prjvef, menses, and pyyrj, a rup- ture) ; 'Poof nohlog, Hippocrates. Hemor- rhagia uterina, H. uteri, Menstrua immodica, M. superfl.ua, Auct. var. Metrorrhagia, Frank. Hysterrhagia sanguinea, Swediaur. Parame* nia supaflua, Good. Menorrhea, perte ute- rine, Fr. Der Mutterllutfluss, Germ. Inordi- nate or profuse menstruation. • Classif.—II. Class, I. Order {Author). 104. Defin.—A too abundant or a too frequent return of the uterine discharge. 105. In the article upon Haemorrhage from the Uterus, I have treated of “ discharges of blood from the uterus occurring independently of the menstrual evacuation,” and have con- sidered them with due reference to the several periods of life and to the various circumstan- ces in which they occur {see article referred to, t) 220, et seq.). I here confine myself to the consideration of excessive or profuse menstrua- tion, as above defined. 106. The quantity of blood discharged from the uterus at each menstrual period has been variously estimated. In temperate climates it varies from four to ten ounces, from five to seven or eight being the usual amount in this country. Less than four may be considered as scanty, and more than nine or ten excessive. That climate influences the quantity of this dis- charge is extremely probable ; but I do not be- lieve that it has this effect nearly to the extent estimated by some waiters ; for it is impossi- ble to obtain precise information on the sub- ject. Even when the quantity is unusually large, the discharge may take place in a short period, or during a longer time in recurring gushes ; or it may continue for a long period, as a slight or moderate drain. 107. Dr. Churchill distinguishes three forms of menorrhagia: 1st. That in which the dis- charge is of the natural character, but is ex- cessive as respects its quantity, continuance, or frequency of recurrence. 2d. That in which the discharge is mixed with clots of blood, but is not attended by alteration of the cervix or os uteri. 3d. That in which there is change in the cervix, or in the size or position of the ute- rus. This division is not altogether undeserving of adoption ; but as the discharge must neces- sarily present the characters either of the men- strual fluid, or of haemorrhage, it is preferable to arrange the forms of the disease according- ly, namely, into true menorrhagia, and hemor- rhagic menorrhagia. 108. i. Menorrhagia, with a natural state of the Discharge—True Menorrhagia.—In this va- riety the discharge is excessive, either as to its quantity, its continuance, or the frequency of its recurrence. It may come on suddenly and most abundantly, thus continue for a long- er or shorter period, almost cease for some hours, and then return more or less copiously. It may recur or remit in this manner several times or for several days, the excessive dis- charge assuming this form at each period. Sometimes it commences and proceeds regu- larly, in an unusually abundant quantity, the period not being much prolonged; but, more frequently, it lasts for a long time, occasionally for a fortnight or even longer, the quantity not being great at any time, but becoming so from its continuance. In other cases, the discharge returns every two or three weeks, without being in an augmented quantity. This last state is not infrequent among unmarried fe- males of a plethoric system, or sanguine tem- perament, with much activity of the uterine organs. 109. This variety of menorrhagia is often associated with uterine leucorrhcea, which may either precede or follow each recurrence of it. In some cases, also, leucorrhcea only may have been the primary disorder, menorrhagia su- pervening ; while, in others, it may have fol- lowed this malady. An examination per vagi- nam furnishes no information, excepting of a negative kind. There is neither heat, nor ten- derness, nor swelling of the os uteri. 110. After repeated returns of menorrhagia, the constitution indicates the debility and loss of blood produced by it; and the patient com- plains of weakness or aching across the loins and hips ; of languor, exhaustion, faintness, tinnitus aurium, giddiness; and of headache, or throbbings in the temples, or palpitations ol the heart. The countenance is pallid, and the lips, tongue, and gums are pale. If the dis- ease continue, these symptoms become aggra- vated ; the stomach and bowels are deranged ; pains in the side, particularly the left, are com- plained of; the face is sallow, and all the indi- cations of anaemia appear. Ultimately, aedema of the ankles, anasarca, diarrhoea, convulsions, and various nervous affections, may supervene. 111. ii. Menorrhagia with discharge of pure blood, or coagula—Hemorrhagic Menorrhagia.— This variety is met with chiefly in married fe- males of a leucophlegmatic temperament, and in those who have been weakened by disease, or by frequent child-bearing, or by prolonged suckling; and in these circumstances it is gen- erally complicated with leucorrhcea. But a dif- ferent, and a more acute or active state of the complaint occasionally is met with, which has been altogether overlooked by Dr. Churchill. I have observed it on several occasions, and it has also been noticed by Dr. Ashwell. This variety of menorrhagia has therefore been prop- erly divided by him into three states, viz., the active, passive, and congestive. The first and * [Dr. Mackintosh states that he treated twenty-seven cases by bougies, and cured twenty-four, and that, in eleven of the latter number, pregnancy subsequently occurred. Recent writers on dysmenorrhoea seem, however, to place but little confidence in this mode of treatment, although Dr. Ashwell thinks that the views of Dr. Mackintosh “ are more correct than is generally supposed.” Some have recommended the belladonna, in smnll doses, prior to the menstrual effort, but we have had no experience as to its success. Dr. Meigs, of Philadelphia (Am. ed. of Colom- BAT, p. 481), gives the following directions for introducing a bougie into the uterus : The patient should lie across the bed, or near the foot of it, with the knees drawn upward, and separated with a pillow. A flexible block-tin bougie, of proper size, is next to be conducted along the right index finger to its point, which is placed on the os uteri, and serves to guide the bougie to the canal of the cervix. If the bougie be somewhat curved, its apex enters without difficulty, and passing upward slowly, to the distance of one inch and a half to two inches, is left in situ for a min- ute or two, and then withdrawn, to be followed by another of a larger size.] MENSTRUATION, EXCESSIVE—Menorrhagia. second of these are generally attended by a natural state of the cervix and os uteri, while the third is usually accompanied with some change in the state and position of these parts. 112. A. Active or Acute Hcemorrhagic Menor- rhagia—Inflammatory Menorrhagia.—This is the least frequent kind of the complaint. It occurs chiefly in robust or plethoric married women, who live fully, or who addict themselves to sexual excesses ; but it is also, although more rarely, met with in young, florid, and plethoric unmarried females ; and in both classes of pa- tients it may assume, according to the temper- ament and habit of body, more or less of an in- flammatory, or of a spasmodic character. In this state of the complaint, a sense of tension, weight or fulness in the pelvis, is complained of for a day or two before the accession of the discharge. Sometimes there is also a sense of throbbing in the uterus, with pain, swelling, or tenderness of the mammae; and occasionally even pain in the uterine region. The pulse is quickened, and sometimes fuller and stronger than usual; and there are generally headache, costiveness, and sympathetic fever. In the spasmodic state, the pain in the uterine region is more severe, but it occurs only in paroxysms, and is attended by a twisting sensation in the pelvis and lower part of the abdomen ; or it re- curs after intervals, and resembles labour-pains. These pains usually precede, for a shorter or longer period, the discharge, which is extremely various as to amount and continuance. Some- times the discharge comes on in gushes, with coagula, and recurs more or less frequently. These generally afford relief, at least for a time, the febrile symptoms subside, and the rest of the period is passed as in the more healthy state. But in more severe or protracted cases, after a shorter or longer remission, during which either a draining merely continues, or the dis- charge is in almost a natural state, an exacer- bation, in a more or less severe form, takes place ; and thus the complaint may return oft- ener than once, and be prolonged for seven or eight days, or even much longer, especially if the patient attempts to keep about, or to use any ex- ertion. On examination per vaginam, the os ute- ri and cervix, sometimes with the vagina, are oft- en discovered to be fuller, hotter, and more ten- der than natural. The discharge usually leaves the patient exhausted, and several days elapse before her usual health is restored. This form of the complaint may return during several suc- cessive periods, each of which may be so pro- longed that the intervals between them become greatly reduced, and the health remarkably im- paired. In these cases, this active form pass- es into the next, or the passive state of the complaint. 113. B. Passive or chronic hcemorrhagic men- orrhagia is generally gradual in its accession, unless when it is consequent upon the acute state. It is the most common form of the com- plaint, and affects chiefly delicate, hysterical, and debilitated females/ It exists in various grades, from the slightest increase of the men- strual discharge to the most severe haimorrha- gic prostration. In some cases, the disease at first, or even for several periods, possesses the usual features of true menorrhagia. In other instances, one, two, or more coagula are ob- served at first upon the accession of the period, and then an intermission takes place. The discharge afterward recurs more abundantly, and with larger or more numerous clots. It may be so abundant, or continue so long as to occasion faintings and great exhaustion; the back being weak and aching, the countenance and lips pallid, the strength exhausted, and the pulse always becoming small, feeble, and quick. The constitutional symptoms and consequences of the malady already noticed (§ 110), become urgent or even dangerous, if the discharge be not checked or arrested. The uterus, on ex- amination, generally betrays no change. 114. C. Congestive Menorrhagia—Menorrha- gia with change in the Uterus.—This variety gen- erally occurs after forty years of age, or about, or even after, the cessation of the menses. The discharge is generally more profuse, and its effects more severe in this than in the oth- er varieties; and it takes place in all consti- tutions, temperaments, and habits of body. The attack is usually preceded for some time by irregularity of the menses, as to quantity and time, as well as to the duration of the pe- riods ; and uterine leucorrhcea has generally existed during the intervals. About twenty- four hours after the discharge has commenced, large clots are expelled, and the sanguineous flow becomes still more abundant. The attack lasts from six to ten days ; but, in cases of longer standing, Dr. Churchill has occasionally known it to continue throughout the interval, and terminate after the next period, either grad- ually or suddenly ; but it may continue for sev- eral periods, with remissions merely during the latter portion of the intervals. The quantity lost, in some instances, has been sufficient, in one attack, to excite fears of a fatal result. The discharge is increased by standing or exer- tion, but it is not materially diminished by the recumbent posture. In addition to all the symptoms above noticed (§ 113), which are oc- casioned by exhaustion and loss of blood, and which are still more rapidly and severely in- duced in this than in the preceding varieties, the patient complains of weight, dull pain, or bearing down in the pelvis. There is also oc- casionally dysuria ; but more frequently irrita- tion only, extending to the urethra and neck of the bladder. The pulse is weak, small, some- times quick, and the general health remarka- bly impaired. On examination per vaginam, the os uteri is generally found low in the va- gina, and is directed more backward, and is more open than in the healthy state. The cer- vix uteri is also more swollen, the body of the organ being thrown forward so as to press upon the bladder. There is no increased heat of the cervix or vagina, but the former is slight- ly tender on pressure, and the body of the or- gan seems somewhat swollen. 115. iii. Diagnosis.—A. As respects the Forms of the Complaint.—a. The first form of the dis- order is readily distinguished by the absence of coagula from the separation of the discharge into crassamentum and serum; when such separation takes place, the complaint is no longer true or simple m'er.orrhagia, but one of the haemorrhagic varieties.—b. Of these varie- ties, the first is distinguished by slight fever, pain in the region of the uterus, or spasms in this region and in the abdomen, by slight heat and tenderness of the os uteri, and by the other 977 978 MENSTRUATION, EXCESSIVE—Prognosis—Causes. circumstances of its occurrence as pointed out above (5> 91). The hydro- cyanate of iron has been used by MM. Dupuy and Jolly in the following form : No. 299. R Hydrocyan. Ferri, gr. xviii.; Quinime Sulph., gr. xii.; Extr. Opii, gr. i.; Conserv. Rosa:, q. s. ut fiant Pi- late xii. Capiat unam 2dis vel 3ti is horis. 93. c. The preparations of zinc have been pre- scribed for neuralgia, but chiefly in combina- tion with some one of the narcotics about to be noticed. The sulphate was preferred by Meglin, and the chloruret or chloride by Hanke, who directs one grain of it to be dissolved in two drachms of chloric aether, and from five to ten drops of the solution to be given every fourth hour in sugared water. The chlorate of potash has been praised by Helmenstkeit and Meier, who gave it in doses of from three to five grains every fourth or fifth hour. I have prescribed it in somewhat larger doses in the decoction of bark or infusion of valerian. It is ndt devoid of efficacy in the rheumatic and hysterical states of the disease. 94. d. Nux vomica and strychnia have lately been suggested in the treatment of neuralgia. Linnaeus gave the former in gastralgia ; and I have prescribed the alcoholic extract of it in a few instances—in one or two with decided ser- vice, but in others with doubtful advantage. * Of the oil from the livers of the torsk, ling, and cod, I can speak from experience. When obtained from the fresh livers, and used before it becomes rancid, it is not unpalata- ble, and does not offend the stomach. The fishermen in the parts above mentioned usually employ it as the only sauce to either of these fish ; and I have very frequently partaken of it in this manner, and esteemed it above any other sauce. But the livers of these fish (that of the torsk more especially, it being prized much above the others), when prepared in the following way, are admirable articles of diet for the complaints under consideration, as well as for rheumatism and some others. The stomach of the fish is well washed, two parts filled with the fresh liver, and firmly tied at each end, so as not to allow any of the oil to escape while being boiled. When ate quite warm, with a little salt and spice, the liver still containing the greater part of its oil, this is very palatable. The fresh livers of these fish, and also of the young coal fish and haddock, are prepared in various other ways as articles of diet, or they enter into the composition of several dishes much relished in the countries I have mentioned. I may add, that they often served me as articles of diet very many years ago; and that I now would as soon partake of them as of turtle or venison, although no lukewarm admirer of these admira- ble articles of diet, which, when excellent of their kind, gratify the palate, humour the stomach, and harmonize all the organic functions. 1024 NEURALGIC AFFECTIONS—Treatment of. This preparation is in many respects preferable to strychnine, both in this and in paralytic af- fections ; but it is not suited to the more con- tinued and inflammatory stages of this disor- der. The same remark applies to phosphorus, which has been employed by Loebenstein- Loebel, dissolved in oil, of which, however, I have had no experience. 95. e. Of camphor, given in tolerably large doses, with opium or some other narcotic, or with quinine, or sulphate of iron, I entertain a favourable opinion, as well as of valerian and guaiacum, the ammoniated tincture of these be- ing the preparations I have preferred. Schnei- der employed the oil of valerian both internal- ly and externally by friction. The prepara- tions of guaiacum with colchicum, or with acon- ite, and the alkaline carbonates, are most use- ful in the rheumatic forms of neuralgia. Musk has been prescribed by Beaumes, and by J. Frank conjoined with calomel and antimony. 96. d. Narcotics and Sedatives. — a. The several preparations of opium, and more re- cently the salts of morphia, have been prescri- bed in this class of affections, in various com- binations, and with different effects. I have found them of service in full doses with calo- mel, camphor, and ipecacuanha, particularly in sciatica, after the bowels have been freely evacuated ; and in toothache, opiates with cam- phor, creasote, and capsicum, applied to the gums, or to a carious tooth,, often affords re- lief. Recamier advises the following pills in neuralgia: No. 300. ft Pulv. Opii puri; Pulv. Ipecacuanha, 55, gr. iij.; Camphor® ; Ammonia sesquicarb., 55, gr. xij.; Muci- lag. Acacia, q. s. M. Fiant Pilul® xx. Capiat j. ad iij. 2dis vel 3tiis horis. 97. b. Aconite was first prescribed in neural- gia by Murray ; but it was previously used in rheumatism. More recently it has been much employed in neuralgic affections by Jahn, Tea- lier, Hufeland, Turnbull, and others. Spiel- mann advises it to be given with the golden sul- phuret of antimony ; Rademacher with the de- coctions of guaiacum and sassafras ; Wildberg with the succinated spirit of ammonia, the gal- banum plaster with opium being employed ex- ternally ; and Fritze with the boracic acid. I have prescribed it with the biborate of soda. The preparations of aconite that are chiefly to oe depended upon are, the alcoholic extract and the tincture, both for internal and for external use (§ 110); but they are most quickly effica- cious when applied externally. Aconite has succeeded in several cases in my practice, but it failed very recently in a case of femoral neu- ralgia. It is, however, a very valuable remedy, particularly in the rheumatic forms of the com- plaint, and in neuralgic affections of the heart and diaphragm, as wrell as of the nerves of the trunk and extremities. It is not indicated in the inflammatory states of the disease ; and it should not be given in these until local deple- tions have been resorted to. The modes of exhibiting it advised by Hufeland and Jahn deserve notice: No. 301. ft Extr. Aconiti ; Calomelanos, 55, gr. ij.; Re- sin® Guaiaci, 3ss.; Sulphureti Antimonii Aurei, gr. ij. ; Olei Valerian® AS the re i, Tlffi. i Sacchari Albl, 3j. M. Fiat Pulvis. Capiat dimidium mane nocteque. No. 302. ft Extr. Aconiti, 3ss.; Extr. Conii; Res. Guai- aci ; Asafoetid®, 55, 3j.; Calomelanos, gr. xv. M. Fiant Pilulaj sing. gr. iij. Capiat ii1 ad vj. ter quotidie. [Dr. Fleming, in his recent work on aconite (An Inquiry into the Physiological and Medicinal Properties of the Aconitum napellus, Lond., 1845, 8vo, p. 160), has given a table of 40 cases treat- ed by this remedy, of which 27 were perma- nently cured, and 13 only temporarily relieved. In some of them the medicine was used inter- nally, in others externally; sometimes both. Dr. Fleming suggests, that if the neuralgia de- pends on inflammation either in the painful part of the nerve or farther up in its course, or in sympathetic irritation, the internal use is more likely to be beneficial; if from local func- tional irritation, the topical application. We should prefer to depend chiefly on its external use, as we do not regard its internal use as free from danger. Dr. F. states that he has met with several cases of neuralgia in which the individuals had, for weeks or months, been in the habit of procuring sleep, and a tempora- ry cessation of pain, by opiate draughts, and who, on using the aconite, obtained permanent relief of the disease. Dr. F. has tried it in 40 cases of toothache, by rubbing the gums with a few drops of the tincture, or by introducing a piece of cotton, soaked with a drop or two, into the carious tooth. In 7 of these cases it failed ; in 6 it succeeded only for a short time ; in the rest the relief was complete.] 98. c. Belladonna has been very generally pre- scribed in neuralgia. I have given it with cam- phor and sulphate of quinine, and at the same time applied it externally, as about to be noticed (§111). In some instances I have found it oc- casion stupor and malaise, without materially relieving the pain. M. Trousseau has advised the extract of it, in doses of a quarter of a grain, to be given every hour until it causes vertigo, and then it is to be taken at longer intervals. He also has given it with sulphate of quinine, or with preparations of iron ; or he has exhib- ited these after the narcotic effects of the bel- ladonna had become manifest. Siebold, Thomp- son, and Deleau have recommended it to be employed both internally and externally. Pe- reira considers it inferior to aconite in this disorder. [We regard belladonna as one of the most successful remedies for the relief and cure of this.obstinate class of diseases. In a very ag- gravated case of neuralgia at Geneva, New- York, which had resisted a great variety of treatment for twelve months, during which the patient suffered the most excruciating agony, a perfect cure was accomplished by the use of a pill composed of three grains of pil. hydrarg., and one grain of extract of stramonium. One of these was ordered to be taken every night at bedtime, until the gums were a little affected; then to leave off for a few days, and resume. In two weeks a cure was effected. Whenever threatened with a return of the complaint, the same remedy always prevented it (Bost. Med. and Surg. Journ., vol. xviii., p. 178). In the same journal, vol. xix., p. 77, is contained an account of a very severe case of neuralgia cured by the repeated use of emetics. The following formula will prove exceeding- ly efficacious in many cases of obstinate neu- ralgia : R Extr. Belladonna, §ss. ; Opii. Pulv., 3ij. ; Adipis Suis, gss.; Olei Thymi, HI vj. M. A portion of this ointment as large as a hazelnut is to be well rubbed upon the affected part two NEURALGIC AFFECTIONS—Treatment of. 1025 or three times a day, or whenever the parox- ysms of pain are severe. The rubbing should be continued for eight or ten minutes at a time, until the ointment is quite absorbed by the skin ; a little saliva may be added now and then, to promote the absorption. If the sight becomes affected, or any unpleasant symptoms super- vene, it should be suspended for a while. This application is peculiarly well adapted to cases of facial neuralgia.] 99. Stramonium has also been extensively used in neuralgic affections. Lentin prescri- bed it in the form either of tincture or of ex- tract. It has been favourably mentioned by Marcet, Trousseau, Begbie, Vaidy, Richter, and others. It is advantageously given with camphor and ipecacuanha. Dr. Rowland found it to succeed only in three cases out of ten, and in these three, partially in two, and com- pletely in one. Dr. Elliotson considered it most useful in enteralgia. 100. d. Conium was strongly recommended by Fothergill for this affection. It afterward fell into disuse ; but it has since been favoura- bly mentioned by Chaussier, Dumeril, and Rowland. The reputation of hyoscyamus is probably equal to that of conium in the treat- ment of neuralgia. Breitung prescribed the extract of it with calomel; and Herison the tincture, with the tincture of guaiacum. It en- ters into the composition of the pills of Meglin, which have obtained some notoriety in this complaint. No. 303. ft Extr. Hyoscyarai; Extr. Rad. Valerianae ; Oxydi Zinci, 55, 3j. M. et divide niassam in Pilulas lx. Capiat j. ve) iij. 2dis vel 3tiis horis. 101. /. The Rhus toxicodendron has been ad- vised for neuralgic affections, but it has never come into general use. Anderson gave three grains of the powdered leaves three times a day ; and Goeden prescribed the resin of guai- acum, the powdered leaves of the toxicoden- dron, and calomel in the form of pdls. 102. g. Colchicum has not been so generally employed in this class of affections as it de- serves ; and it has not proved so successful in some of the cases in which it has been prescri- bed as it might have been if it had been given in those forms and combinations in which I have found it beneficial in these affections. In some persons, especially in those subject to visceral neuralgia, it is very liable to occasion remarkable depression of nervous power. It should, therefore, be exhibited with much cau- tion, and in conjunction with stimulants or ton- ics. Accumulated faecal matters and morbid secretions should be evacuated before it is ta- ken. I have found it most serviceable when given with ammonia, or camphor, or with cin- chona and an alkaline carbonate ; the powder of the corrnus, or the extract with sulphate of quinine and camphor, or with sulphate of iron and powdered capsicum, in the form of a pill; the tincture or wine, with the decoction, and the compound tincture of cinchona, and the sesquicarbonate of ammonia, or the carbonates of the fixed alkalies ; or any of the preparations of this plant with magnesia, and appropriate stimulants and restoratives. I prescribed, in 1820, for a lady in Walworth, suffering a most acute attack of facial neuralgia, colchicum, with the decoction and compound tincture of cinchona, the sesquicarbonate of ammonia, and the tincture of capsicum, after the bowels had been completely evacuated by means of cholo- gogue purgatives. The removal of the attack was rapid, and the patient did not experience a return of it for some years. Some years after- ward I had recourse to the same combination for neuralgia of the muscles of the arm, in a young gentleman who had experienced a very severe epileptic seizure, for which he had been largely blooded and much reduced. It was con- tinued during a few days, and was aided by act- ive purgatives. The neuralgic affection ceas- ed ; but some months afterward he was again seized with epilepsy; a physician saw him in my absence, and directed blood-letting, which was followed immediately afterward by anoth- er attack of epilepsy and paralysis of the arm, formerly the seat of neuralgia. 103. h. Hydrocyanic acid is often of service, but chiefly in cases of visceral neuralgia, more particularly gastralgia and enteralgia. I have found it successful in some cases in which col- chicum produced remarkable depression. It may be given with camphor, the sesquicarbon- ate of ammonia, or with other stimulants and restoratives, or with carminatives. When vis- ceral neuralgia is complicated with anaemia, it may be prescribed at the same time with the salts of iron. 104. e. Sialagogues and Errhines were for- merly much employed in painful affections of the head and face ; and in some forms and ca- ses of facial neuralgia they may still be em- ployed with some hopes of benefit. When it is considered that the substances which are used locally as errhines or as sialagogues act di- rectly upon branches of the trifacial nerves— upon ramifications of the very nerve which is generally the seat of the affection—the modern neglect of these means is deserving of remark. —a. Errhines, however, should be used with caution when there is reason to infer any seri- ous affection of the encephalon, or active de- termination of blood to, or congestion in, that organ. As respects the choice of substances which may be used in this way, those which most efficiently promote a discharge from the pituitary membrane are the most efficacious. Sugar, in a fine powder with a small quantity of black pepper or capsicum intimately mixed in it; the various kinds of snuff; and powders containing a small proportion of veratrum or of asarum, may be employed, according to the cir- cumstances of the case. 105. b. Sialagogues and maslicatories may be used without any risk in all cases. Tobacco is tne common local sialagogue among sailors, and the community of the United States of America, and is probably both a cure and pre- ventive of facial neuralgia and toothache in many instances, particularly of the latter form of the disorder. But the continued or frequent use of this substance as a masticatory proves injurious to the digestive organs, and to the or- ganic nervous energy, owing to the quantity of saliva imbued with the juice of it which is swal- lowed. When it is desirable to use any of the warmer substances as a masticatory, horserad- ish, ginger, mezereon, pellitory of Spain, Oi cap- sicum may be selected. If a tonic and antisep- tic be preferred, the betel nut, catechu, myrrh, the astringent barks, &c., may be employed. If a refrigerant be indicated, camphor, alum,. 1026 NEURALGIC AFFECTIONS—Treatment of. sal ammoniac, &c., may be used. For tooth- ache several substances have been employed as masticatories or as sialagogues with advantage, and various combinations of them with narcot- ics, or with antiseptics, have been resorted to. Thus camphor dissolved in the tinctures of opium and capsicum, creasote being added to the solution, acts both as a sialagogue and as an anodyne in this complaint, when applied by means of a piece of lint or cotton to the gums or to a diseased tooth. [In the treatment of tic douloureux, we are to bear in mind that it originates from a great va- riety of causes, as, 1st. From some peculiarity of constitution or neuralgic habit ; 2d. From dyspepsia ; 3d. From dyspepsia complicated with congestion of the liver and other viscera; 4th. From anaemia ; 5th. From morbid action in the spine ; 6th. From disorder of the uterus; 7th. From disease of t[ie brain ; 8th. From lo- cal mechanical causes, as decayed teeth, exos- tosis, tumours, &c.; 9th. From malaria. Each of these different forms will be best treated by adapting our remedies to remove the original pathological condition on which the disease depends. .For information on these points the reader must consult the appropriate articles, which he will find scattered through thework.] 106. £. External modes of medication have been resorted to in neuralgic affections, in al- most endless variety.—A. Of local blood-letting notice has already been taken, and the propri- ety of it vindicated in many instances, and wherever a chronic state of inflammation of the nerves is inferred to be present. Various modes of employing galvanism, electricity, and, more recently, electro-magnetism, have been adopted by Andry, Thouret, Lebreton, Bal- ly, Harris, and Harles.* Acupuncture has been recommended by Recamier, Bergamaschi, Sachs, Churchill, and others, especially in sciatica. Of these means I have had no expe- rience. The affusion of cold water, the shower bath, and cold salt-water bathing have been sev- erally advised ; but they may be hurtful more frequently than beneficial if they be not pre- scribed with discrimination, and if they be not immediately followed by frictions and other means to secure reaction.! 107. B. The strictly local applications to neu- ralgic parts are numerous. They may be ar- ranged into, 1st. Those which are intended to alter the sensibility of the affected nerve, with- out causing vesication or suppuration ; 2d. Those which, by causing vesication or suppu- ration, in addition to the local excitement, may thereby more permanently impress and change the morbid affection ; 3d. Those which may still more powerfully affect the seat of disorder, by being applied more immediately to the nerves and capillaries in the vicinity, and after the cu- ticle has been removed ; or those which admit of being endermically prescribed ; and, 4th. Those which interrupt the communication be- tween the seat of the affection and the senso- rium, and which may remove the cause of irri- tation in the part affected. 108. a. Those applications which are intended to alter the sensibility of the affected nerve without causing vesication or suppuration consist chiefly of compresses, epithems, cataplasms, pomades, and ointments, frictions with ointments, or lin- iments, embrocations, and plasters.—(a) Com- presses and epithems of various kinds have been prescribed by Ricotti, Mondiere, and others ; and the chief of these are compresses moisten- ed with cold water, or with a solution of prus- sic acid, or with laurel water. Epithems with a solution of corrosive sublimate (4 grs. to fj. of distilled wTater) have even been resorted to by Wedekind and Fleischmann. Hufeland advises compresses moistened with equal parts of laurel water, Goulard’s lotion, and rose wa- ter, or with this last somewhat in excess. Trousseau recommends an epithem of a de- coction of stramonium (§j. of the plant to ibj. of water). [The hydrocyanate of potash is one of our most efficient local remedies in this disease. We have known numerous cases of tic douloureux relieved by it. It should be dissolved in dis- tilled water, in the proportion of from 10 to 30 grains to ?iv., or, in bad cases, even stronger, and applied by friction over the affected part.— (See Bost. Med. and Surg. Journ., vol. v.)] 109. (b) Cataplasms, or poultices, containing various active substances have sometimes proved beneficial. The powdered leaves of hy- oscyamus, of conium, of tobacco, and of the solanum nigrum, have been made into poultices with linseed meal and decoction of poppies, and applied to the affected part. Poultices con- taining one or more of these, and some stimu- lating or irritating substance, as capsicum, mus- tard, &c., so as to conjoin a narcotic with an irritant or rubefacient effect, have likewise been advantageously applied. 110. (c) Various pomades and ointments, with or without friction, have been recommended: those containing the extract of belladonna, or the acetate of morphia, by Lambert, Bartels, Lesieur, &c. ; those containing the iodides of mercury, by Thompson and Scott, or the iodide of potassium; those containing the sub-car- bonate of lead, by Ouvrard ; and those with veratria, aconite, &c.,by Turnbull, Rowland, and others. Several of these are more service- able when applied by friction, so as to occasion * [Dr. Thomas Harris, now chief of the Medical Bu- reau of the United States Army, has reported several cases of neuralgia successfully treated by galvanism, applied af- ter the manner recommended by Mansford in his work on epilepsy.—(See Am. Jour. Med. Sci., vol. xiv., p. 384 and 311.) We have known repeated instances where the ap- plication of tile horseshoe magnet, in neuralgia, toothache, &c., has almost instantly afforded relief. For several cases of this kind successfully treated by the magnet, at St. Thom- as Hospital, Lond., see Am. Jour. Med. Sci., vol. xiii., p. 247. Neuralgia is often relieved by the manipulations of animal magnetizers ; on what principle is not as yet fully established.) t [Electro-puncture in Neuralgia.—M. E. Hermel (An- nul es Medico-Psychologiques. Paris, Janv., Mars, and Mai, 1844.—Jour, des Connaiss. Paris, Julliet, 1844, p. 27-8), as ar. evidence of the successes which electro-puncture has had in his hands in the treatment of some of the severest forms of neuralgia, almost all of them lumbo-sacral and sci- atic, accompanied in some instances with partial paralysis, gives eight cases in which perfect cures were speedily ef- fected by electro-puncture, when all the usual modes of de- pletion, purgation, &c., were of no avail. He says nothing, however, of the still more formidable and distressing forms of neuralgia, known as tic douloureux. Nevertheless, he is inspired with full confidence in the value of this remedy, and while he promises to supply fresh evidence thereof, meanwhile comes to these conclusions: 1. That electro- puncture is applicable to idiopathic or essential neuralgias. 2. The violence of the pains is not a counter indication to the employment of this therapeutic agent; they have never, in any case, been aggravated by its use. 3. The paralysis which supervenes in the progress of idiopathic (essentielles) neuralgias yields to the same treatment.—(Velpeau.)] NEURALGIC AFFECTIONS—Treatment of. 1027 considerable rubefacient effect, as those with the iodides of mercury or of potassium, or with veratria or aconite. [Veratria and aconitine are two of our most important topical remedies in the treatment of neuralgia. An ointment composed of twenty grains of veratria to one ounce of lard may be rubbed over the part affected, from time to time, with the best effects. The usual strength in which we have employed it is from ten to twen- ty grains to the ounce of lard, or simple cerate; or the alcoholic tincture, which is a neater prep- aration, may be used. When used internally, which we do not recommend, the veratria may be given in doses of one sixth of a grain, with half a grain of extract of hyoscyamus, three times a day, obviating costiveness by the use of rhubarb and blue mass. (See Dr. Turnbull’s Essay on the Medical Properties of the Natural Order Ranun- culacece.) We prefer the internal use of extract of belladonna to that of veratria, delphinia, or aconitine, which are too powerful to be em- ployed with safety. Veratria may be applied very successfully in these cases by dipping the point of a lancet in a saturated solution of the alkaloid, and making a number of punctures over the part affected. Each puncture will become at once the seat of a sharp pain, similar to that caused by the prick of a fine needle. This lasts but for a few min- utes ; ten or twelve punctures should be made night and morning, and continued till the dis- ease yields.] 111. (d) Frictions with stimulating liniments or with strong solutions of narcotic substances, o.r with both conjoined, have been employed. Col- ville found frictions with tar of service ; and Todd derived advantage from friction with a strong solution of extract of belladonna (3ij- of extr. in ?j. of water). I have had recourse to friction of the affected parts with narcotic and rubefacient substances conjoined, and frequent- ly prescribed, the following with marked benefit: No. 304. It Linimenti Camphors Co. ; Linira. Terebin- thinae, 35, jss. ; Olei Olivae, jijss.; Olei Cajuputi, 3jss. ; Extr. Belladonna (vel Tinct. Alcohoi. Aconiti), 3iij. Misce, ut fiat Linimentum. 112. (e) Embrocations with various substan- ces have proved equally serviceable with any of the foregoing applications. Warm flannels, or several folds of cotton made warm, and thoroughly imbued with any of the liniments re- ferred to in the Appendix (F. 295—314), or with the liniment just prescribed, and then closely applied to the affected part, and covered by a warm napkin, or by oiled silk to prevent evap- oration, are often of essential service in most of the varieties of neuralgia, particularly when I renewed from time to time, or according to the effect produced. 113. (/) Plasters of various kinds have like- wise been placed on the part, and some of them have been intended to produce a rubefa- cient, in addition to their other effects. Those plasters which contain belladonna, or both this narcotic and camphor, have usually been pre- ferred. M. Trousseau has employed the ex- j!tract of stramonium in this manner. The fol- lowing plaster has been frequently applied in sciatica: i[ No. 305. R Cerse Albas, Jj.; Olei Tcrebinthina, fss., . Ifiiu igne colliquefactis, adde Pulveris Euphorbia, 3j.~3ss. M. Fiat Emplastrum. I 114. b. Various means of producing vesication, pustulation, or suppuration have been resorted to for this complaint.—(a) Blisters applied, and even repeated, in the course of the nerve, have been praised by Cotugno, Magendie, and oth- ers. Moxas have likewise been recommended by Bontius, Cotugno, Larkey, Barras, and Walther. Compresses moistened with a strong solution of tartarized ointment, and ap- plied until redness or pustulation is produced, has been prescribed by Magri ; but an oint- ment containing the tartar-emetic, or mercu- rial ointment with it (3J. of ant. tart., and fj. of the oint.) as used by Scott, is more imme- diate and certain in its effects than the solu- tion. Issues and setons have been employed in the more obstinate or chronic cases. For sci- atica they may be placed near the trochanter major, and, in cases of facial or occipital neu- ralgia, particularly when there is reason to dread organic lesion near the base of the cere- brum or cranium, they may be inserted in the nape of the neck, or somewhat higher, or even in the occipital scalp. 115. c. Applications to the affected part after the cuticle has been removed from the surface—or endermic medication, as it has been termed— have been frequently tried in neuralgia, and recommended by Trousseau, Ricotti, Bonnet, Ansiaux, Radius, and others. Various nar- cotic substances have been thus employed ; but the acetate of morphia, sprinkled over the surface thus denuded of its cuticle, or ten grains of the acetate intimately mixed in from one to two drachms of an ointment, a portion of this being applied to it, and an ointment with a small portion of the extract of belladon- na, are the means most frequently selected, al- though various other substances may be simi- larly applied. 116. d. The affected nerve in some instances has been divided above the seat of pain, in order to interrupt the communication between the seat and the sensorium ; but there are very few cases on record in which this measure has succeeded beyond a short period, or given per- manent relief. When there is reason to infer the existence of any irritating substance in the nerve or part affected, the removal of it, if this be at all possible, should be attempted ; and, when the affection seems to proceed from the exposure of a fibril of nerve in a cicatrix, or from the irritation of an eruption, the applica- tion of a caustic to the former, suppuration being afterward promoted, and of appropriate means to the latter, according to its nature, is chiefly indicated. [M. Berard has seen (Malgaigne’s Manuel de Med. Operat., 4th edit , Paris, 1843, p. 130) an infra orbitar neuralgia return after having exsected three inches (nine millimetres) of the nerve ; and Swan has seen the two ends of a nerve in a horse reunite {lb.) after having ex- sected a segment near nine inches long! M. Malgaigne suggests {lb.) whether it might not be advisable, after dividing the nerve, to de- tach both ends by dissection, and fold them back on the trunk so as to form a noose, or to interpose between the ends a small fleshy flap from the immediate neighbourhood, the better to intercept, when the cicatrization is comple- ted over this, the continuity of nervous influ- ence. M. Bonnet, of Lyons, proposes in the frontal nerve to divide it freely down to the 1028 NEURALGIC AFFECTIONS—Treatment or. bone by a sub-cutaneous incision.—(lb., 151, 152.) M. Malgaigne, for the infra-orbitar nerve, prefers also the sub cutaneous section on the groove of the nerve in the floor of the orbit; after which he tears out the divided fragments from its groove by means of a for- ceps applied to the portion of the nerve laid bare, and divided a little below the orbit (lb., p. 155). M. Bonnet makes only a sub-cutane- ous division of the nerve.—(74.—Townsend’s Velpeau, vol. ii., p. 435.) Dr. Mott was one of the first surgeons in this country who treated neuralgia by exsec- tion of a portion of the nerve ; but after exten- sive trials he laid the operation aside, as he found the disease very certain to return as se- vere as ever. In that form of neuralgia which results from an injury or wound of the nerve, Dr. Mott has in several instances effected a cure by exsecting the cicatrix, in which will generally be found a nervous fibrilla. (See Lec- ture on Neuralgia, in the N. Y. Lancet, Feb. 12, 1842, No. 7, vol. i.) Dr. J. C. Warren, of Boston, has reported several cases of tic douloureux cured by the division and removal of a portion of some of the facial nerves.—(Boston Med. and Surg. Journ., vol. i., p. 1.) In one very aggravated case of a man aged 70, who had been affected for 14 years with severe pain in the side of the face, beginning near the ear, and thence darting into the lower and upper jaw, lips, eye, forehead, and scalp, and who had previously undergone three operations, with only temporary relief, viz., two on the sub-orbitar nerve and its branches, and a third on the nerve of the low- er jaw, wrhere it comes out on the chin, Dr. Warren proceeded to divide the facial nerve, between the parotid gland and the mastoid pro- cess, with the effect of removing the pain in the upper part of the face, while that in the lower was as acute as ever. A portion of the submaxillary nerve was then exsected by tre- phining the lower jaw beneath the masseter muscle and near its angle, when the pain en- tirely ceased, and the disease did not return.— (Loc. cit.) In another case, neuralgia of a branch of the plantar nerve, which caused convulsions in a female, and which was occasioned by including a nerve in the ligature of a small vessel, was perfectly cured by making an incision in the sole of the foot, behind the interstice of the fourth and fifth toe, and dividing the internal plantar nerve going to the fourth and fifth toe, of which a portion, one inch in length, was re- moved. But one spasmodic attack occurred after the operation, and the patient speedily re- covered her usual health. The observations of Dr. Warren on the va- rious forms of neuralgia, with numerous illus- trative cases, as contained in several numbers of the Boston Med. and Surg. Journal, are high- ly valuable, and well worthy the attention of the practitioner. Amputation has been had re- course to, but without any benefit, however, in cases, for example, where the little finger, from a mere blow, has, without any externa?le- sion, been followed by severe neuralgic pain, and finally wasted away. Dr. Wigan, in a case of this kind in a lady who struck her little fin- ger against a garden roller, amputated it; but finding the distress continue in two others, am- putated them also, with a like unsuccessful re- sult. Neuralgic pain in every part of the body came on, and the patient died a martyr.—(Pro- ceedings of the Med. Society of London, March, 1845; London Lancet, May 3, 1845, p. 505.) Mr. Crisp proposes, in such cases (lb., loc. cit.), the possible advantage of removing a portion of the nerve, from the remarkable effect known from this kind of operation on the lame foot of horses. According to Mr. Pilcher (Ib.,loc. cit.), the nerves of the organ of sense, as of the eye, may become paralytic by pure concussion, i. e., by a blow, without any ecchymosis or change of structure. M. Dendy, however (lb., !oc. cit.), has known a family, the members of which were so delicate that slight pressure on the surface produced a kind of thrombus. It is difficult, however, to determine how far neu- ralgic and paralytic diseases of the nerves are dependant on the influence of the nervous cen- tres, or on local causes. Surgery, in most such cases, seems to have less resources than in- ternal constitutional treatment and external applications.—(Dr. Townsend’s Velpeau, vol. ii., p. 435.) The cold dash is a powerful remedy in many cases of neuralgia. We lately succeeded in curing two severe cases of sciatica, which had resisted blue pill, belladonna, and the whole routine of ordinary treatment, by turning cold water upon the hip and leg from a pitcher ele- vated some feet above the patient. The great- er the shock the more advantageous did the remedy prove, and the speedier relief did it bring. Dr. La Roche, of Philadelphia, has also succeeded in allaying and completely removing the pain of acute and protracted sciatica, which had resisted various remedies, by the applica- tion of ice over the affected part. Dr. Bell also speaks favourably of the same application. Numerous cases of neuralgia of the face have been cured by extracting decayed or wisdom teeth, a remarkable instance of which is re- corded by Dr. Post, of New-York, in the 6th vol. of the New-York Journal of Med. and Coll. Sciences. ] 117. C. The diet and regimen for neuralgic patients must necessarily depend upon the pe- culiarities, causes, and complications of indi- vidual cases. In most instances, however, regular and abstemious living ; due exercise in the open air; the avoidance of all depressing physical and mental causes; and a pure, dry, and moderately warm air, avoiding all injurious exposures, night air, dews, and crowded as- semblies, are most conducive to recovery, and to the prevention of those recurrences of the complaint to which all are subject who have once been tormented by it. Above all, the pre- disposing and exciting causes ($ 52, et seq.) should be guarded against; the stomach preserved in good humour; and all the secretions and ex- cretions healthily promoted, without being in- ordinately increased, or increased so as to oc- casion debility. In some instances, a course of chalybeate or alkaline mineral waters proves of service, after appropriate medical treatment has ceased ; and when the complaint has been caused by malaria, cold, and other physical in- fluences, these are often extremely beneficial when the state of the digestive organs receives due attention. Bibliog. and Refer.—Aretarus, De Morb. Diuturn.,Iitk i, cap. ii., edit. Boerhaave.—Degener, in Act. Nat. Cur., t. i.—Andre, Observ. Prat, sur les Malad. de Urethre, 8vo. Paris, 1756.— Cotugno, De Isohiade Nervosa, 1770.—Thou- ret, Hist, de la SocietA de MAdecine, t. ii., iv.—Fothergill, Med. Observat. and Inquiries, vol. iii.—/. C. Tode, in Soc. Med. Hann. Coll., t. i.—Van Swieten, Commen. in Apho- rism. Boerhaavii, t. ii., sect. 757.—Murray, Apparat. Medi- cam., vol. iii., p. 17 {Aconite).—A. Pujol, Essai sur la Mal- adie de la Face nomine le Tic Douloureux, 12mo. Paris, 1787.—C. C. Siebold, Doloris Faciei Observationibus illus- trati Adumbratio, 4to. Wirceb., 1795.—J, Girault, Mem. sur la Guerison d’une Sciatique Universelle, 12mo. Bruns., 1800.—P. R. Baily, Essai sur la Neural. Femora-Poplitee, 4to. Paris, 1803.—J. P. Hamel, De la Neuralg. Fac , in Journ. Gin. de MAd, t. xvii.— F. Chaussier, Table Synop- tique de Neuralgies, fol. Paris, 1801.—S. Fothergill, A Concise Account of Tic Douloureux, 12mo. Lond., 1804.— Langenbech, De Nervis Cerebri in Dolore Faciei Consid- eratio, 4to. Goett., 1805.—Corkindale, Edin. Medical and Surg. Journ., vol. iv., p. 306.—Barras, Biblioth. MAd, Dec., 1813.—Pinel, Nosographie Philosophique, t. iii., cl. iv., ord. 3.—A. Portal, Anat. Medicale, t. iv., p. 142.—J. P. Puzin, Observ. sur quelques Faits rares et sur les Neuralgies, 4to. Paris, 1809.—J. L. Duval, Sur quelques Affec. Douleureuses de la Face, 8vo. Paris, 1814.—Rostock, Amer. Med. and Phil. Recorder. New-York, 1814.—Colville, Edin. Med. and Surg. Journ., vol. x., p. 288.—D.Pring, A View of the Relations of the new Syst, in Health and Dis, 8vo. Lond., 1815, p. 111.—Murray, An Essay on Neuralgia. New- York, 1816.—M- Meglin, RAcherches sur la Neuralgie Fa- ciale, 8vo. Strasb., 1816. — Marcet, Med. and Chirurg. Trans, of London, vii., p. 522.—Vaidy, in Journ. Comple- ment du Diet, des Sc. MAd, t. iii., p. 180.—J. Bailey, Ob- servat. on the Use of Belladonna in painful Disorders, 8vo. London, 1818.—C. F. Bellingerir De Nervis et Neuralgia Faciei, 8vo. Turin, 1818.—J. Kirby, Cases with Observat. of Wry Neck, &c, 8vo. London, 1819.—B. Hutchinson, Cases of Tic Douloureux successfully treated, 8vo. Lond., 1820.—Todd, in Transact, of Associat. Apothecaries and Surg. Apoth. of England and Wales, 8vo. Lond., 1823, p. 183.—herrison, London Medical Repository, 1819.—Magri, Lond. Med. and Phys. Journ., May, 1820.—Henry, in Ibid., 1825. —Thompson, Lond. Med. Rep., July, 1822.—R. Evans, in Edin. Med. and Surg. Journ., vol. xxi., p. 278.— Wilson, in Ibid., vol. xix., p. 208.—Schmidlmann, Observ. Med., t. iii., p. 149-182.— Van de Keer, in Journ. Univers. des Sc. Med., t. xxv., p. 64.—Reveillb-Pariset, in Archiv. GenAr. de Med., Dec., 1825.—Lasserre, in Journ. Univers. des Sc. Med., No. 64, art. 14.—Bonnet, Bullet. GAnAr. de Therap., t. v., p. 191.—J. Frank, Praxeos Med. Univers. Proecepta, p. ii., vol. i., sect, ii., cap. 6.—Martinet, Revue Med., t. i., p. 86, 1824; Ibid., t. iv., p. 329 ; Ibid., t. ii., p. 52, 1834.— Bergamaschi, Annali Univer. de Med., 1826.—Bayle, Bibl. de Theran t. ii., p. 280.— Wolff, in Journ. des Progres des Sc. MAd, t. iii., p. 237.—Stokes, Amer. Journ. of Med. Sc., No. xxxiv,p. 496.—Nicod, Nouv. Journ. de MAd, t. iii., p. 247, Ann. 1818 (On Thoracic or Intercostal Neuralgia).— Wardrop, in Trans, of Med. and Chirurg. Society, vol. viii., p. 246. — Marcet, in Tbid., vol. viii., p. 551. — Elliotson, in Ibid., vol. xiii.—Yeats, Hist, of severe Case of Neuralg., 8vo. Loudon, 1822.—L. Martinet, Mem. sur 1’Emploi de l’Huile de Terebinth, dans la Sciatique, 8vo. Paris, 1823. —Ribes, Observ. de Neuralg. du Nerf Facial.—Magendie’s Journ. de Physiol., t. ii., p. 219.—Author, in Lond. Med. and Physical Journ., vol. xlvi., p. 193 ; and London Med. Repos., vol. xvii., p. 374.—Montfalcon, Diet, des Sc. Med., t. xxxv., p. 500.—Andral, Clinique MAdicale, t. ii. and t. v.; and Precis d’Anatomie Pathologique, t. ii.—C. Bew, Opin- ions on the Causes and Effects of Tic Douloureux, 8vo. Lond., 1824.—M. Duparque, in Nouv. Biblioth. MAd, t. iii., 1826. —P. Jolly, in Ibid., t. i. et t. ii.; et Diet, de Med. et Chirurg. Prat., art. Neuralgie.—Abercrombie, Pract. and Pathol. Researches on Dis. of the Brain and Spinal Chord, 6vo, p. 324.— T. Tyrrell, in his edit, of A. Cooper's Lectures on Surgery, vol. ii., p. 407.—C. Scudamore, A Treatise on Rheumatism and Neuralgia, Svo. Lond., 1827.—Brown, in Glasgow Med. Journ., 1828.—Campaignac, Sur les Neuralg. des Organs GAnito-Urinaires et de l’Anus, in Journ. Heb- dom. de MAd, t. ii., p. 396, Ann. 1829.—Bardsley, Hospital Reports, 8vo. Lond., 1830, p. 101.—T. P. Teale, A Trea- tise on Neuralgic Diseases, &c, 8vo. Lond., 1829.—Rev., in Johnson's Med. and Chirurg. Rev., No. xxiii, p. 112.— G. Strombio, Giorn. Analitico di Med. Milano, Setternb., 1828.— Barras, Traits sur les Gastralgies et les Enteralgies, 8vo. Paris, 1829, 2d edit., 2 tomes.—J. Macculloch, An Es- say on Remittent and Intermittent Diseases, including gen- erally Marsh Fever and Neuralgia, Ac., and treating of Tic Douloureux, Sciatica, Headache, Ophthalmia, Toothache, Palsy, aya, is but seldom inflamed or congested with blood I compared with other parts of the digestive I canal, unless consecutively upon eruptive dis- eases, particularly scarlatina. It is generally injected or congested with black blood in rabies, especially its upper portion. It is sometimes thickened either generally or in parts. Its folli- cles are occasionally enlarged and apparently congested and obstructed, particularly in young subjects and in mucous or gastric fevers. Ve- getations or excrescences, of various sizes and forms, have been found to shoot from it, nar- rowing the passage and most seriously ob- structing deglutition. Cases of this descrip- tion are mentioned by Schneider (in Haller’s Collect. Dissert., viii., No. 258), Dallas and Monro (Edin. Essays and Observ., v. iii.), and Baillie. Ulcers are, perhaps, less frequently observed in this part of the digestive tube than in any other. I have, however, met with sev- eral cases of this lesion, which is not infre- quent in children. Ulcers in this situation have been described and delineated by Sandifort {Museum Anatomicum, tab. civ., tig. 3) and Baillie {Series of Engravings, &c., fasc. iii., pi. 3 and 4); but notwithstanding that Brunner had described ulceration of the oesophagus as commencing in its mucous follicles, this form of ulceration has been overlooked by those pathologists. I shall, therefore, notice this le- sion more fully in the sequel. Agglutination of the opposite parietes of the oesophagus, by coagulable lymph thrown out upon its mucous coat, has been said to have been found in a fatal case of smallpox (Bartholinus, in Act. Hafn., t. i., obs. 109). This is, however, an extremely rare occurrence. Exudations of lymph, forming a false membrane upon the mu- cous surface of the canal, is not rare, and is found generally in the upper part of it, in cases where this exudation is thrown out over the tonsils and pharynx (see (j 23). [Dr. Gross states {Path. Anat., 2d ed., p. 534) that he examined, in 1838, the stomach and oesophagus of a boy, 13 years old, who sud- denly expired in convulsions after an illness of three days. The patient complained of severe pain in the fauces, and had great difficulty of swallowing; every attempt of the kind being followed by spasm of the throat, especially when the substance was of a fluid nature. On inspecting the oesophagus, it was found lined throughout with a thin layer of lymph, closely adherent to the natural mucous coat, which was itself highly injected, and of a bright red colour. The stomach was perfectly sound, the inflammatory appearances terminating abruptly at the cardiac orifice. The adventitious mem- brane was also traced around the mouth of the larynx, and over the whole of the fauces. Dr. G. states that these membranes rarely become organized. When the inflammation subsides, they gradually lose their moisture, together with their adhesive properties, and are either vomited up in small tubular fragments, or swal- lowed and digested, or passed by stool. Andral relates an instance where an exudation of lymph lined the oesophagus of a new-born in- fant for about a third of its extent.—{Loc. cit.)] 5. £. The sub-mucous cellular tissue of the canal is sometimes inflamed or congested, in the same circumstances as those just mention- ed : infiltrations of serous, sero-puriform, or sanious fluids are also observed in it as conse- quences of inflammation. It may also become thickened and indurated, particularly after pro tracted inflammatory irritation. It may be transformed into a fibro-cartilaginous substance, or into scirrous structure, thereby narrowing, even nearly to complete obliteration of the tube. Instances of scirrous degeneration of the tube passing into the ulcerative or carcinoma- tous state are not rare, especially in the extrem- ities of it; but simple thickening and induration caused by chronic inflammation have often been mistaken for scirrus. Transformation 1042 OESOPHAGUS—Inflammation of the. of a portion of the tube into a cartilaginous state has been observed by Morgagni, Haase, and others. This canal may be partially or entire- ly obstructed also by abscesses formed in its parietes or even exterior to them ; or by the growth of tumours in its vicinity : thus slowly increasing difficulty of swallowing attends upon aneurism of the aorta, or upon a mass of ob- structed lymphatic glands pressing upon the oesophagus. Bleuland has seen this effect produced by exostosis of the body of a vertebra. The dysphagia, however, Which proceeds from these causes is seldom so urgent or distressing as that which depends upon disease of the coats of the tube. 6. d. Softening and attenuation of the oesoph- agus are occasionally met with, and these states may even go on to spontaneous perforation, presenting all the anatomical characters which this lesion evinces in the stomach. Gangrene of the tube is very rare. I agree with M. An- dral in considering the majority of cases of this occurrence recorded by authors as pulpy softening of the part, which is not uncommon in infants and children. It, however, some- times occurs, especially near the pharynx in malignant scarlet fever. 7. e. Perforation of the oesophagus generally is followed by effusion into the thorax. M. Andral states that the perforation in all the recorded cases has taken place in the thoracic portion of the canal near the cardiac orifice ; and the surrounding part of the parietes has sometimes been found altered and softened, and at other times without any appreciable al- teration. There are, however, cases on record in which the perforation had taken place about the middle and upper part of the tube. The perforation in a case attended by me was above the middle of it; and similar instances are pub- lished by Kade (De Morbis Ventriculi, &c., Hala;, 1798), and by Reil (Memorab. Clin., fasc. i., p. 13), who met with it in cases of typhus fever. 8. Perforation of the oesophagus occurs at all ages. M. Veron met with it in an infant just born. M. Guersent observed it in a child of seven years of age. M. Bouillaud found it in an adult, in whose stomach four perforations also existed. I have seen it in a child. It oc- curs more frequently at the periods of infancy and childhood than at any other. In some cases, the perforation is stopped by the aorta or trachea, so that no effusion takes place. In other cases, a double perforation occurs, and the canal of the oesophagus communicates with that of the trachea or even of the aorta. In- stances of the communication of the oesophagus with the trachea in this manner have occurred to Zeviani (Memoric de Fisica di Verona, X. vii.), Monro (Morb. Anat. of the Gullet, &c., 8vo, 1830, p. 373), and to myself. In the majority of cases of perforation, the ulceration appears to commence in one of the follicles (see $ 37). 9. /. Purulent and tubercular matters have sometimes been found underneath the mucous membrane of the oesophagus. Albuminous ex- udations also form, either in patches, or to such an extent as to form false membranes, as al- ready noticed (§ 4, 23). M. Guri found a lay- er of whitish firm matter adhering closely to the mucous surface in a new-born infant; and Hjldenbrand states that its formation is not infrequent, but that it generally separates and passes into the stomach, being rarely excreted upward. This agrees with what I have ob- served in some cases of epidemic croup and scarlet fever. 10. g. Dilatation of the gullet seldom occurs unless, as remarked by Portal (Anat. Med., t. v., p. 204), from stricture of the cardia and of parts of the tube below the dilatatipn. In some cases the dilated part forms a large sac, a por- tion of which falls lower than the seat of stric- ture, constituting a kind of diverticulum. Ca- ses of this description have been noticed by Isenflamm and Sandifort (Med. Anat., t. i., p. 242). 11. h. Polypous excrescences have been found shooting from the internal surface of the gullet, narrowing the passage and obstructing degluti- tion, but they occur less frequently in this situ- ation than in the pharynx. They present the same appearances as in other situations, and have been noticed by Pringle, Monro (Edin. Essays and Observ.,vol. iii.), Baillie, Graeffe, and Schneider (see Haller’s Coll. Dissert., vii., No. 257). They often grow from a pedi- cle sufficiently long to permit of their rising into the pharynx upon efforts to vomit. 12. i. Cartilaginous and osseous degeneration of the oesophagus are observed in rare instan- ces, and generally confined to a small portion of the tube, forming a kind of ring. Gyser (De Fame Lethali ex Calloso (Esophagi Angus- tia, 4to, Argent., 1770) found a cartilaginous ring restricting the canal, so as to prevent the passage of a sound. Similar cases have been recorded by Becker, Bang, Baldinger, Andral (Anat. Pathol., t. i., p. 276), and others. Carti- laginous degeneration of the gullet in its whole extent has been said to have occurred to Sampson (Miscell. Curios., &c., Ann. 1613), Garnia (Morgagni, De Sed. ct Caus. Mori., epist. xxviii., 15), and Desgranges (Journ. de Boyer et Corvisart, &c., t. iv., p. 203). Os- seous and cretaceous deposites are also very rare- ly met with in the parietes of the gullet. In- stances, howmver, have occurred to the elder Monro, Abrahamson (in Meckel’s Archiv., b. i., st. iii., p. 16), and to Walther (Mus. Anat., b. i., No. 278). 13. k. Rupture of the oesophagus has been very rarely observed. Instances of its occur- rence after vomiting and muscular efforts have been published by Boerhaave, Zeisner (Disser. de Raro (Esophagi Mo) bo. Regiom., 1732), Sedil- lot (Recueil Periodique, t. vii., p. 194), Meier (Baldinger’s Magazin, b. iii., p. 399), Guer- sent (Bulletins de la Faculte de Med., Z. 1), by Bouillaud (Archives Gindr. de Med., t. i., p. 521), and by Mr. W. King (Guy's Iiosp. Rep., pan. xv). In all these the parietes of the oesoph- agus have been either ulcerated, rupture taking place in the seat of ulceration, or softened and attenuated in the manner already described ((>4). II. I NF LAMM ATI ON OF THE (ESOPHAGUS. — SYN. (Esophagitis ; Inflammatio (Esophagi ; Inf Gulce, Auct. (Esophagite, Fr. Entziindung der Speiserdhre, Germ. Classif.—III. Class, I. ORDER(AM^ior). 14. Defin.—Pain between the shoulders, or be- hind the trachea or sternum, augmented by deglu- tition, which is rendered more or less difficult oi even impossible, with symptomatic fever, &c. 15. Inflammation of the oesophagus occurs (ESOPHAGUS—Inflammation of the—Causes—Symptoms. 1043 more frequently in a complicated and consecutive, than as a simple and primary disease. It varies as to its intensity and form or character, and as to the particular tissues of the canal in which it may occur. It may be acute, sub-acute, or chronic; it may be limited to the mucous sur- face, or it may extend to the more external coats, through the medium of the connecting cellular tissue ; it may even affect only the mu- cous follicles of the canal, the internal mem- brane being either entirely exempt, or affected only in the immediate vicinity of the follicles. 16. A. Causes.—a. (Esophagitis is most fre- quent during infancy and childhood, but it is occasionally also observed during middle and advanced age. Long-continued and severe dyspepsia, constipation, the abuse of spirituous liquors, the habit of wearing too warm clothing around the neck and throat, the use of tightly- laced corsets, the strumous diathesis, and san- guine and plethoric habit of body, predispose to it. 17. b. The exciting causes are chiefly those physical agents which act directly upon the canal, and diseases of adjoining organs or parts which extend to it, either in their course, or upon their disappearance in their original seats. The former are draughts of cold fluids, or the ingestion of ices, while the body is overheated or perspiring; the deglutition of too large a mouthful, or of too warm fluids or substances ; or of hard, irritating bodies ; the abuse or in- cautious use of irritating medicines, as iodine, squills, ammoniacum, ammonia, &c.; exposure of the neck and chest of females ; the use of highly-seasoned or spiced articles of food ; the accidental or intentional ingestion of acrid or corrosive poisons, as the mineral acids, the bi- chloride of mercury, preparations of arsenic, &.c. ; acrid and septic animal poisons, particu- larly those developed in preserved or smoked meats, mushrooms, &c. ; and the injudicious exhibition of acrid emetics. (Esophagitis is often caused in young children by sore nip- ples, and by an unhealthy state of the milk of nurses. 18. This disease may also occur upon the disappearance of cutaneous eruptions, or after the suppression of accustomed secretions and discharges. It may appear in the gouty or in the rheumatic diathesis, and thus assume a modified form ; but it is very rarely a conse- quence of suppression or metastasis of either of these diseases. It most frequently occurs during the progress of some diseases, and as a sequela or extension of others, particularly of eruptive fevers, aphthae, erysipelas, pertus- sis, inflammatory affections of the fauces and pharynx, and of the internal surface of the stomach. 19. (Esophagitis is, moreover, not only caused by, but also often complicated with, one or oth- er of the foregoing diseases, particularly scar- latina, smallpox, erysipelas, aphthae, gastric and mucous fevers, inflammation of the fauces and pharynx, or inflammation of the stomach. In nearly all these associations the inflamma- tion of the oesophagus is a consecutive affec- tion ; but, although arising from the extension of the inflammatory action, chiefly by continui- ty of surface, it is not the less important as re- spects its consequences. Inflammation of the internal surface of the oesophagus may also be complicated with spasm of some part, or of the whole of the canal. In this case, the irritabil- ity of the muscular coat of the tube is so inor- dinately increased in consequence of the in- flamed and sensible state of its mucous sur- face, that it becomes spasmodically and pain- fully contracted upon the passage of substan- ces along it. The disease is also occasionally complicated with chronic laryngitis, this latter affection being consecutive upon the former. A case of this description lately came before me. The laryngeal affection, which, owing to the paroxysms of suffocation and cough accom- panying it, was the prominent complaint, and attracted the chief attention, was removed after the treatment had been appropriately directed to the primary disease. 20. ii. Svmptoms.—A. Of Acute Oesophagitis. —Pain in some form or other is always com- plained of, and is usually accompanied with a sensation of heat. It extends in general be- hind the trachea, from the middle of the throat to between the shoulders, and the ninth dorsal vertebra. This burning pain varies in degree, is sometimes chiefly felt about the bottom of the pharynx, and behind the glottis; at other times, behind the sternum and xyphoid carti- lage ; and is occasionally accompanied with the sensation of a foreign substance in one of the above situations. In some instances the pain is dull and slight, and in others attended by the feeling of a cord extending in the course of the canal. In all cases, the pain or uneasy sensa- tion is greatly augmented by deglutition ; so much so, on some occasions, that the patient either obstinately refuses to swallow, particu- larly liquids, or experiences an instant regur- gitation of them. Sometimes, in the more acute cases, the matters thus thrown up are ejected forcibly through the nose, or irritate the glottis so as to occasion violent and suffo- cative fits of coughing. Independently of the regurgitation of matters attempted to be swal- lowed, there is frequently an expuition of a glairy fluid, secreted from the pharynx and tip- per part of the oesophagus. The patient is gen- erally tormented with thirst and singultus. This latter symptom is seldom wanting when the lower part of the tube is inflamed. In this case, the more consistent substances which are swallowed are arrested by spasm of the in- flamed part, occasioning great pain, generally referred to the space between the shoulder blades, and are afterward ejected or vomited, with a considerable quantity of mucus, some- times streaked with blood. 21. In children, oesophagitis, in its more acute states, is not infrequent, particularly du- ring infancy ; and in them the diagnosis is dif- ficult'. The child generally refuses drink, or drinks little, cries, and regurgitates the inges- ta. Hiccough is almost constant, and frequent- ly vomiting, which does not often occur in the adult from this disease. When the milk is thrown up unchanged, we should always sus- pect the existence of inflammation of the oesophagus. 22. Besides the foregoing, there are also many of the usual signs of symptomatic fever, generally of the inflammatory type, but fre- quently of a remittent form. The tongue is red at its point and edges, sometimes through- out ; at other times it is loaded and furred in 1044 (ESOPHAGUS—Inflammation of the—Terminations. the middle and base. The fauces are red and injected, or natural; the uvula is generally re- laxed. The bowels are confined ; the urine scanty and high-coloured. 23. iii. Terminations.—Acute inflammation of the oesophagus may terminate (a) in resolu- tion ; (4), in suppuration ; (c), in softening of the coats of the canal, or (d), in gangrene, or (e), it may pass into a chronic state of disease. —A. Resolution takes place generally W'ith a gradual subsidence of the acute symptoms, and a more copious discharge of mucous or muco- purulent fluid ; or with critical evacuations, as hypostatic urine, copious perspiration, &c. It occurs chiefly on the fifth, seventh, ninth, or eleventh day ; and occasionally with the exu- dation of an albuminous substance, the dis- charge of which disposes to a resolution of the inflammatory action. This substance is secre- ted on the internal surface of the tube, as in croup, forming a false membrane, sometimes extending upward to the pharynx and fauces. As the inflammation subsides, this false mem- brane is thrown off from the mucous surface, the secretion of the mucons follicles gradually detaching it from its adhesions to this surface, and it is passed with the ingesta into the stom- ach. 24. B. Suppuration sometimes occurs in one or other of two forms : 1st. The purulent mat- ter may be discharged, in consequence of vio- lent inflammation, from the whole internal sur- face of the tube ; this, however, seldom takes place unless oesophagitis is occasioned by very irritating ingesta. I was called some years ago to a case of this description by a practi- tioner in Westminster. The patient, a robust young man, had attempted to poison himself with laudanum. In order to procure the evac- uation of the poison, a considerable quantity of mustard, mixed with warm water, was exhibit- ed. This produced full vomiting, after the other means had failed. Inflammation of the oesophagus, however, in its most distressing form, supervened, and in the course of two or three days was followed by a most copious and entirely purulent discharge regurgitated from the oesophagus. The quantity discharged be- tween each visit, and collected in the vessel, was surprising. He nevertheless recovered, and without any affection of the nervous sys- tem, as is often observed after poisoning from opium. 2d. Suppuration more commonly oc- curs when the inflammation attacks a part only of the tube, and implicates all its coats. A dis- tinct abscess usually forms in this case, most frequently in the cellular tissue connecting the mucous with the muscular Coat. It occurs in neglected cases of the disease, and in scrofu- lous habits ; and is generally indicated by the complete stop put to deglutition, by great thirst, excessive pain, and by a sense of fulness, and of pulsation in the situation of the oesophagus. In most of the cases on record the abscesslias burst into the canal, either spontaneously upon efforts at deglutition or vomiting, or upon in- troducing a bougie or probang along the pass- age ; and the patient has obtained instant re- lief. Interesting cases of this description have been published by M. Bourguet (Gazette de Santi, 1823, p. 221), and by M. Barras (Archives Gen. de Med., t. x., p. 134). Recovery general- ly takes place rapidly after the matter is dis- charged ; it either passes into the stomach or is ejected upward. 25. C. Gangrene occasionally terminates in inflammation of the oesophagus, but not so often as is stated by some writers. It occurs chiefly after oesophagitis complicating scarla tina, or following that disease, in which cir- cumstances I hare observed it on several oc- casions, generally, however, associated with gangrenous pharyngitis. I have, likewise, seen it after oesophagitis caused by poisonous in- gesta, particularly the animal poison generated in preserved or spoiled meats. Although it may commence previously to dissolution, yet the morbid appearances usually described as constituting this change are somewhat increas- ed after death. When the inflammation ter- minates, the sphacelus is chiefly confined to the internal surface of the tube, which presents more or less, along its whole extent, soft, tu- mefied patches, of an irregular form, of a dark gray or slate colour, and emitting a peculiar foetid odour. 26. The symptoms indicating this change du- ring the life of the patient are not always man- ifest. Two cases of this mode of termination, occurring independently of poisoning, and of complication with scarlatina, have come be- fore me in practice, and were recognised du- ring life, and verified by an examination aftei death. The one occurred in a child, the other in an aged female. In both, great tumefac- tion and tenderness of the lateral and anterior parts of the neck ; a deeply-incrusted tongue, with a dark sordes ; a feeble, small, unequal, and intermittent pulse ; singultus, and fre- quent foetid eructations ; great prostration of strength, with leipothymia, and cold clammy perspirations, were remarked. There was no vomiting ; but in one of tire cases a small quan- tity of an offensive, sanguineous mucus was occasionally regurgitated upward shortly before death. 27. D. The changes of structure most com- monly observed in fatal cases of acute oesopha- gitis are injections in patches, striae, or gen- erally of the mucous surface, with partial de- struction of its epithelium, particularly in in- fants. This surface is usually reddened, the tint, however, varying from a rose hue to a reddish-brown. The mucous membrane is commonly tumefied, its subjacent cellular tis- sue thickened, injected, infiltrated with a se- rous or sero-puril’orm or sanguineous fluid, and both the one and the other softened and more easily torn than natural. Sometimes they are reduced to a nearly pulpy state, and are of a reddish-brown or purple colour. The sub- mucous cellular tissue sometimes presents mi- nute collections of a puriform matter, which elevate the internal surface into pustular em- inences. The whole parietes of the canal are softened, sometimes (Edematous, injected with blood, and more lacerable than usual. In rare cases, purulent collections form exteriorly to the muscular coat. Ulceration seldom occurs after this state of inflammation : it is more fre- quently met with after that hereafter to be de- scribed. When, however, it does occur, the ul- cerated part generally varies in size and in depth, the parts in its immediate vicinity being very much softened, inflamed, and somewhat thickened or tumefied. (ESOPHAGUS—Stricture of the. 1045 28. E. The changes produced in the oesoph- agus after the ingestion of strong acids are generally of a disorganizing nature in the more vapidly fatal cases. The mucous surface is eroded, and of a brownish, or brownish-black hue, and the tube generally more or less con- stricted. The erosion or partial solution of the internal surface sometimes extends to the connecting cellular tissue, so that the muscu- lar coat may be readily denuded, as by rubbing a sponge firmly along the exposed surface. 29. iv. Sub-acute and Chronic (Esophagi- tis.—A. The less active forms of the disease are more.frequent than the acute. They may take place primarily, or they may be the conse- quences of neglected, or partially subdued states of acute oesophagitis. Many of the slighter cases that have occurred primarily never come before the physician until organic changes se- riously interrupting the process of deglutition have taken place.—a. The slight or chronic states of oesophagitis are characterized chiefly by the same symptoms as characterize the acute form (§ 20), but in a milder degree ; by soreness and tightness under the sternum, or between the scapulae ; the discharge of a ropy fluid, or acrid eructations ; sometimes rumi- nation after a full meal, by a hawking or short cough, or frequently hawking or spitting, by a weak, irritable pulse and emaciation ; and sometimes by obstinate dyspepsia and costive- ness. 30. 1. The chronic states of the disease are generally caused by previous disorders, partic- ularly by inflammatory or neglected dyspepsia, inflammations of the internal surface of the stomach, by eruptive fevers, and inflammation of the fauces or pharynx ; by the acute states of the disease, and by the causes producing these states. 31. c. The milder or more chronic states of oesophagitis terminate in resolution, or in some one or more of the organic lesions described in another section of this article, or in thickening and induration of the parietes of the canal, gen- erally with some degree of stricture, and in ul- ceration. 32. B. Thickening and induration of the parietes of the oesophagus sometimes take place after repeated attacks of inflammation, but generally after chronic inflammation, oc- curring either in its primary form, or consecu- tively on the acute state. Thickening of the parietes is usually accompanied with narrow- ing of the passage, forming permanent stric- ture or obstacle to the passage of the ingesta into the stomach. This change may affect the whole of the canal in a greater or less degree, or it may be limited to any one part of it.—a. The circumstances which especially favour this termination are, inefficient modes of cure ; the taking of stimulating food too soon after the acute stage of disease has been subdued ; the injudicious use of astringent and tonic medieines, particularly gargles, which have been suggested by the state of the fauces and uvula that I have described as frequently ac- companying the different states of the disease ; and the strumous diathesis. But I believe that the most frequent cause of this lesion is the use of ardent spirits, as has been proved by the observations of Michaelis (Hufeland und Him- a,y, Journ. der Pr. Heilkunde, 1812, p. 52). This state constitutes the permanent organic stricture of Doctor Monro, and is ably illustrated in his work on the morbid anatomy of the digestive tube. 33. 1. The symptoms of thickening of the parietes, with stricture of the oesophagus, are the continuance of dysphagia after the decline of the more acute symptoms ; dyspnoea, obscure pain, soreness, and a sense of tightness in the course of the oesophagus ; sometimes the dis- charge of a very tenacious mueus; impaired digestion, despondency, costiveness; and feb- rile exacerbations. In some cases, a gurgling sound is heard upon attempts at swallowing fluids, and a portion of them is regurgitated, exciting a choking cough. The deglutition of more solid substances is slow, difficult, and painful. The patient often feels the substance lodged some time in the canal; and, afterward, as if forcibly thrust through a narrowed passage. When the stricture is seated low in the canal the portion above it is often very much dilated, forming a sac in which the ingesta lodge, and whence they are afterward partly regurgitated and partly pass into the stomach. In thickening of the parietes of the oesophagus and permanent stricture, fluid substances are more readily swal- lowed than those possessed of some degree of consistence ; while in spasm of the oesophagus, fluids pass with greater difficulty and distress to the patient. 34. c. Permanent stricture of the oesophagus, although generally resulting from inflammatory action of the kind now described, may occasion- ally also proceed from a different cause. It may, although rarely, arise from scirrous degen- eration, or from tumours of a jibro-cartilaginous nature developed in the parietes of the tube I believe, however, that a great proportion of the cases which have been said to be scirrus of the oesophagus have been only the simple thickening and induration resulting from chron- ic inflammation. Permanent stricture of this passage may also result from the enlargement of, and pressure upon the tube, occasioned by a cluster of enlarged lymphatic glands. This is, however, a rare occurrence, and is chiefly met with in childhood and early life, in those of a strumous diathesis, and in whom the sub- maxillary, and other superficial glands, are tu- mefied ; while scirrous degeneration occurs at an advanced age, and is attended by appearances of the scirrous cachexia. The dysphagia ari- sing from the pressure of tumours exterior to the tube is seldom or never so urgent as that which depends upon narrowing of the passage from change of the parietes themselves. The pressure on the oesophagus produced by aneu- rism of the aorta, even shortly before its open- ing into this canal, seldom occasions very mark- ed difficulty of deglutition. This distinction has been judiciously remarked by Mondiere, and is based on the cases recorded by MM Bertin, Laennec, Bouillaud, Raikem, Ouv- rard, and others. This canal may also be partially obliterated from increased thickening —a hypertrophy of the mucous membrane itself, which is also as if puckered or drawn together. In the majority, however, of such cases, there is permanent constriction also of the circular muscular fibres of the part affected. 35. Permanent stricture of the oesophagus, whether proceeding from inflammatory thick- 1046 ening and induration of its coats, from scirrous or other formations, or tumours developed in the parietes of, or external to the tube, may be seated in any part of the tube, either at its commencement in the pharynx, or in any inter- mediate portion between this and its termina- tion at the cardia. Sir E. Home thinks that it occurs most commonly in the former situation ; but, although this may perhaps be, upon the whole, the part most frequently affected, the other parts are also not unfrequently the seat of this change. It is, however, generally re- marked that, even when the disease is confined to the lower portion of the tube, many of the more urgent symptoms are often referred to the lower part of the pharynx and top of the oesophagus. 36. d. The Diagnosis of permanent stricture of the oesophagus is somewhat difficult. This lesion may be confounded with spasm of the tube, with inflammation of the internal surface of the canal, with disease of the cardiac orifice of the stomach, or even with affections of the larynx and trachea ; or these maladies may be mistaken for stricture of this tube. The per- manence of the symptoms, generally attributed to this stricture, would serve to establish the existence of it in doubtful cases, if such per- manence were always observed ; but Heineken, Leroux, and others have noticed marked re- missions in the symptoms of cases of this lesion. In these cases, the exacerbations have been owing to more or less of spasm attending the permanent stricture. Indeed, when diffi- culty of deglutition occurs in any of the diseases just mentioned as simulating permanent stric- ture of the gullet, it is generally owing to spasm. In some diseases of the larynx, or of the stom- ach, spasm may occur in the gullet* as in the case recorded by Mr. Shaw (Lon. Med. and Phys. Journ., vol. xlviii., p. 185). When difficult deg- lutition is observed in affections of the stomach, or of adjoining parts, and even in consequence of tumours in the vicinity of the tube, it gen- erally is either owing to, or aggravated by flatus rising into this canal from the stomach, the flatus occasioning both obstruction to the de- scent of the matters swallowed and spasm in parts of the tube. The chief diagnosis, there- fore, between permanent stricture of the gullet and other affections is thus actually between the former and spasm of the parietes of the tube. Permanent stricture is generally consequent upon inflammation, and is slowly and gradually progressive, until deglutition is impossible. When it is far advanced, the difficulty of swal- lowing is more or less permanent, although ex- acerbations are remarked in some cases. The difficult deglutition which is occasioned by spasm, and is sometimes caused by disease of adjoining parts, occurs chiefly in hysterical and hypochondriacal persons, and in nervous and delicate constitutions. When the difficulty is caused by the pressure of scrofulous or enlarged lymphatic glands, this circumstance is generally rendered apparent by the state of the neck and throat, and by the appearances and sounds in percussion, near the top of the sternum and sternal ends of the clavicles. 37. C. Ulceration of the (Esophagus may occur in consequence of inflammation of its in- ternal surface, in one of two forms; namely, ulceration commencing in the mucous follicles, OESOPHAGUS—Ulceration op the. and ulceration of the mucous and sub-mucous cellular tissue unconnected with change of the state of those glands.—a. It has been consider- ed doubtful whether or no the ulceration, which is seated in, and proceeds from a particular change of the follicles, is actually a consequence of inflammation. It is very probable that ob- struction of those glands may give origin to ul- ceration, and that the inflammatory irritation either preceding or accompanying the ulcerative process may be very slight—and possibly of an unhealthy description. I believe, from several instances which have occurred to me among children, that such is the case, and that neither the local appearances nor their causes, nor the attendant circumstances and phenomena, are such as mark sthenic action, or energetic vital endowment. This form of ulceration was first noticed by Brunner (De Glandulis Duodeni, cap. x., p. 136), as occurring in the oesophagus ; and I believe that it occasionally proceeds to perforation of the tube, and affects most fre- quently its lower part, while the next form of ulceration is more commonly found in its upper portion. 38. b. Ulceration which takes place independ- ently of the follicles, I consider to be more de- cidedly a result of inflammatory action than the foregoing variety. The procession of phe- nomena in cases of this description appears to be the following: The inflammation of the mucous surface often implicates more or less of its subjacent cellular tissue, and a serous or sero-puriform fluid is effused in distinct points, elevating, in the form of pustules or minute blisters, the mucous tissue, the detached por- tions of which lose their vitality and separate, leaving an excoriated or ulcerated spot, which extends in width and depth, according to the habit and temperament of the patient, to the cause in which the disease originated, and to the treatment employed. Ulcerations of this description, as well as the preceding, are most commonly met with among infants and young subjects, and are frequently connected in them with softening of the coats of the tube. When ulceration occurs in adult subjects or in persons advanced in life, it is generally accompanied with, if not consequent upon, either thickening or narrowing of the parietes of the oesophagus, or both; and it is usually seated in the part above the constriction, excepting in scirrus of the tube, when the narrowed portion itself often becomes ulcerated, and in this case carcinoma- tous. But it sometimes is met with independ- ently of either thickening or induration of the parietes of the tube. Ulceration from inflam- mation of the internal coats of fche oesophagus is very seldom seated in several different parts of its surface in the same case, the ulcers of this description being never so numerous as those commencing in the follicles, and rarely exceeding one or two. This kind of ulcer most frequently attacks the upper portion of the canal, and extends from three to eight or nine lines in width. M. Scoutetten met with a case in which the ulcer was twelve lines in diameter, and had destroyed all the coats of the posterior part of the tube, and had even laid bare the an- terior part of one of the vertebrae. Generally, when the ulcer is large, one only is found. Sir Everard Home thinks that the posterior part, or that applied to the vertebrae, is more usually (ESOPHAGUS—Ulceration of the—Symptoms. 1047 the seat of ulceration; but this is not satis- factorily shown. There can be no doubt that this form of ulceration occurs more frequently in the upper part of the tube, while the ulcera- tion which originates in the follicular glands is more usually found at its lower part, and is more generally consequent upon eruptive fevers and febrile diseases, particularly those charac- terized by depressed energies of life. Ulcer- ation of the oesophagus may occasion ulterior effects of a very important character, previous to its usual termination in death. A case, to which I shall more particularly allude, occurred to me where it occasioned a fatal haemorrhage. And Dr. Monro mentions a case where the ulcer penetrated the trachea and occasioned death, by the escape of matter from the oesophagus into the trachea. A similar case I have already noticed as having occurred to Zeviani, and another has been seen by myself. Rupture, as well as perforation of this tube, may also be oc- casioned by ulceration. 39. c. Symptoms.—When the ulceration is seated in the anterior and superior portion of the oesophagus, posterior to the larynx and trachea, many of the symptoms of laryngitis and tracheitis are observed. An interesting case of this description is recorded by Paletta (Exercitat. Patholog., p. 228). Ulcers in the oesophagus are generally accompanied with many of the symptoms which attend simple in- flammation of this tube. The pains, however, are usually more acute, particularly upon deglu- tition ; sometimes there is vomiting of a glairy matter, generally streaked or coloured with blood. Solid substances are swallowed with difficulty, but fluids, when taken in considera- ble quantity, pass with more ease. Salivation often occurs during the last stage of the dis- ease. M. Mondiere mentions a case in which a large ulcer of the oesophagus was seated near the cardia, and where the patient, during the four months he was under treatment, complain- ed of a burning sensation at the superior part of the epigastric region. This patient frequent- ly rejected rounded and purulent matter, a symptom noticed both by Paletta and Leroux. In some rare cases, the ulceration may give rise to sudden death from haemorrhage. A case of this description occurred to me a few years ago in an aged female who had been under my care for several years for disorders of the di- gestive organs, accompanied w'ith psoriasis. A few days previous to her death she was affect- ed with oesophagitis complicated with pharyn- gitis, and attended by a constant hacking cough, and great depression of the powers of life. I was suddenly called to her about the eighth or ninth day of the attack for sudden and profuse discharge of blood, which was described as hav- ing been ejected upward without evident effort; but before 1 reached her she had expired. The quantity of blood thus discharged was very con- siderable. Upon examination, the stomach contained about a pint and a half of blood part- ly coagulated, and its coats, particularly the mucous coat, were considerably softened. The pharynx was of a dark colour, in patches, some of which were of a purplish tint. In the upper third of the oesophagus, towards its anterior parietes, upon the left side, was a large irregular ulcer, which had destroyed, in some points, the muscular coat, and in all, the mucous and sub- mucous tissue. The internal surface of this part of the tube, particularly around the ulcer, was of purple hue, tumefied, soft, and easily torn. The bottom of the ulcer was of a deep red colour, and the subjacent parts red, vascu- lar, and injected. The haemorrhage had most probably arisen from erosion, by ulceration of some of the small vessels. 40. Ulceration, perforation, and rupture, in consequence of ulceration of the parietes of the oesophagus, are generally followed by death with more or less rapidity; and, until shortly before death, the patient may not have come under treatment, either from the slightness 01 neglect of the symptoms. Instances have even occurred in which sudden death has taken place, the patient not having had recourse to medical advice, and, upon dissection, a large perforating ulcer has been found in some part of the tube. In a case of this kind which I saw, the ulcer was seated a little above the cardia. [A case of cancer of the oesophagus, opening into the right lung, has been recently reported by Dr. Jackson in the New-Eng. Quarterly Jour, of Med. and Surg., Oct., 1842, p. 253. The pa- tient was a female, 53 years of age, and for the last 8 or 10 she laboured under difficult deg- lutition, with regurgitation of food, but with- out pain or nausea. The skin was sallow, and the body quite emaciated. Latterly, she had haemorrhage from the bowels, and shortly be- fore death was seized with acute pulmonary symptoms. The disease was found to have commenced two inches and a half above the in- ferior extremity of the tube, extending upward in front 1 j of an inch, and behind 2J- inches. The cavernous surface was ulcerated, soft, rag- ged, and of a whitish aspect, not unlike enceph- aloid. The cut edge exhibited no trace of the original structure. At the centre of the dis- eased mass, on its anterior surface, was a per- foration through into the substance of the right lung, which was gangrenous at this part. The descending aorta adhered to the altered por- tion of the tube, and had upon its outer sur- face, near this point, an apparently malignant deposite.—{Gross.) See an interesting case of stricture and ul- ceration of the oesophagus by Dr. Francis, in the Transactions of the Literary and Philosophi- cal Society of New-York, vol. i.] 41. Scirrous ulceration, or carcinoma of the oesophagus, most frequently occurs either at the upper or the lower extremity, more fre- quently extending from either the pharynx or the cardiac orifice of the stomach, than affect- ing the tube primarily. It rarely or never ap- pears without being attended by the lancinating and burning pains, and the carcinomatous ca- chexia characteristic of this disease. 42. d. The prognosis of inflammation and per- manent stricture of the gullet should necessarily depend upon the causes, progress, complica- tions, and severity of the disease. Acute and sub-acute oesophagitis, in which the prognosis is generally more favourable than in the chronic state of the malady and in permanent stricture, should be viewed as a most serious disease, as respects either its more immediate results, or its contingent consequences; and it is still more so when it occurs in cachectic habits and in the course of exanthematous and continued fevers. When it is caused by powerful stimu- 1048 lants or irritants calculated to produce a local effect merely, without directly disorganizing the parts, or remarkably depressing the vital power, it is generally removed by appropriate means ; but when it is caused by agents which occasion these injurious effects, and which even extend from thence to adjoining parts, the prognosis should be very unfavourable. When the symptoms indicate the passage of the acute or sub-acute into the chronic disease, a cautious, if not an unfavourable opinion ought to be form- ed of it; and when they indicate the superven- tion of stricture or of ulceration with or without stricture, the prognosis should be very unfa- vourable, although the result may be long de- layed. The history of the case, the previous health and present state of the patient, and the effects of treatment, ought always to be duly estimated in the opinion which is to be formed as to the result. 43. v. Treatment.—A. Of acute (Esophagitis. —a. General and local bleeding is indispensable in this state of the disease. Bleeding from the arm should never be neglected; and afterward local depletion may be employed, either by leeches or by cupping. In oesophagitis, the lo- cal blood-letting recommended by Ccelius Au- relianus, viz., the opening of the sub-lingual vein, may be practised. It has received the sanction of the greatest, even in the present day, of practical authorities, that of Hoffmann, as well as of Janson and others. Hildenbrand recommends the application of leeches in pref- efence to cupping: in children, either or both may be employed, according to circumstances. When the local depletion is directed to the throat, leeches are certainly preferable. Next to depletion, as perfect inaction of the tube as possible should be enforced. The patient should be deprived of all ingesta, excepting cooling fluids, which may be used merely to moisten the mouth and throat, without attempting to swallow them. After the acute symptoms are removed, and the necessity of having recourse to light nourishment is urgent, the blandest and most mucilaginous substances, in a semifluid form, and of the temperature of the blood, may be taken. The patient should at the same time be kept quiet, not be allowed to talk, and have the bowels freely evacuated by cathartic enemata, which, while they procure the evacuation of accumulated and hurtful matters, may occasion a derivation of the circulating fluid to the low- er part of the digestive tube. In the slighter forms of oesophagitis, these means, even with- out any considerable depletion, will be often sufficient to remove the disease. 44. b. WThen it is necessary to exhibit medi- cines by the mouth, particularly those of a pur- gative nature, my experience leads me to pre- fer a full dose of calomel, either alone or com- bined with James’s powder, exhibited in a semi- consistent substance. The advantages result- ing from the use of calomel are, that it dimin- ishes vascular action in the part to which it is immediately applied, while it occasions vascu- lar derivation to the lower part of the intesti- nal canal. It may be mixed in some swreet but- ter, which should be allowed to melt gradually and pass insensibly along the oesophagus, the mouth being guarded by subsequent ablution. When it is necessary to act decidedly on the bowels, and yet prevent the increase of thirst— (ESOPHAGUS—Inflammation of the—Treatment. one of the most distressing symptoms of the disease—the supertartrate of potash, with a fourth part of the sub-borate of soda, given in the form of electuary, and combined with con- fection of senna and the inspissated juice of el- der-berries, is one of the best means that can be employed. If the inflammation be attended with much spasm of the tube, or if an irritable state of it still continue after depletions, or if the morbid action be apparently still unsub- dued, the hydrochlorate of ammonia or nitre should be prescribed in the form of linctus or mixture with mucilages, sirups, and anodynes, in frequent doses, and these, swallowed gradu- ally and often, will generally afford marked re- lief. When the upper part of the tube is affect- ed, some benefit may be procured from the use of emollient fomentations and poultices to the throat, particularly after the application of leech- es to the part. 45. c. Revulsive or derivative means are some- times of service, especially when they follow, as they always should, vascular depletions car- ried as far as the state of the case may require. Revulsions ought to be prescribed in a decided manner; for, in order to be beneficial, the ar- tificial irritation should surpass in degree that which it is intended to supersede. The irrita- tion of blisters while inflammatory action re- mains unsubdued will often chiefly tend to in- crease febrile commotion, and thereby to aug- ment the local excitement. As to the means of derivation and the situation of applying them, opinions are various. Bleuland recommends blisters and moxas to be applied between the shoulders. Many prefer sinapisms and irrita- ting pediluvia. The turpentine embrocation or epithem applied to the throat and sternum, or between the shoulders, or a mustard poultice in the same situations, are the most decided and the most rapid in their effects. Either ot these may be used for children ; but blisters ought not to be applied to them for a longer pe- riod than three or four hours, when a warm bread and water poultice should replace them. 46. d. CEsophagitis, in various degrees of ac- tivity, is not infrequent in children, but it is oft- en complicated with inflammation of the fauces and pharynx, or with bronchitis, or with in- flammation of the villous surface of the stom- ach, and is generally seated in the mucous membrane, seldom extending deeper than the submucous tissue. In them, also, the mucous follicles are often chiefly implicated. The lo- cal affection is, moreover, often associated with weak vital power, and sometimes with general cachexia—circumstances which require a very modified practice. After active inflammatory action has been subdued by depletion, or inde- pendently of depletion, in this latter class of cases, I have derived much advantage, partic- ularly in the complications now alluded to, from the hydrochlorate of ammonia, or the sub-borate of soda given in honey, or in the inspissated juice of elder-berries and sirup of marsh mallows, or of roses. 47. e. CEsophagitis, complicated with the in- flammations just mentioned, requires very near- ly the same treatment and regimen as above recommended ; but when it supervenes in the course of eruptive or continued fevers, very different means are necessary, and particularly when those fevers acquire an asthenic or ma- (ESOPHAGUS—Hemorrhage from. 1049 lignant character. I have seen several cases of this description in children and young per- sons, and have never obtained in them any ad- vantage from vascular depletion, except from a cautious recourse, in some cases, to local de- pletion. The mineral acids, particularly the muriatic, camphor, the pyroligneous acid with camphor, the boracic acid, and sub-borate of soda, small doses of the sulphate of zinc, or of the sulphate of quina in confection of roses ; the solution of the acetate of ammonia with camphor mixture and the decoction of marsh mallows ; the hydrochlorate of ammonia or the nitrate of potass in the sirup of roses, &c., are severally beneficial in these associations of thfe disease. When oesophagitis is compli- cated with pharyngitis, as observed in the more malignant states of scarlatina, or in oth- er exanthematous and continued fevers, the sulphate of quinine, the preparations of cin- chona with camphor or the mineral acids, par- ticularly the hydrochloric ; or the decoction of bark with the chlorate of potash ; or small do- ses of the chloride of lime in honey or sirup, may be prescribed, the derivative means above noticed ( 45) being also employed. 48. B. The sub-acute and chronic states of oesophagitis require similar means to the above, but in a less active form. In these, local de- pletions are often required, and they may be repeated according to circumstances. Purga- tives are generally also necessary. The fre- quent use of refrigerant, demulcent, and sooth- ing linctuses and mixtures, as almond emul- sion or sirup of marsh mallows with hydrocy- anic acid, or the mucilages and sirups with sal ammoniac or nitre, should not be neglected. In some cases of the chronic as well as of the acute form of the disease, calomel or the gray powder may be mixed with a little fresh butter and placed upon the tongue. As this melts, and is gradually and slowly swallowed, a heal- ing effect is produced by it upon the inflamed surface. When there is reason to infer the existence of ulceration, this is often of service. If the bowels require farther aid, enemata should be administered. Advantage will often accrue from the more permanent derivatives, as blisters frequently repeated, or kept open and freely dis- charging, and pustulation by means of the tartar- ized antimonial ointment, or of croton oil, rubbed in the situations about to be mentioned. In the more obstinate cases, moxas may be applied, or an issue made near the top of the sternum, or a seton inserted in the nape of the neck. 49. For permanent stricture 34), as well as for ulceration (<) 37) of the oesophagus, the same means as have been advised for chronic oesoph- agitis may be employed. If these fail, after having been fully and appropriately tried, sur- gical aid should be obtained, and dilatation or cauterization be had recourse to. But of these and other surgical measures it is not my duty to treat.* III. Haemorrhage from the (Esophagus. — Synon. (Esophagorrhagia; Blutung aus der Speichelrohre, Germ. Classif.—See art. Haemorrhage. 50. Haemorrhage very rarely takes place from the oesophagus, unless from mechanical injury. When occurring spontaneously, the source of the hajmorrhage is ascertained with great diffi- culty during the life of the patient. Blood ef- fused from the internal surface of this tube is seldom excreted directly upward, but generally passes almost insensibly into the stomach, where it is partially digested, and carried, with the other ingesta, into the intestines, if it be in small quantity, or is vomited, if the effusion be very considerable. In this latter case, hajmor- rhage from the oesophagus simulates Haemor- rhage from the stomach (which see). The chief circumstances which lead us to suspect, when blood is discharged upward in any way, that it is effused from the internal surface of the oesophagus, are the symptoms of previous dis- ease of this part, especially pain and heat in a frequent and copious flow of saliva and mucus from the mouth ; the thyroid bodies were larger than usual, and one or two lymphatic glandular swellings existed on either side of the throat, just below the angles of the jaw. The fauces were free from inflammation, the tonsils were not enlarged. Everything about the fauces appeared perfectly healthy, and the patient had previously enjoyed good health. After trying simple bougies and catheters, an armed bougie was passed down to the stricture, and a piece of lunar caustic, as large as a pin’s head, allowed to melt at the seat of ob- struction. This afforded no relief, although repeated on the day following. The patient was then supported by nu- tritive injections for ten days, which were statedly admin- istered through a long gum elastic tube passed into the co- lon. They consisted of beef-tea, broth containing boiled flour, boiled starch and arrow-root, boiled eggs, and such other articles as could be administered. The injections had a marked effect in recruiting his strength and in assuaging the sense of hunger. They increased the volume of the pulse and the fulness of the capillary vessels ; but at times they excited tormina, and occasionally purged him, espe- cially when highly seasoned with salt. All other resources failing, the (Esophagus was laid open, opposite the thyroid cartilage ; the patient’s life was thus protracted, but he sank and died, three months after the operation. On examination after death, the pouch of the pharynx and upper part of the oesophagus were extensively ulcera- ted, the whole surface of the ulcer being irregular, and of a greenish colour; its upper and lower edges were ragged and irregular. It was nearly encircled by a series of tu- bercular deposites, of a pale, yellowish white colour, vary- ing in size from that of a pea to a small nutmeg, and seated in the sub-mucous cellular tissue. Some of them had bro- ken down in the centre, so as to admit a probe to pass through them and under the tissues, among which they were situated. The mucous membrane, over a great part of the ulcer, was wanting, or hung in shreds, or was bri- dled and undermined. The septum between the gullet and trachea was perforated in two places on the cesophagial sur- face, both of which were like irregular, longitudinal slits, a quarter of an inch or more in length, one just under the lower edge of the cricoid cartilage, the other two inches lower down. Below the ulcer, the oesophagus was healthy throughout its whole extent. Permanent contractions of the oesophagus are generally considered as the result of carcinoma; but the disease in the present instance, according to Dr. Watson, was of a scrofulous character. This was clearly shown by the large tubercular masses imbedded in the surrounding tissues. There had been no lancinating pains, nor were there any appearances of scirrus. Dr. W. mentions another case which came under his care, which had a similar origin, and one which resulted from an attempt to swallow some very hot food. In another case, which occurred in the New-York Hospital, stricture of the (esophagus was produced by at- tempting to swallow a solution of corrosive sublimate. This was cured by gradual dilatation of the canal by means of a stomach tube. There are but four cases of lesophagotomy on record in the living subject, according to Dr. W., and this is the only one in which it has been employed for the relief of stricture. For these cases, and for some very ju- dicious practical observations on organic obstructions of the oesophagus, see the 8th vol. Am. Journal Med. ' Sciences, loc. cit.l * [Surgical operations for the relief of organic obstruc- tions of the (Esophagus are rare. For a very interesting and instructive case of this kind, by John Watson, of New- York, see Am. Jour. Med. Set., vol. viii., N. S., p. 309. In thin case, which was of several months’ standing, the ob- struction existed about the middle of the oesophagus, which was contracted so as to scarcely admit an ordinary-sized bougie. The patient subsisted entirely on fluids, was free from cough, had no pains of any sort, no soreness or tender- ness about the throat, either from pressure or from attempt- ing to swallow. He was feeble and much emaciated, had 1050 (ESOPHAGUS—Spasm of the—Causes—Symptoms. the course of the canal, with difficulty of, and increased pain on, deglutition ; and a sense of heat and titillation behind the trachea, in the situation of the tube. Haemorrhage seldom or never occurs in this part of the digestive canal, unless from pre-existing disease of a severe character, as inflammation terminating in ul- ceration, a case of which I have had an oppor- tunity of observing ; or from the presence of a foreign body lodged in the canal, circumstances tending to facilitate the diagnosis ; but without which it will be difficult to determine whether or no the haemorrhage proceeds from the stom- ach, or even from the respiratory organs. The phenomenon already alluded to is calculated to confound it with hsematemesis, while the cough, which frequently accompanies disease of the cesophagus, particularly when seated in its up- per portion, is likely to mislead us, and to sug- gest its origin in pulmonary disease. 51. Treatment.—When the source of the ef- fusion is tolerably manifest, the treatment dif- fers but little from that which is indicated in haemorrhages from other parts. It should have reference to the states of vital power and of vascular tone. (Esophageal haemorrhage very rarely occurs under circumstances requiring general or even local blood-letting. The ap- plication of cold externally—as a stream of cold water poured on the throat; the use of ices, as the lemon ice, or of acids and other astringents internally, particularly in the form of linctus or electuary, or in any semifluid ve- hicle, are means which should never be over- looked. The most certain remedy, however, in these cases, is the spirits of turpentine mix- ed with honey or the yolk of an egg, and taken in repeated doses. In addition to these, hot pediluvia, cathartic enemata, sinapisms, blis- ters, and other derivatives, may be prescribed. As haemorrhage from this part is generally con- sequent upon chronic oesophagitis and ulceration, the same treatment as already recommended for these diseases (tj 48, et seq.) should gener- ally be instituted after the effusion has been arrested. IV. Spasm of the (Esophagus.—Syn. Spas- modic stricture of the oesophagus. (Esophago- spasmus; der Speiserdhrenkrampf, German. CEsophagisme, Fr. Classif.—II. Class, I. Order (Author). 52. Defin.—Difficult and painful deglutition, occurring either suddenly, and without evidence of previous disease of the oesophagus, or as a symp- tom of such disease, and of several nervous affec- tions. 53. This affection has attracted but little at- tention, although the justly celebrated Hoff- mann wrote a treatise on it (De Spasmo Gulce Inferioris, Halae, 1733). It is, I suspect, in its slighter forms, more frequently brought before the physician than recognised by him. It forms a most distressing part of the series of morbid phenomena attending rabies, tetanus, hysteria, and hypochondriasis; and it constitutes the form of dysphagia which is sometimes met with in delicate and nervous females, particularly those in whom the uterine functions are disor- dered, or the uterus itself in an irritable and slightly inflamed or congested state. 54. i. Causes.—The circumstances just al- luded to may be viewed as predisposing causes of this affection. It may also be considered as occasionally appearing hereditarily, particularly in connexion with the nervous temperament and delicate and hysterical constitution. The most common exciting causes are swallowing cold fluids when the body is perspiring; fits of anger or passion in nervous or irritable per- sons ; the irritation occasioned by the ingestion of acrid, unwholesome, and injurious substan- ces ; and flatus rising into the canal and caus- ing spasm of one part and dilatation of another part adjoining the former, particularly upon at- tempts at deglutition. Owing to this last cause, temporary spasm of the (esophagus is not an infrequent occurrence during the course of dyspeptic, hysterical, asthmatic, and hypochon- driacal affections. Indeed, the dysphagia*often attending the slight or imperfectly developed form of hysteria, consisting chiefly of the glo- bus, or of borborygmi, is entirely owing to oesophageal spasm ; or, rather, this spasm is chiefly the cause of these phenomena, espe- cially when a portion of the tube is distended by flatus. That spasm of this tube is often symptomatic of inflammations or irritations of the stomach, and of the uterus and ovaria, is fully established. Hoffmann states that it is often attendant upon inflammation of the upper portion of the spinal marrow. It has also been caused by inanition, by worms rising into the canal from the stomach, by sea-sickness, by excessive retchings or vomitings, by menstrual or uterine irregularities, and even by powerful mental emotions, particularly those of a de- pressing kind. It forms a most distressing symptom of rabies, and is a chief cause of the distress which attempts at deglutition occasion in that malady ; although spasm of the pha- rynx is also present in that as well as in some other diseases in which it is a prominent phe- nomenon. (Esophageal spasm is occasionally caused by the influence of the imagination, as shown by impossible deglutition, or the forcible regurgitation of a substance through the mouth or nose, when disgust is conceived against it, and by attempts to take disagreeable medicines by children or even grown-up persons. Gra- pengeisser says that he has seen this spasm produced by electricity. It has already been stated (§ 19, 20) that it heightens the distress in cases of acute, sub-acute, and chronic oesoph- agitis. 55. ii. The Symptoms of oesophageal spasm are chiefly the sudden occurrence, without pre- vious disorder referable to the oesophagus, of difficult or even impossible deglutition, and pains excited by attempts to swallow that are felt in some portion of the tube. The symp- toms vary with the part of it affected. When the spasm is seated at the top of the oesopha- gus and pharynx, then deglutition is almost or altogether impossible, and substances are for- cibly rejected. When it is seated in the lower portion, then the morsel swallowed is arrested at its seat, and is either immediately regurgi- tated, or remains there for a considerable pe- riod, when it slowly passes into the stomach, or is violently ejected from the canal. If the spasm be attended, or is caused, by flatulent distention of a portion or portions of the tube, attempts to swallow are often very painful, dif- ficult, or even choking; but the distress is re- lieved, or entirely removed, by eructations of flatus, the dysphagia occurring only at the com- (ESOPHAGUS—Paralysis of—Diagnosis. 1051 mencement of eating, although it sometimes only occurs towards the close. In some in- stances the most urgent distress is produced by the retention of the substances swallowed in the oesophagus, attempts to pass them into the stomach or to reject them being equally unavailing. I have seen this occurrence con- nected with the presence of flatus in the tube. 56. The nature, consistence, fluidity, and temperature of the substances taken often in- fluence, or aggravate, or alleviate the symp- toms, but in no uniform or definite manner. In some cases, fluid or warm substances are most easily swallowed ; in others, consistent or pulpy, or semifluid, or cold food. 57. The duration of this affection varies with its causes, and with the disorders of which it is a symptom, or with which it is associated. It may be, hence, of very short continuance, and may not again recur; but where it has once appeared it generally returns after irregu- lar intervals, or upon the recurrence of its causes. When symptomatic of, or associated with, any of the disorders above alluded to, it is very prone to recur as long as they exist, although it may be removed for a time, or pre- vented from recurring, by attention to diet and by treatment. Fear of its occurrence often as- sists in occasioning an attack, as well as in ag- gravating its severity. 58. iii. Treatment.—The cure of this affec- tion, which, as above shown, is most frequent- ly symptomatic, must necessarily depend upon the nature of its pathological cause and rela- tions. When it seems to arise from inflamma- tory irritation in the oesophagus itself, the means advised for acute and chronic oesopha- gitis (s the consequence, the dead bone exhibits va- rious differences. If the bone die in conse- quence of gangrene of the surrounding parts, the necrosed bone is spongy, light, frangible, and blackish brown. If the necrosis be caused by scurvy or hospital gangrene, it is similarly discoloured and softened. In common necrosis, however, the dead bone is dry, rough, deficient in gelatin, porous or corroded externally, gen- erally white, but sometimes coloured blackish or brown by the offensive sanies 'poured out around it. When necrosis follows osteitis, it may be either the consequence or the cause of caries. Mortification sometimes occurs only in certain layers of bone : in the external—super- ficial or external necrosis; or in the internal layer or table—internal or central necrosis; or the whole substance or mass—total necrosis. The first usually arises from exposure or de- nudation of the bone, but it may also proceed from inflammation of the surface or external layer of bone, and the consequent detachment of the periosteum. Internal necrosis occurs al- most only in tubular and round bones ; total necrosis in solid bones also. Total necrosis, especially in tubular bones, is attended by a dis- charge from the internal surface of the perios- teum, and external to the dead bone, of a jelly- like mass, which gradually hardens and is os- sified, surrounding, like a sheath, the necrosed bone, or sequestrum. As this bony sheath sep- arates from the enclosed sequestrum or dead bone, it becomes lined by a delicate medullary membrane. In the midst of the bony sheaths are one or several holes—the foramina grandia of Tkoja, the cloaca of Wiedmann—which com- municate with the existing sinuses of the soft parts, and form an outlet for the continually- absorbed and diminished sequestrum, as well as for the secreted pus or lymph, and when these are discharged, these holes gradually close. In the internal necrosis the process is nearly the same ; but in this case the jelly-like matter forming the new bone is poured out from the internal surface of the remaining liv- ing bone—from the surface of the living bone adjoining the dead bone ; the living bone often swelling at the same time, and being somewhat softened. 17. a. Causes of Necrosis.—Whatever, either in the substance of the bone or in the perioste- um, interrupts the nutrition of the bone, or in- flames it, may conduce to necrosis. But if the mischief in the periosteum, medulla, or sub- stance of the bone, be of trivial extent, limited suppuration, or abscess, passing into caries and ulceration, are the more common results. The causes of necrosis are the same as those of os- teitis—are external, or internal and constitu- tional. But either of these may be so energetic as almost immediately to destroy the life of the bone ; but more commonly they excite inflam- mation of the bone, of which the necrosis is a termination or consequence. Mr. Stanley has shown that bone may perish from inflammation of it without our being always able to recognise inflammatory symptoms, and yet the existence of inflammation antecedent to the necrosis is undoubted. Owing to the grade, severity, and constitutional relations of the inflammation, or to other causes, the symptoms of osteitis may be so slight as to escape notice. The existence of necrosis is generally more easily detected. 18. Osteitis productive of necrosis may be 1056 either mild, slight, or severe and active. The symptoms of osteitis are sometimes so mild as to render the diagnosis difficult. This most commonly occurs in debilitated constitutions, in which the necrosis affects only the external part of a bone, and originates in some chronic and constitutional cause, as scrofula, syphilis, scurvy, &c. But when necrosis supervenes in the substance and the interior of a bone, and occurs in plethoric, irritable, or robust persons, it is both preceded and attended by acute symp- toms, by severe pain, much fever, and restless- ness ; the disease proceeding more rapidly to a termination. 19. h. Symptoms.—The swelling accompany- ing necrosis forms and increases gradually, par- ticularly when caused by osteitis. In the slow- er and more mild cases, the pain is inconsid- erable and dull or aching ; but when the swell- ing increases rapidly, or when the patient is plethoric and irritable, it is more violent. The swelling, as soon as mortification takes place, is much greater than in osteitis ; still it is not elevated into an apex, but is so diffused along the bone that its limits cannot be distinguished ; and this diffusion of the swelling is the more remarkable the more deeply seated the inflamed and necrosed bone. It may even extend over the whole bone or limb. The swelling com- mences with the osteitis, and increases until the matter which is formed finds its way out through the soft parts, when the tumefaction partially subsides. When necrosis is advan- cing, cedema of the soft parts is often present. The abscess attending necrosis proceeds more rapidly the more intense the inflammation, and the nearer the bone is to the surface ; but when the necrosed bone is deeply seated, and the in- flammation more chronic, the abscess is great- er and advances more slowly to the surface ; but when the necrosed bone is deeply seated, and the inflammation more chronic, the abscess is greater and advances more slowly to the sur- face, often forming sinuses, particularly if fas- cia intervene. The matter discharged varies in character with the constitutional symptoms and origin of the osteitis which has thus ter- minated. It is sometimes pure pus, but most frequently it is sanious, acrid, and foetid. As the necrosis proceeds the sinuses formed by the outlets of the matter become fistula, through which not only the matter, but the remains also of the dead bone make their way. 20. The swelling attending necrosis is always diffused and situated upon a bone, the bone seeming included in the swelling. Even when suppuration has commenced and advanced, it appears deeply seated and obscure. The skin long retains its colour, and does not exhibit a red or livid hue until matter is advancing through the soft parts. 21. c. The formation of new bone is a most important part of the phenomena attending ne- crosis, and much discussion and experimenting have been devoted to the subject by modern surgeons, the results being nearly as follows : When the bone dies, consequently either upon osteitis, or upon destruction of the medullary membrane or of the periosteum, the phenomena vary with the part which is first destroyed. If the medullary membrane is destroyed, and the inner layer, or the whole substance of the bone becomes dead, then the periosteum acquires a OSSEOUS SYSTEM—Inflammation of Bones—Treatment. high degree of vascularity, and becomes thick- ened, soft, spongy, and loosely adherent to the bone. The cellular tissue also surrounding the periosteum becomes more vascular and infil- trated with lymph. The periosteum thus chan- ged, quitting its hold of the dead bone, is now the formative organ of the new bone; and a reddish fluid mass is secreted by the internal surface of this membrane, and is gradually changed into new bone, and thus the same periosteum which had covered the old bone is also the periosteum to the new. If, on the other hand, the periosteum is destroyed, togeth- er with the bone, while the medullary mem- brane, which performs the office of an internal periosteum, is preserved, this membrane under- goes changes similar to those ascribed to the external periosteum, and is the medium of the formation of the new bone. This latter fact, insisted upon by Wiedm.ann and Boyer, has been fully confirmed by the recent experiments of Mr. Stanley, who states that, “ if one side of the walls of a bone be removed without much injury to the medullary texture, the lost bone will be reproduced by the vessels of the me- dullary membrane.” Mr. Mayo also remarks, that if one aspect of the cortex of a cylindrical bone is killed by an injury, the cancellous struc- ture granulates, and reproduces what has been lost. 22. Mr. Stanley has shown that, when ne- crosis is attended by destruction of the bone and medullary structure, the bone may be re- generated from three sources : 1st. From the articular ends of the original bone, which are seldom implicated; 2d. From the periosteum which invested the dead bone ; 3d. From the soft parts indifferently, whatever their nature may be, which surround the periosteum, suppo- sing this to be destroyed. Mr. Stanley re- moved the periosteum from a dog’s tibia, and destroyed the medullary texture, yet reproduc- tion ensued, evidently by the vessels of the surrounding cellular tissue, which had become exceedingly condensed and adhered to the sur- faces of the new bone, thus forming its perios- teum. This result agrees with the evidence furnished by the experiments of Villerme, Breschet, and Dupuytren on the formation of callus. I believe that the surface of bone it- self, particularly its divided surface and ex- posed cancellous structure, will produce granu- lations, or a fluid substance which will be con- verted into bone, even independently of the surrounding tissue. I once observed in the cranium of a man who had been trepanned many years before for injury of the head, the circular portion of bone removed being unusu- ally large, that the aperture had been fully filled, up with new hone, and that the ossific matter had evidently been produced from the divided mar- gins of the old bone, as it proceeded from them in striae, which converged to the centre of what had been the opening, these striae being larger near the margin of the old bone, and tapering as they converged to the centre of the opening which they had closed. The new formation was dense and without diploe. 23. v. Treatment.—The treatment of oste- itis and of its consequences necessarily de- pends chiefly upon the predisposing and exci- ting causes, and upon the constitution of the patient. The pain and swelling should be com- OSSEOUS SYSTEM—Organic Lesions of Bones—Softening—Fragility. bated by local depletions, and the antiphlogis- tic regimen ; by warm and emollient cata- plasms and fomentations ; by the frequent ap- plication of a small number of leeches to the seat of pain ; by alterative aperients and diaph- oretics. If suppuration take place, an early vent should be given to the matter that is form- ed. These means should be pursued with an activity commensurate with the severity of the symptoms and the strength and youth of the patient. If pus accumulate in the medullary canal, it may be necessary to procure it an out- let by perforating the bone. Dr. Macfarlane trephined the tibia in two cases with success, in order to give vent to the pent-up matter. The diagnosis, however, of such cases is the chief difficulty. 24. If the disease proceed from syphilis or scrofula, the preparations of iodine, especially the iodides of potassium or of mercury, or the bichloride of mercury, with sarsa or the com- pound tincture of cinchona, or the iodide of po- tassium with liquor potassae and sarsaparilla, are the most efficacious constitutional reme- dies. I have lately prescribed Mr. Donovan’s solution of the iodides of mercury and arsenic with great benefit in one case of venereal oste- itis. If scurvy be connected with the appearance of osteitis, the means advised for that disease should be chiefly relied on (see art. Scurvy). 25. If necrosis supervene, the indications sug- gested by Wiedmann are most appropriate, namely, to remove the original cause of the disease; to alleviate the symptoms; to sup- port the patient’s strengh and improve the state of the constitution ; and, lastly, to remove the dead portions of bone when they become loose. These comprise the same means as have just now been recommended. In order to improve the constitution of the patient, whether syphi- litic or scrofulous cachexia be present, the prep- arations of iodine, or of mercury, or a combina- tion of both ; those of sarsaparilla and cincho- na ; the chlorides, particularly the chlorate of potash, combined, according to circumstances, with other remedies, should be principally em- ployed, and aided by pure air, and suitable diet and regimen. II. Organic Lesions of Bones, occurring in- dependently of Inflammation. Classif.—IV. Class, IV. Order {Author). 26. There are various lesions found in bones which are independent of inflammation at their commencement, although limited or slight os- teitis may be excited by them in their course, particularly around them, or in their immediate vicinity. These lesions are generally of rare occurrence compared with those which proceed from inflammation. 27. A. Softening of Bones—Osteomalacia, malacosteon, osteosarcosis, mollities, ossium — is sometimes caused to a slight extent by the long continued rest of a joint, but commonly by rick- ets and scrofula. Softening is owing to the disproportion of the phosphate of lime to the amount of animal matter or jelly; the former being generally reduced to one half its usual amount, and the latter increased about one third. Softened bones are more or less flexi- ble, and are usually bent or misshapen, partly by the action of the muscles, and partly by the weight of the body. Softening of bones occurs in two forms, 1st. In connexion with rickets and general debility in childhood; 2d. In adults and aged persons, from constitutional vice or debility. —(a) Rickety hones, according to the increase of their vessels and the expansion of their cells with jelly, become of a red colour and swollen. This softening is sometimes congenital, but it usually occurs in children, and is rarely so general and so malignant as that which affects persons advanced in age.—(£) The softening observed in adults and old persons is often very remarkable, and even in the slighter cases is very rarely controlled by treatment. It is ei- ther partial or general. It is met with chiefly in females, and has been observed consequent upon scurvy, syphilis, mercurial disease, tuber- cles, scrofula, diabetes, lepra, rheumatism, and gout, and the accidents connected with parturi- tion, or the more usual consequences of child- bed, as disordered lochia, &c. 28. a. Softening of bones, particularly in adults, is generally attended by pains resem- bling those of chronic rheumatism, or by ach- ing in the bones affected. Afterward the bones bend or yield to the action of the muscles, or to the weight of the body, and the pains in- crease on muscular action. The height, size, and form of the body are diminished, changed, and deformed respectively; and the affection usually continues to advance, with all the indi- cations of general debility, until it terminates fatally. In some cases, the teeth are the only bones which altogether escape change. 29. b. The softening of bones in adults dif- fers from the rickets of children. The latter is generally cured by treatment or by the prog- ress of age; but the former is progressive, what- ever may be the remedies employed. The soft- ening accompanying rickets is not attended by pain; that of adults always is accompanied with pain, although the pain is not constant through- out the disease. The softening in the latter also is usually more general and much more remarkable. These circumstances indicate that they are distinct maladies. 30. c. The treatment consists in the employ- ment of tonics, with lime-water, and small do- ses of phosphoric acid, or other prepartions of lime and phosphorus. Sea-air and sea-bathing, chalybeate and refreshing mineral waters, ex- posure to the light and to the sun’s rays, nu- tritious and light diet, a dry and pure air, and sleeping in a large airy apartment, are the most appropriate remedies. (See, also, art. Rickets. ) These are generally efficacious in softening in children; but their influence upon the soften- ing of bones in adults is very doubtful. 31. B. Fragility of Bones.—Brittleness.— Spontaneous Fracture.—This change is very rarely congenital, and also rarely observed in youth. It usually occurs in advanced age. In it the animal matter is comparatively less abundant than the earthy constituent. The cancerous cachexia is often the cause of this alteration, as shown by Hamilton, Strack, Lobstein, and others. Fragility of bones has been observed also consequent upon gout; and, in rare instances, upon the same maladies as have preceded softening of bones. Otto states that fragility is not infrequently observed at Breslau consecutively upon cancer, syphilis, and scrofula. It is often preceded by pains in the banes. It is rarely amenable to treatment. 32. C. Erosion of Bones generally arises 1057 1058 OSSEOUS SYSTEM—Organic Lesions of Bones—Fragility. from the pressure of aneurisms or tumours of any kind. In these cases, the cause is mechan- ical : the portion of the bone subjected to press- ure, having its vitality thereby impaired, is re- moved by absorption; or the pressure, while it obstructs the circulation, favours absorption in the part pressed upon. Otto and others, how- ever, believe that the pressure excites inflam- mation in the parts subjected to it; that the inflammation is rapidly followed by ulcerative absorption, and that this change differs from caries only in not being attended by suppura- tion or discoloration of the eroded part. 33. D. Sanguineous tumours are sometimes found in bones, and numerous instances of the occurrence have been recorded by authors.—a. Some of these tumours are manifestly aneuris- mal, or owing to a remarkable dilatation of the vessels penetrating the bone. As the small aneurismal tumour enlarges, the surrounding osseous tissue is absorbed, a cavity is formed, the two tables of the bone are thinned, and ul- timately perforated. When the tumour be- comes considerable it presents the same char- acters as other aneurisms. The periosteum around the tumour is generally thickened, and the nerves and surrounding tissues pressed upon, stretched, flattened, &c. In some cases, related by Dupuytren, Breschet, Pearson, Lallemand, Scarpa, and others, the tumours acquired very large dimensions. They gener- ally occur in adults, consequently upon injuries, contusions, &c., and are attended by a pulsa- ting pain. When they are large, the superficial veins are distended, and the limb swollen and sometimes discoloured. The pulsations cease upon firm pressure on the artery of which the aneurismal vessel is a branch. The treatment of these cases is principally surgical, by liga- ture of the principal vessel or by amputation of the limb. 34. b. Sanguineous tumours of a doubtful na- ture are sometimes found in bones. These tu- mours are described by M. Berard as differing from the aneurismal and from the fungoid, or haemato-fungoid, and as consisting of a reticula- ted structure, resembling" that of the cavernous body, containing altered blood and clots of fibrin. These tumours resemble those usual- ly termed aneurism by anastomosis. M. Bres- chet considers them to arise from a peculiar inflammation of the osseous tissue, in which the venous canals of the bone are chiefly affect- ed. They may be also viewed as erectile vas- cular tumours. Their progress is similar to that of aneurismal tumours, but more slow. They are not amenable to treatment, amputa- tion being the only certain cure. 35. E. Tubercular formations are occa- sionally found in bones, and have been very minutely described by MM. Delpech, Nichet, Nelaton, and Berard. They present them- selves in two forms, the encysted and the infil- trated. The encysted is found in two states, the crude and the softened.—a. In the former state, tubercles occur in the substance of the bone, the places or cavities they occupy being a loss of the substance of the bone, owing to the absorption of it as they are developed and increased. The cavities are smooth at first, but become, as they increase, rugous and an- fractuous. They ultimately, by their enlarge- ment, open, either into each other, if the tuber- cles are clustered, or ultimately in the perios- teum, or into a joint. The bone is generally slightly injected to the extent of one or two lines around the tubercles. As they open into the periosteum this membrane becomes inject- ed at that part, and deposites a layer of ossific matter, which, for a time, resists their farther progress. These tubercles commence in small grayish, semitransparent granulations, each of which is enclosed in osseous cells with solid partitions ; but as they increase the partitions are absorbed, and the matter is contained in a single cavity, and one cyst (Nelaton). They thus resemble tubercles in other organs. As the tubercular mass, thus formed, increases, it becomes softened generally from the centre to the circumference, but sometimes at first at its periphery, and it ultimately assumes a pul- taceous state, in which it escapes by an open- ing, or a fistula, in the surface of the bone, and gives rise to an abscess in the soft parts cov- ering the outlet from the bone. As it is evac- uated, the cavity in the bone is obliterated gradually by thickening of the membrane of the cyst, and ultimately a spontaneous cure is thereby effected. The filling up and cicatriza- tion of the tubercular cavities is thus fully es- tablished in respect of bones. 36. b. Tubercular infiltration of bone has been only recently described by M. Nelaton, who particularizes two forms of it, one semi-trans- parent and firm, the other opaque and puriform. The infiltrated matter softens gradually, and be- comes liquid and puriform. At the same time, the osseous cells of the infiltrated part become partly obliterated by thickening of their parti- tions, and the blood-vessels obstructed by this interstitial hypertrophy, so that the death of the portion of bone thus affected often ultimately follows, the necrosis not being the result of in- flammation, as supposed by M. Delpech, but of obliteration of the vessels of the part. 37. c. Tubercular disease of the bones is much more common in childhood than at any other age. It may occur in adults, but is the more rarely observed the more advanced the period of life. It affects chiefly the spongy parts, but it may affect any of the bones. It is most com- monly observed in the bodies of the vertebrae, in the extremities of the long bones, in the sternum, &c. 38. d. The duration and progress of the mal- ady varies with the parts affected by it. The encysted variety generally advances to the ex- ternal surface of the bone as it softens, pene- trates the periosteum, notwithstanding the de- fence offered by this membrane to its progress (§ 35), opens into the soft parts, suppurates, and forms a fistula, and the matter, advancing to the surface, is discharged externally. Ulti- mately the cavity in the bone is obliterated in the manner stated above, if the case proceed favourably. When the tubercular mass forms in the extremity of a long bone, it generally makes its way to the articular surface, in pref- erence to the periosteum. The infiltrated va- riety proceeds more slowly, and generally ter- minates by caries or necrosis. 39. e. The symptoms of tubercles of the bones are very obscure in the early stages. As long as the disease is confined to the substance of the bone, slight or occasional pains are only complained of. But when the mass affects the OSSEOUS SYSTEM—Organic Lesions of Bones—Osteosarcoma—Hydatids. 1059 periosteum, and especially if it have penetrated into the soft solids, the abscess that is formed, and subsequently the tubercular character of some of the discharge, will point out the na- ture of the disease. The changes which after- ward take place vary much; but the state of the bone may be partly ascertained by exami- nation, by the local appearances, and the con- stitutional symptoms. 40. /. The treatment is necessarily the same as I have suggested for scrofulous osteitis and scrofulous necrosis ($ 24, 25). See, also, the article on Abscess. 41. F. Osteosarcoma, or Malignant Tu- mour of Bones—Bony Cancer—Osteosteatoma— Fungus ossium—Cancer ossium—Exostosis fun- gosa — Exostosis carnosa — Ex. carcinomatosa, 4-c.—presents various forms.—a. In some cases it approaches the fungo-haematoid or encepha- loid character; in others it more nearly resem- bles the scirrous ; in a few it is fleshy, and in many it presents cavities filled with a substance of varied density and colour. In general, how- ever, the tumour at first consists of a some- what homogeneous, grayish, or grayish white, unvascular mass, intermixed with bony points and fibro-cartilaginous fibres, more or less firm- ly consolidated with albumen. As the tumour advances, its tissue becomes rarefied or loosen- ed, forming cells of various sizes, filled with a light-coloured, semi-transparent jelly. Inflam- matory action or vascular excitement now oft- en takes place in the tumour, and the cellular tissue lining the cells becomes thickened, and secretes an albuminous substance, which is sometimes soft and bran-like, at other times more consistent, or even hard. In other cases, cellular tissue, loaded with albumen, is formed in it. The blood-vessels gradually enlarge in the periosteum, and in the interior of the tu- mour, and cavities are formed in the latter fill- ed with venous blood. Blood is sometimes also effused in the brain-like substance, or is mixed with it. Innumerable bony fibres or plates commonly project from the hone out- ward, penetrate the tumour in various direc- tions, and, becoming softer and larger, are finally united with the fleshy and membranous patts lying upon it. 42. These tumours assume various changes and appearances in different cases. If they are formed in the centre of a bone, they distend the layers or plates, and reduce them to a thin shell. In many cases the bone almost disap- pears, and merely a few irregular osseous spic- ulae or plates are formed in the tumour. These tumours may reach a very large size — may even be two feet or two feet and a half in cir- cumference, and ten or twelve pounds in weight. They are generally knobbed or irregular on the surface, and of various degrees of hardness. The bone adjoining the tumour is altered to some extent. The cells are enlarged, red or inflamed, occasionally even carious. New for- mations of bone are sometimes produced in the vicinity. 43. b. Osteosarcoma may affect any bone, but it is observed most frequently in the bones of the face, at the base and arch of the cranium, in the long bones. It is most frequently ob- served in adults and advanced age, and very rarely in childhood. The precise tissue in which the malady originates has not been fully deter- mined. Boyer supposed that the disease com- mences in the soft parts, and attacks the hones only secondarily. Others believed that it be- gins in the bone itself. M. Sanson supposed that it originates either in the medullary mem- brane, or in that lining the spongy cells, an opinion which seems to accord with that enter- tained by Sandifort, Siebold Walther, Eb- ermayer, and Ossius. Lobstein, however, considered the medullary membrane not to be its original seat, as the tumour is sometimes found external to this membrane, which has remained sound. It may probably arise either from this tissue, or from the membrane lining the vascular canals and spongy cells. 44. c. Symptoms.—This malady is first an- nounced by acute, deep-seated pains, which oft- en are long felt before any tumour can be de- tected. The constitution also frequently be- trays disorder before it is observed. As soon as swelling appears, its hard, knobbed, unequal surface, the manner of its involving the whole bone, and its complete immobility indicate its nature. At a still farther advanced stage, the pains become more acute and lancinating, the soft parts are involved in the tumour, and are also painful; the skin sometimes is inflamed and ulcerated, particularly when the disease is very far advanced, and red, fleshy, or fungous excrescences, which bleed on the slightest con- tact, spring from the surface. The patient’s condition becomes rapidly worse ; fever, sleep- lessness, and marasmus characterizing the last period of his existence. 45. d. The prognosis of this malady is most unfavourable ; amputation or complete extir- pation of the disease, where either can be done, so as completely to remove the affected part, being the only treatment which is of any avail. 46. G. Hydatids are rarely found in bones ; but instances of the occurrence have been re- corded by Van der Haar, Cullerier, Web- ster, Wickham, Fricke, Dupuytren, Cooper, Keate, and others. The hydatidic cyst, con- taining the small rounded vesicles, &c., pre- sents the same appearance and changes as are described in the article Hydatids. It is usu- ally found in the spongy part of the long bones, or in the diploe of the flat bones ; but it is also sometimes seen in the diaphysis of the former. In very rare instances the hydatidic mass, af- ter having perforated the bone, if seated near a joint, may penetrate into the articular cavity. 47. a. The progress of the disease is very slow, being seldom of shorter duration than several years. Having perforated the bone, the hydatidic cyst invades the adjoining soft parts. Ultimately these are destroyed, and it reaches the surface. But in all the cases on record, the tumour formed by it has been opened by the surgeon before it has perforated the skin. The hydatidic mass, of various bulk, being evacua- ted, suppuration is established in the cyst, and the debris of membranous cysts and dead hy- datids, generally mixed with a foetid pus and sanies, are discharged. When the cyst is in- flamed it becomes the seat of an abundant sup- puration, which can rarely be arrested without its destruction. When a considerable portion of a long bone is destroyed by the cyst, fracture of it may take place. Cases of this kind are recorded by some of the writers referred to ; and is, upon the whole, a less evil than the next 1060 OSSEOUS SYSTEM—Bibliography and References to be noticed. If the hydatids are seated near a joint, they may penetrate into it, causing acute inflammation of it at first, that generally pass- es into a chronic state with structural change of the tissues composing it, and of the heads of the bones. 48. b. Hydatids of the bones are caused by the influences which produce them in other tissues. The majority of cases on record show that con- tusions or other injuries had been received on the part in which the hydatids were seated, or that the venereal disease had preceded their appearance. 49. c. The symptoms of hydatids in bones are extremely obscure ; the first indication furnish- ed by them being a tumour in the part affected, and this rarely appears until they have pene- trated the bone. The tumour is attended with little or no pain or tenderness, and no constitu- tional disturbance besides that constitutional weakness or deficiency of vital power which favours the development of parasitic forma- tions. As the tumour increases, it becomes softer and more elastic, similar to lipoma or fungo-haematoid tumours. Ultimately it may present more or less fluctuation. It still occa- sions little or no pain, although it may altogeth- er prevent the use of the limb in which it is seated. The absence of pain, the slow prog- ress of the disease, and the slight affection of the constitution are the chief means of diagno- sis afforded by it. Still, in most of the cases on record, the nature of the malady was not known until the hydatids were evacuated. 50. d. The prognosis of this malady is always more or less unfavourable. As long as the tu- mour is unopened, it occasions but little con- stitutional disturbance ; but when it is opened, inflammation takes place, which seriously af- fects the general health, commonly already im- paired, and a prolonged and weakening suppu- ration is the usual result, which often destroys the patient. The amount of danger, however, depends upon the seat of the hydatids, and the possibility of removing not only them, but the cyst containing them. When they are seat- ed in the bones of an extremity, and are not developed in any other part, surgical interfe- rence, aided by tonic or restorative constitution- al means, will often prove successful. 51. e. Treatment.—The indications of cure are, 1st. To remove or destroy the hydatidic cyst, or to remove the portion of bone containing it; 2d. To support the constitutional powers, and to enable them to throw off or to resist the dis- ease ; and, 3d. To subdue accidental changes of an unfavourable or inflammatory nature, whether local or constitutional, as they arise. The fulfilment of these indications is to be ac- complished by surgical and medical measures, of so obvious a kind as not to require particu- lar notice. 52. H. Spina Ventosa.—I agree with M. Bekard in considering this not to be a distinct disease of bones, as generally supposed ; but the result of the organic maladies described above, when they are attended by tumour, swelling, or protrusion of the external plate of bone and periosteum, or by that external con- figuration which has been described as consti- tuting spina ventosa. These changes and ap- pearances are most commonly produced by the malignant, hydatidic, tubercular, and sanguin- eous tumours, which have been as fully descri- bed as my limits will permit. 53. I. Foreign Bodies have been found in bones ; and these have lodged in them, either from external injury, especially by leaden bul- lets, small shot, &c., or been conveyed to them through the medium of the circulation, as in cases where mercury, arsenic, or sulphur has been detected in them. Neither of these, how- ever, requires more than a simple notice at this place. It may be remarked, however, that leaden balls may remain a long time in bone without producing much disease ; still caries or necrosis may be occasioned by them. Biblioo. and Refer.—I. The Pathology of the Osseous System generally. — C. Havers, Osteologia Nova, or New Observations of the Bones and Parts belong- ing to them, 8vo. London, 1691.—J. L. Petit, Trait6 des Maladies des Os, &c., 12mo. Paris, 1723.—Cheselden, Os- teographia, or Anatomy of the Bones, fol. Loud., 1733.—S. Schaarschmidt, Kurzer Unterricht. von Krankheiten der Knocken, 8vo. Berlin, 1740.—J. G. Duverney, Traitd de Maladies des Os, par Senac, 2 vols., 12mo. Paris, 1751.— F. Sandifort, Museum Anatom., 4 vols., fol. Leyden, 1763, passim.—A. Murray, in Act. Med. Suec., t. i., p. 395.—A. Bonn, Descrip. Thesauri Ossium Morbosorum Hoviani, epu, fero), Hilden- brand. Ovaritis, Ovarite, Fr. Eierstocksent- ziindung, Germ. Classif.—III. Class, I. Order {Author). 4. Defin.—Pain in either or in both sides of the hypogastrium, increased on touch or pressure, oc- casionally with tumour in these situations, and symptomatic fever, generally of an inflammatory character. 5. It has been asserted by M. and Madame Boivin, that a case of inflammation of the ovarium can hardly be adduced, independ- ent of the pregnant and puerperal states. It must be admitted that cases occurring inde- pendently of these states are rare ; still they are met with, and I have notes before me now of four cases which occurred in my practice un- 1062 OVARIA—Inflammation of the—Causes—Symptoms. connected with these states. Primary and un- complicated ovaritis is comparatively rare ; but ovaritis is more likely to occur in a primary and unassociated form in females who are neither pregnant nor recently confined, than in those who are thus situated. When it occurs after parturition, it is most frequently complicated with metritis, or with inflammation of the uter- ine veins. 6. i. Causes.—A. The predisposing, as well as the exciting causes of ovaritis, have not been sufficiently ascertained, owing to the dis- ease having been very generally overlooked by writers and practitioners, but the following may be considered as the chief; and the au- thority of Hildenbrand and others may be ad- duced in proof of their influence, especially when any of the exciting causes come into op- eration. Excitement of the imagination by reading voluptuous or immoral works or ro- mances, or by descriptions of circumstances which affect the desires and emotions, particu- larly in females unaccustomed, or unable, from infirmity of mind, to resist the impulses of feeling and passion; frustrated expectations of mar- riage with a beloved object; venereal desires often excited without being fully gratified; fre- quent abortions and difficult parturition ; and sudden continence on the parts of those addicted to sexual indulgences; hence, says Hilden- brand, prostitutes, when they are imprisoned, and widows, are more frequently than others affected with diseases of the ovaria. 7. b. The exciting causes are exposure to cold, particularly soon after delivery ; injuries re- ceived upon or near the hypogastrium ; the use of emmenagogues, and of substances to produce abortion ; disordered, and especially suddenly suppressed menstruation ; metastasis of rheu- matism ; sexual excitement at the period of menstruation ; inordinate venereal excitement and masturbation ; premature addiction to ve- nereal impulses, or coition too soon after men- struation, or after parturition, or after inflam- matory affections of the uterus. Walther states that, in his numerous post-mortem ex- aminations, he very rarely found the ovaria of prostitutes free from inflammatory and structu- ral lesions.* 8. Ovaritis is often observed after delivery, but it is then rarely unconnected with metritis or metro-peritonitis, or with inflammation of the uterine and ovarian veins, or of the Fallo- pian tubes and connecting cellular tissue • bu* the associations of ovaritis, in the puerperal states, vary much with the prevailing epidem- ic, with the predisposing and exciting causes, and with the different circumstances in which the disease presents itself. These complica- ted forms of ovaritis are often observed in ly- ing-in hospitals, in close, ill-ventilated apart- ments, and in low, crowded localities ; and oc- cur most frequently after difficult parturitions, after floodings, and upon the sudden disappear- ance or suppression of the lochia or milk. 9. ii. Symptoms.—A. The mild, and more chron- ic states of ovaritis, whether in the unimpreg- nated or puerperal states, is generally an insid- ious, latent, and deceptive disease, unless the nature of the case be strictly investigated. In- deed, in many instances, the complaint is not brought before the physician until it has gone on to structural change, or it is confounded with hysteria, from the circumstance of hys- terical symptoms being its common attendant. In these cases, a careful examination will gen- erally detect tenderness upon firm pressure, and sometimes even slight fulness or tumour of either or both sides of the hypogastrium, a little above the groins, with slight febrile ex- citement ; a variable, but usually a more fre- quent pulse than in health, variability and ex- citement of the desires, emotions, and disposi- tion, associated with many hysterical and ner- vous phenomena ; irregularity or suppression of the catamenia ; and costiveness, with scanty or varying conditions of the urine. 10. B. The more acute form of ovaritis is at- tended by nearly the same symptoms as the above, but more decidedly or acutely marked. The pain, tenderness, and swelling in the hy- pogastrium are more fully pronounced, the mind more evidently affected, and in the san- guine, the irritable, and plethoric, the desires inordinately excited, so as to amount almost to utero-mania. In some cases, numbness of one or both thighs is felt, particularly on. that side where the fulness in the hypogastrium is most evident. Symptomatic fever and hysterical symptoms are sometimes also very prominent. The bowels are constipated, the urine scanty, and sometimes retained ; occasionally it is voided in large quantity. 11. C. In the puerperal state, the symptoms vary remarkably with the prevailing epidemic and the causes and complications of the mal- ady ; and is often attended by general asthe- * I have preserved the notes of four cases of acute uncom- plicated ovaritis, occurring independently of the puerperal states. Besides these, slighter and less clearly defined cases have been seen by me, which have usually been considered as cases of hysteria depending upon vascular excitement or irritation of the ovaria. Of the four cases alluded to, one was caused by the sudden suppression of the catamenia, and one from metastasis of rheumatism. The others might be referred to a concurrence of several of the causes assigned above for the disease. The case, arising from metastasis of rheumatism, was remarkable in several respects, espe- cially for the acuteness of the attack. The following is abridged from the original notes : Mrs. P , of street, Walworth, was attacked, 15th of July, 1821, with most excruciating rheumatic pains in the loins and limbs, increased on the slightest motion, or on attempts to turn in bed. She was in a profuse perspira- tion ; and her pulse was full, strong, and about 100. She attributed the attack to sleeping in a damp bed when trav- elling. She was about 26 years of age, strong, plethoric, and of the sanguine temperament. The catamenia were usually very abundant, and seldom at longer intervals than 14 days. Their recurrence was, therefore, soon expected. She had never been pregnant. About three days after the commencement of the rheumatic attack, and while I was attending her, she suddenly experienced an attack of most acute pain in the hypogastrium, a little above each groin. Soon afterward two tumours could be distinctly felt in the regions of the ovaria. They were extremely painful and tender upon pressure. The pains in the limbs were greatly abated, but pain was still complained of in the loins. All the inflammatory symptoms continued. The bowels were costive, the urine scanty and high-coloured, with frequent calls to micturition. The countenance was flushed, anima- ted, and excited ; the temper variable and hysterical. The treatment consisted of one bleeding from the arm ; of repeated doses of calomel, ipecacuanha, and opium com bined, saline aperients being interposed, so as to keep the bowels freely open; of the application of a considerable number of leeches below each groin ; and of the warm hip bath. Four or five days after this attack commenced, the catamenia came on, and the pain, tenderness, and swelling gradually disappeared from the hypogastrium. This lady, the wife of an old acquaintance, was, some years afterward, the subject of abscess between the vagina and rectum, which opened into the latter. She subsequently was attacked by gout ; and ultimately became consumptive, from an excess- ive addiction to brandy; but was carried off by delirium tremens before the pulmonary disease had reached its ut most limits. OVARIA—Inflammation of the—Terminations—Treatment. 1063 nia, by contamination of the circulating fluids, and by depression of the vital powers. But the occurrence of the disease in these circum- stances, and thus associated, is fully considered in the article on Puerperal Diseases. 12. iii. Terminations and Consequences.— A. Resolution is the most frequent issue of in- flammation of the ovaries when the disease oc- curs independently of the puerperal states ; and is indicated by subsidence of the pain and swelling ; by the accession of the catamenia ; or by a more abundant flow of the lochia when this discharge had been diminished or sup- pressed in the puerperal state of the disease. (See Puerperal Diseases.) 13. B. Softening and friability are generally present in a greater or less degree when ova- ritis is very acute and the swelling considera- ble. In this state the organ is generally three or four times its natural size, or even larger. In addition to these changes, it is infiltrated with a yellowish serum, or with a violet-col- oured fluid, and occasionally it presents nu- merous small ecchymoses or bloody points. 14. C. Suppuration may occur in the puer- peral and in the non-puerperal states of the malady, but most frequently in the former. Hildenbrand met with a case in the latter state which opened externally and terminated favourably. Ovaritis is very commonly fol- lowed by suppuration in an advanced stage, when softening of the organ is very consid- erable, a puriform matter or serum, infiltrating the substance of the ovarium, partially break- ing down portions of it, and forming either one large or more small abscesses. This result is often observed in the puerperal states, but the disease is then usually associated with metri- tis, or metro peritonitis, and the case termi- nates fatally, from other changes in the pelvic and abdominal viscera and circulating fluids, before any large abscess is formed or breaks into adjoining parts. But in cases occurring independently of parturition, a considerable ab- scess is sometimes formed, which may open into the peritoneal cavity, or into the rectum, or some other adjoining viscus. [Dr. Meigs (Am. ed. of Colombat, p. 412) re- lates a case of ovaritis in a female after con- finement, attended with very painful symp- toms, and where a hard and extremely painful tumour formed in the lower part of the left il- iac region, which fluctuated and pointed. It was opened with a common lancet, and dis- charged near a pint of pus, the discharge con- tinuing for many days. At length, the patient completely recovered. Dr. M. also relates a second case of a similar kind in a lady affected with carcinoma of the cervix uteri; the dis- charge was very great, but the abscess was cured.—(Loc. cit.)] 15. D. Effusions of a puriform lymph or serum, or of a gelatinous lymph, are sometimes observ- ed upon the peritoneal surface of the inflamed ovaria and Fallopian tubes, the latter effusion often gluing their surfaces to adjoining parts. It is not improbable that, in the slighter and more chronic cases of ovaritis, a similar effu- sion of coagulable lymph takes place gradually into the structure of the organ, and occasions the enlargement, with various grades of indu- ration observed in a few instances. In these latter cases the enlargement of the organ is somewhat greater than that observed in acute ovaritis, amounting commonly to the size of an orange. It often remains stationary for a very considerable time, and affects but little the general health. 16. Whether or not the Graafian vesicles are ever affected by inflammation, excepting in common with the substance of the ovarium, it is difficult to determine. Purulent matter has been met with in cysts after ovaritis of a sub- acute or chronic character, but it has not been proved whether this arises from inflammation and suppuration of the vesicles, or is circum- scribed abscess in the cellular tissue. Dr. Sey- mour remarks that it would be still more diffi- cult to say what is or would be the effect of in- flammation of the corpora lutea; that is, of vas- cular excitement greater than what is necessa- ry for their formation ; for their formation may be said to be owing to increased action of the vessels of the part. Corpora lutea form, in some cases, after rupture of the vesicle, in- dependently of impregnation, owing to excited feelings connected with the generative system; and hence it is reasonable to expect that any morbid affection of the ovaria dependant upon such excited feelings would have their origin in the corpora lutea.* In the cases on record, in which the ovaria were altered in structure, in conjunction with furor uterinus, no farther information is generally given than that puri- form matter was found in the ovaria. The coats of the vesicle, Dr. Seymour remarks, un- dergo in advanced life remarkable thickening; “ and, instead of containing fluid, are filled with a thick matter of a red colour, from the pres- ence of vessels, sometimes nearly solid, at oth- ers of a thinner consistence. This change ex- hibits on a small scale some of those hard tu- mours which are sometimes found in the pa- rietes of an ovarian cyst. Is it not possible that these may be some of the superficial vesi- cles, having undergone the change alluded to, and magnified by disease V’ The fluid con- tained in the Graafian vesicle is sometimes al- tered, it being red, or even black from the ad- mixture of blood. [After death from puerperal peritonitis, we generally find the peritoneal surface of the ova- ries red, vascular, and imbedded in lymph with- out any visible alteration of the parenchyma- tous structure ; or their whole volume may be much enlarged, swollen, red, and pulpy; blood is seen effused into the Graafian vesicles, or around them, and circumscribed deposites of pus will be found often dispersed throughout the substance of the enlarged ovaria. In some cases we find the structure of the ovaria re- duced to a soft vascular, flocculent pulp, no traces of their original organization being left. We often meet with inflammation of the peri- toneal coat of the ovaries and false membranes, by which they are firmly united to the Fallo pian tubes and uterus.] 17. iv. Treatment.—The treatment of ova- * [Recent investigations in medical jurisprudence seem to have placed this fact of the origin of corpora lutea, inde- pendent of impregnation, beyond the reach of controversy. So long ago as in 1821, this doctrine was inculcated bv the then Professor of Midwifery in the University of New-York, Dr. Francis ; and Professor Valentine Mott gives posi tive assurance that corpora lutea have repeatedly been ob- served by him in his dissections of bodies which had never been impregnated.] 1064 OVARIA—Organic Lesions of Ovarium—Cysts. ritis should depend entirely upon the causes, the circumstances in which the complaint oc- curs, and the constitution of the patient. The means most beneficial when the disease is un- connected with parturition are generally either inappropriate or unavailing when it occurs at this period. The treatment of puerperal ovari- tis is, therefore, comprised in the article on Puerperal Diseases. 18. A. The slighter states of the complaint require chiefly local depletions, as the applica- tion of leeches to the thighs a little below the groins, cooling aperients, and diaphoretics, with a mild, unexciting diet and regimen. In the more acute cases, general blood-letting or cupping in the loins or sacrum, antimonial di- aphoretics with nitre, small doses of camphor with nitre, the tepid bath, when much tension of the hypogastrium is complained of, and low diet, with perfect quietude, and the avoidance of mental and sexual excitements. 19. B. Where the slighter states of ovaritis occur in persons of the scrofulous diathesis, they generally become chronic, particularly in those who present indications of their having experienced scrofulous affections of glandular parts, and are commonly attended by severe pains, and much swellirg or enlargement re- mains after the treatment now recommended. In these cases, abscess not unfrequently is formed, and all the symptoms are aggravated until it makes its way either into the rectum or vagina, the most favourable course it can take. If it burst into the peritoneal cavity, fa- tal peritonitis is usually the result. In this form of the disease, small doses of the hy- driodate of potash, with liquor potassa;. eo- nium, and sarsaparilla ; and injections, per va- ginam, of emollient and anodyne fluids, or opi- ate suppositories, are chiefly indicated. I have prescribed suppositories consisting of the ex- tracts of hyoscyamus and conium, and vaginal injections containing the same medicines, with very marked relief. Dr. Seymour praises the extract of colchicum, given in the dose of a grain, twice or thrice daily. 20. C. When abscess forms in consequence of either acute or chronic ovaritis, and makes its way into the rectum, or vagina, or bladder, or even externally—this latter being the most rare course it takes—the strength of the pa- tient ought to be supported, particularly in the scrofulous diathesis, by the preparations of cin- chona, by suitable diet, pure air, and residence near the sea-side. Attention should be paid to the digestive functions, and moral and physical quietude should be recommended. The alka- line and chalybeate mineral waters may be sub- sequently tried. III. Organic Lesions of the Ovarium, appa- rently INDEPENDENT OF INFLAMMATION. Classif.—IV. Class, I. Order (Author). 21. i. Cysts, of various sizes, having their origin in some part of the ovarium, are the most frequent lesions to which this organ is liable. When one or more of these cysts con- tain fluid, the term encysted, or ovarian dropsy has been given to the disease, although the se- rous cysts are sometimes formed in the broad ligaments and Fallopian tubes. These cysts are to be distinguished from hydatids by their being nourished by vessels supplied to them from the parts in which they are found ; while hydatids are parasitic formations, having an in- dependent vitality, and are unconnected with the cyst containing them. One or both ova- ria may be changed into simple cysts ; and when the cysts are either numerous or large, the cellular substance and vesicles disappear the fibrous coat of the organ becoming the fibrous covering of the cyst. 22. Dr. Seymour and M. Cruveilhier agree in considering this disease to originate in al- teration or enlargement of one or more of the Graafian vesicles. When the enlargement takes place to a great degree, it is usually on the side nearest the proper coat, which often becomes distended to an enormous extent, the internal membrane of the cyst secreting a great quantity of fluid. When the cyst is sin- gle, the ovarian dropsy exists in its simplest state, and often in its greatest degree. When one, two, or more of the Graafian vesicles un- dergo the change, the disease consists of an equal number of cysts filled with fluid. The quantity of fluid furnished by this disease is sometimes very remarkable. In a case under the care of my friend Mr. Worthington, of Lowestoft, the quantity of fluid taken away by him amounted nearly to as much as in the case detailed by Mr. Martineau, in which 6631 pints were lost by tapping in 25 years. [A case is related by Mr. Atkinson (Lancet, July 20, 1844), in which a woman aged 53 was tapped 78 times in 7£ years, six gallons be- ing drawn off at each of the first 50 operations, but only half that quantity on each subsequent occasion. The interval between the opera- tions, which used to be five months, came at last to be only three wreeks, but the patient re- sumed her active habits in a day or two after each puncture.] 23. The symptoms attendant on these tumours are not severe, and are occasioned chiefly by pressure on adjoining parts. When the tumour is seated low in the abdomen, pressure on the nerves and veins often occasions swelling ancl numbness of the leg and foot on the side where it is largest; but it may continue stationary for many years, or even for the greater part of a long life. In some cases the discharge of urine is more or less affected. The history of the case generally assists the diagnosis of this disease ; but I must refer the reader to the ar- ticle Dropsy of the Ovarium, for a full account of its symptoms, history, diagnosis, and treat- ment. (See art. Dropsy, <) 198-213.) 24. ii. Cysts containing fatty matter, inter- mixed with hair and teeth, have been met with, either in the substance of one of the ovaria, or adhering to it by a narrow neck, and generally before the period of puberty ; consequently they do not arise from impregnation. Similar cysts have been found in other parts of the body, in different individuals. They may be viewed as a species of monstrosity, termed by Ollivier and Breschet, “ Diploginisis par pe- netration,” as the result of an imperfect concep- tion in the mother of the individuals in whom they are found. The hair found in these cysts varies in quantity and appearance. It may be isolated, or mixed with fatty matter, or short or long, with or without bulbs. Teeth have usually been found implanted in fragments of bony or cartilaginous substance, or even of a part or the whole of a jaw. OVARIA—Organic Lesions of—Tumours. 1065 25. iii. Congestion and extravasation of blood in the ovaria have not been satisfactorily ob- served. The former may possibly be of not infrequent occurrence, either in connexion with inflammation, or independently of it; and the latter has very rarely been seen to any great amount, unless in connexion with ovarian fcetation. 26. iv. Fibrous bodies, resembling those found in the uterus, are occasionally found in the ova- ria. They vary in size from a few ounces to 30 or 40 lbs. M. Cruveilhier met with a tu- mour of this kind which weighed 46 lbs. They can hardly be distinguished from similar tu- mours connected with the uterus. Indeed, they have been formed in one or both ovaria, and in the uterus also, of the same subject. 27. v. Cartilaginous, osseous, and even calca- reous formations, are not infrequently found in the ovaria. Meckel considered them to origi- nate in the Graafian vesicles. Fibro-cartilagi- nous transformations, with or without ossific deposites, are often met with in aged females. I have seen this change in a chlorotic female twenty-three years of age, who died of con- sumption, and had never menstruated, but with- out any ossific deposite. Calcareous deposites are more rare ; but have been noticed by Mor- gagni, Saviard, Petermann, Murat, and oth- ers. 28. vi. Hydatids are very rarely seen in the ovaria. Instances, however, of the occurrence have been adduced by Cruveilhier, Roux, and Deneux. 29. vii. Tubercles are also very rarely formed in the ovaria ; but they have been found in this situation by Duges, Boivin, Seymour, Ton- nele, and Dugast. 30. viii. Scirrus of the ovarium is not often observed. The organ is increased in size, sometimes remarkably ; and the tumour is com- posed of a very solid substance intersected by fibrous membranes, running in various direc- tions. Occasionally portions of the tumour contain cysts filled with secretions of various consistence. These scirrous tumours very rarely ulcerate. In a case referred to by Dr. Seymour, the scirrous mass was breaking down into a thick, brown, foetid fluid. This lesion is occasionally found in females who had scirrus or open cancer in the uterus or some other part, and is attended by weight and pain in the seat of tumour, which is hard and move- able, and by signs of general cachexia. 31. ix. Fungoid and other malignant tumours are occasionally found in the ovaria. Some of these consist of a large cyst springing from the ovarium, and containing within it tumours va- rying from the size of a pin’s head to that of an orange. Sometimes a great portion of the parietes of the cyst is formed of tumours grow- ing between the external and internal or se- creting coat, the interior of the cyst having the tumours projecting into it, being filled with fluid secreted from the serous lining. The tumours, when divided, present a semifluid gelatinous substance, with white bands running through it, between which bands are smaller cysts, con- taining the same viscid, glue-like matter (Sey- mour). 32. x. Encephaloid orfungo-hcematoid tumours of a very large size are formed in some cases in the ovaria. M. Velpeau supposes them to be less rare than other malignant diseases of the ovarium. The encephaloid, or fungo-haem- atoid formation, may exist in the same ovarium or tumour, with the scirrous structures de- scribed above (§ 30), or with cartilaginous fibrous, or fibro-osseous formations, as noticed by Meckel, Andral, and Velpeau; but it may compose nearly the whole mass. The walls of the cysts in this disease are thick, and theii cavities gradually enlarge until a tumour ia formed which fills not only the hypogastrium, but the whole abdominal cavity. The outer surface of the tumour is unequal; in some points a fluctuation can be felt, while in others it has a hardness equal to bone. 33. This fatal malady occurs usually in younger subjects than those in whom the scir- rous and fungoid tumours already noticed (