Wtn.;-:: ^Ws-.r'-'i':-,;;;,.':.-::^;.; ::.■; w.i|.»4i, .:.' rip ■;;■ * r fttft*' *irf'l'»■''••• ■•'■■; it i-i'." KS-v ,«K/.^''.';.-Vr"'•■r»> •;. •■ :■; ;:" • , ;•;•„, «M-/,»,5L';/.t v.''''•'■''■■''■■■'■';'-'::' Jl---^XT. ) RY PRACTICAL. MEDICINE: 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 ACCORDING TO PATHOLOGICAL PRIN- CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; AND AN ^ppfirtrtj; of ^pprotortr ffiovmulat: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE, AND A DIGEST OF MEDICAL IffTERATURE. BY JAMES COPLAND, M. D. Consulting Physician to Queen Charlotte's Lying-in Hospital; Senior Physician to the Royal Infirmary for Diseases of Children ; Member of the Royal College of Physicians, London} Member of the Medical and Chirurgical Societies of London and Berlin, etc. vox., i. -V/0 033). BOSTON: - - ' ' ^ LILLY, WAIT, COLMAN, AND HOLDEN. 1834. SOLD BY ALL THE PRINCIPAL BOOKSELLERS IN THE UNITED STATES. / C7?4d v. I CONTENTS . ABDOMEN—External Examination of, in Disease 1 ABORTION 5 ABSCESS 12 ABSORPTION—In relation to the Causation, Continuance, and the Removal of Disease 23 ABSTINENCE—Its Morbid Effects 26 ACNE 27 ADHESIONS—Reparative and Mor- bid 32 ADIPOSE TISSUE —Its Morbid States 36 AFTER-PAINS 37 AGE—Considered with relation to the Nature and Treatment of Dis- eases 38 -Of the early Periods of Age 39 -Of the advanced Periods of Age 44 AUROSIS 50 ,GINA PECTORIS 62 ANTIPATHY 70 AORTA—Nervous Pulsation of the 70 ---Inflammation of the 71 ~r—Aneurism of the 72 APOPLEXY 79 ---Of New-born Infants 107 APPETITE—Insatiable—Bulimia 107 ---Vitiated—Pica 110 ARTERIES—Diseases of 111 ---Nervous Affection of 112 ---Inflammation of 112 ---Morbid Structures of 116 ---Aneurisms, &c, 117 ARTS AND EMPLOYMENTS— In relation to Disease 122 ASPHYXY 128 ---Of New-born Infants 134 ASTHMA 135 ATROPHY 154 AUSCULTATION 156 BARBIERS BERIBERI BLOOD—Its States in Health ---Exuberance of—Plethora ---Local Determinations of ---Deficiency of— Ansmia ---Morbid Effects of its Loss ---Alterations of, in Diseases ---Contamination of the, &c, ---Nervous Influence on the ---Action of Poisons on — Various Morbid States of — Signs and Treatment of, &c, &c, BLUE DISEASE BRAIN — Alterations of its Mem- branes ---Alterations of its Sinuses and Ves- sels ---Alterations of its Substance ---Abscess of the ---Softening — Haemorrhage — Hy- pertrophy — Atrophy — Indura- tion, &c, ---Tumours in the, &c, ---Cerebral Plethora ---Congestion of the ---Inflammation of its Membranes ---Inflammation of its Substance ---Inflammation of its Membranes and Substance ---Softening of the BRONCHI AND AIR PASSAGES ---Alterations of their Structure ---Congestion of the ---Inflammations of the—Acute and Chronic BRONCHIAL FLUX — Bronchor- rhcea BRONCHOCELE BULLAE 163 164 166 168 171 173 175 180 192 193 194 199 201 208 209 210 214 221 226 227 228 230 232 241 244 248 249 267 269 271 CONTENTS. CACHEXY 272 ——African 273 CAECUM—Diseases of the 274 ---Functional Disorders of the 275 ---Inflammation of the 277 --------------of its Appendix, «fec, 278 CANCER 282 CATALEPSY 290 CATALEPTIC ECSTASY 291 CATARRH 293 CELLULAR TISSUE^Alterations of 298 ---Diffusive Inflammation of the 299 ---Induration of the 306 CHEST—External Examination of the 309 ---Deformities of the 310 CHICKEN-POX 312 CHLOROSIS 315 CHOLERA 318 CHOLERIC FEVER OF IN- FANTS 325 CHOREA AND RELATED AF- FECTIONS 327 CLIMACTERIC DECAY 336 CLIMATE—Its Physical Relations 338 Its influence on the Human Con- stitution 342 In the Cure of Disease 349 COLD—Its Pathological Effects 354 Its Remedial Operations 358 COLIC—Forms depending on Func- tional Disorder 360 COLIC—Bilious— Hepatic — Madrid, or West-Indian 362 From the Poison of Lead, &c, 364 From Change of Structure and Relative Position of the Bowels 366 COLIC AND ILEUS—Comprising Introsusceptions, &c, 366 Treatment, &c, 371 COLON—Nature and Treatment of its Morbid States 382 COMA AND LETHARGY 387 CONCRETIONS, BILIARY 392 CONCRETIONS, INTESTINAL 397 CONGESTION OF BLOOD 401 CONSTIPATION 405 CONVULSIONS—Partial and Gen- eral 412 Infantile 417 Puerperal 418 COUGH 436 CRANIUM AND ENVELOPES— Their Lesions ^39 CRETINISM • 441 CRISIS AND CRITICAL CHAN- GES 443 CRITICAL DAYS 448 CROUP 449 Its Varieties 452 Its Complications, &c, 454 Its Treatment 452 DICTTdNARY PRACTICAL MEDICINE. ABDOjMEN. Syn. Ventre, Fr. Unterleib, Bauch, Ger. Ventre, Pancia, Ital. Belly, Eng. External Examination of the Abdo- men in Disease. Classification.—Pathology. Semei- ology, or Symptomatology; Diagnosis. 1. The abdomen may be considered as the fundamental part of the frame, inasmuch as it is never wanting in monstrous foetuses; and as it contains parts which are the first formed in the embryo, and are the centres and sources of or- ganic life. The number and importance of the viscera contained in its cavity; the number, the diversity, the extreme frequency and complica- tion, of the maladies to which these viscera are liable, are circumstances which pressingly urge upon the practitioner a careful examination of the parietes of this cavity, in order to ascertain the nature and extent of disease. Much, however, will depend upon the manner in which the ex- amination is made, in respect both of acquiring information as to the existing state of disease, and of drawing inferences as to its origin, and the best means of removing it. 2. Pathologists have generally divided the ab- domen into certain Regions, with the view of describing with more accuracy the seat of morbid actions. These regions are marked out by means of imaginary lines, drawn in horizontal and ver- tical directions. The horizontal lines, four in number, divide this cavity into three zones. The highest of these lines pass over the xiphoid carti- lage; the second, by the margin of the tenth rib; the third, by the anterior and superior spine of the ilia; and the fourth, by the superior margin of the pubis: thus giving three zones, the epigastric, the umbilical, and the hypogastric. 3. For the sake of additional precision, each of these zones is divided into segments by vertical lines, also four in number, drawn from the acro- mial extremity of the right and left clavicles to the insertion of the ligaments of Poupart; and from the posterior margins of the axillae, over the most exterior part of the crests of the ilia, to the large trochanters. The spinous processes of the vertebrae may likewise be considered as forming a fifth line of demarcation; as we cannot overlook the posterior parts of the body in our investigation of many of the diseases affecting the abdominal organs. The vertical lines now enumerated, di- viding the horizontal lines very nearly at right angles, give us nine regions on the anterior and lateral aspects of the abdomen, and six posterior regions. The anterior regions are the epigastric, umbilical, hypogastric, and right and left inguinal; the lateral regions are the right and left Jiypo- chondriac, and right and left iliac; the dorsal regions are the inferior dorsal — right and left, the right and left lumbar, and the right and left glu- teal regions. 4. It does not belong to the scope of this work to enumerate the anatomical boundaries of the abdomen; the parts forming its parietes; or the viscera contained in each region. These are matters which are, or ought to be, familiar to all who peruse this work. But it is necessary to remind the reader, that organs which, in the healthy state, are always situate in a particular region, will be so changed in form and bulk by dis- ease as frequently to extend to adjoining regions, where they will often be detected upon a careful examination; or they will be altogether displaced, either by the specific gravity of their contents, or by tumours developed in their structure. The former phenomenon is often remarked in respect of the liver, spleen, kidneys, ovarium, uterus, &c.; the latter, in the stomach, pylorus, gall-bladder, colon, &c. 5. This change of the position of the abdominal viscera is chiefly observed in the more chronic kinds of organic diseases, and is pointed out in the articles in which they are described: it is gen- erally more manifest in one posture of the body than in others; and is to be ascertained, with the other maladies to which these viscera are liable, by the modes of examining the abdomen about to be explained, assisted by other rational or infer- ential symptoms. These modes may be made the source of much information as to all the relations of abdominal diseases; but attention, repeated observations, and much natural discernment, are required to obtain from them all the knowledge they are capable of conveying. I shall discuss this subject in the brief manner to which I am necessarily driven, by noticing, I., Inspection; II., Manual examination; III., Percussion; and, IV., Auscultation of the abdomen. 6. I. Inspection by the sense of sight mere- ly, although the best mode of acquiring an idea of the form, size, and motions of the abdomen, is chiefly valuable as a means of investigating the diseases of its viscera in conjunction with the other modes just enumerated; yet simple inspection furnishes us with the most important information in many diseases, particularly in those of infancy and childhood, as well as in many acute and chronic maladies occurring in adults. The form of the abdomen, although necessarily in some 2 ABDOMEN — Investigation of, in Disease. measure changed by marked variation of its bulk, may, nevertheless, be much altered without any decided difference in its size. Thus, it is some- what changed in severe diseases of the respiratory passages, when the entrance of air into the lungs is obstructed; the epigastrium and hypochondria being then pressed inwards and upwards: whilst in some morbid states of the liver and gall-bladder, of the spleen, and of the ovaria, an unusual promi- nence in their respective regions is frequently ob- served. But the most remarkable changes in the form of the abdomen is met with when the size of the cavity is also altered. It is scarcely necessary to allude to examples; but, in all those diseases attended with enlargement or diminution of the bulk of this important part of the body, either in one of its regions, in several of them, or in all, in- spection should always be performed : it gives greater precision to manual examination; enables us to compare the bulk of a region with the corres- ponding region on the other side, and with others in its vicinity; and impresses upon the memory the changes which the part may experience dur- ing the progress of disease. It should, therefore, never be neglected in all the forms of abdominal dropsy; in peritonitis, chronic or acute; in inflam- mation of the stomach, liver, spleen, and bowels; in the dillerent kinds of colic, in fevers, in uterine and ovarian diseases; in affections of the kidneys and urinary organs; in all disorders accompanied with obstruction to the excretions; and, in short, in all chronic maladies. It ought never to be overlooked in the diseases of infancy and child- hood, of whatever nature they may be. 7. Besides, however, attending in those diseases to the form and size of the abdomen merely, the motions which it presents ought not to be neglect- ed. When lightly interpreted, they often furnish important diagnostic and therapeutic hints. But they require to be viewed in connection with the motions of the thorax, and state of the heart's ac- tion. In diaphragmitis, peritonitis, gastritis, enter- itis, and ceitain states of hepatitis, the motions of the abdomen are slight or obscure, whilst the ac- tions of the thorax are increased. On the other hand, in several severe diseases of the respiratory organs, particularly in croup, laryngitis, bronchitis, several varieties of asthma, pleuritis, pneumonia, &c., the parietes of the chest are nearly motion- less; whilst the movements of the abdomen, es- pecially at the epigastrium, in croup and asthma, are remarkably increased, or laborious. The motions of the abdomen, also, are often not limit- ed to those caused by respiration; but in some cases, particularly in organic changes of the heart, pericardium, aorta, &c, and even in certain nerv- ous disorders implicating these organs, comprises those occasioned by the action of the heart, in- creased by the state of the large abdominal vessels, and by the emaciation or other morbid condition of the patient. 8. II. Manual examination of the ab- domen is one of the most important means of di- agnosis we possess but it furnishes information in proportion to the perfection of manner in which it is made. In this very requisite mode of inves- tigation, the temperature of the hand of the prac- titioner at the time of making it should be attend- ed to, in the great majority of diseases; both as a moderate warmth of the hand is necessary to the greatest delicacy and accuracy of touch, and as its application to the surface of the abdomen will not in that state occasion any disturbance or con- traction of the muscular parietes. In entering upon the examination, care should be taken not to excite the alarm of the patient. The hand ought to be applied at first in the gentlest manner pos- sible. By observing this, three very important objects will be best obtained ; namely, a know- ledge of the form, of the temperature, and of the sensibility of the surface of the abdomen. 9. As much more information than this is re- quired from manual examination, the patient should be directed to place himself in a favour- able position for a more general and complete investigation. He should be placed on his back, with the head and shoulders slightly and comfort- ably elevated, and the thighs drawn nearly to a right angle with the trunk. If the bladder be full, it should be emptied. When proceeding to examine, the patient should be told to relax all the muscles, particularly the abdominal muscles. Commencing, therefore, with the utmost gentle- ness, and passing the hand slightly over the ab- domen, we should slowly increase the pressure, with the view of ascertaining the following con- ditions—1st, Its temperature; 2d, Its form and size; 3d, Its sensibility; 4th, Its degree of tension and firmness; 5th, 1 he existence of enlargements, tumours, &c; tth, Ihe presence of efrased flu- ids; 'th, rl he pi obable existence of accumulated secretions and faecal matters; 8th, Hernial protru- sions and displacements. On each of these I pro- ceed to ofler a few remarks. 10. 1st, 1 he temperature of the abdomen fur- nishes most important indications as to the nature of disease. It is generally always higher than natural in diseases of increased action; and is also often higher when the patient is actually com- plaining of cold, particularly at the commence- ment of fevers. In many fevers and inflamma- tions of the abdominal viscera, particularly those of a dangerous or malignant character, the in- creased ten perature is accompanied with a pecu- liar acrid pungency to the sensation of the exam- iner; a phenomenon which indicates the utmost risk of rapidly supervening disorganization. Di- minished temperature of the abdomen is met with in the period of depression, or cold stage at the commencement of fevers, but very seldom at their termination, even in death, unless in the most malignant or liquescent forms. It is also met with after injuries of the abdomen, particular- ly blows on the epigastrium, in anaemia, chlorosis, and other disorders of debility. 11. 2d, 1 he form and size of the abdomen are frequently altered, as already noticed (§6, 7.); but, in order to ascertain the nature of the altera tion, various means of investigation are generally required, particularly those which remain to be considered. When proceeding with the manual examination of the abdomen, it is necessary very gently to increase the pressure, and, when acute pain is not complained of, to make it in various directions,—laterally, downwards, upwards, and backwards to the spine,—so that if altered sensi- bility of any of the contained viscera exist, it may | not escape detection, but be accurately ascertain- | ed and estimated; and the examination should always be made with a careful observation of its effects upon the expression of the countenance of , the patient. It will also often be requisite to per- ABDOMEN—Investigation of, in Disease. 3 form the manual examination, now with the points of several fingers, now with the whole of one, or even of both hands; and occasionally, at the same time that a fall inspiration is being made. But it should always be performed with attention to the sensations of the patient, particularly as expressed by the countenance, and to the feelings and ideas it may excite in our own minds. Even the state of action in which the abdominal muscles are often thrown by the examination ; the degree of pressure occasioning such action ; and the cir- cumstance of tension of those muscles preceding the examination, or being excited by it; as well as the continuance of their contractions, and the pe- riods and occasions of their relaxation, are all im- portant matters in our estimate of the state of the viscera underneath,—more particularly in the various states of inflammation seated in the peri- toneum, in the alimentary canal, &c. 12. 3d, The sensibility of the parietes of the abdomen is most intimately associated with that of the contained organs, both in health and dis- ease. The sensibility of the epigastric region varies most widely in different persons. It is fre- quently, even in tolerable health, very great in delicate and thin females. It is always so in inflammation of the viscera, more particularly when the serous membranes are affected; and the more superficial the inflammation, the more tender is the surface. In order to obtain an accurate idea of the state of the sensibility of the abdomen, pressure should be commenced in the gentlest manner, and with the fingers and palm of the open hand. When the patient cannot en- dure the slightest touch, the disease is then com- monly in the parietes, or in the serous membrane reflected over them. When the cause exists more deeply, the tenderness is less acute, and the muscles are almost instinctively brought into action, even before pressure is made, in order to protect the diseased viscera from it. 13. When superficial tenderness is absent, the examination may be made with increased pres- sure, in order to ascertain the presence of tender- ness, pain, or soreness, in any degree or at any part. But caution in thus increasing the pressure is always necessary when the parenchyma of an organ, particularly of the liver or spleen, is enlarged or otherwise affected ; for many such affections may be very serious, and yet the sensibility of the diseased part not much increased. I have known rupture of an enlarged and softened spleen occa- sioned by the rudeness of the examination ; and writers have mentioned similar accidents to have occurred to the liver. 14. 4th, The tension and firmness of the abdo- men require attention, and due estimation of their actual amount; and in connection with the other diagnostic indications furnished by the examin- ation. Thus, when the tension is associated with increased temperature and sensibility, inflamma- tion of one or more organs underneath, particularly of the peritoneum, may be predicated. The tu- mefaction, degree of sensibility, position of the patient, &c. will further prove the accuracy of the diagnosis. Tension and firmness are always present in the different forms of peritonitis and inflammations of the subjacent viscera, but not uniformly throughout all their stages. Even in the worst or most malignant forms of peritonitis, as those met with in puerperal females, these symp- toms are often either almost altogether wanting, or they exist for a short time only. When efiusion of a serous or sero-purulent matter occurs in peritonitis, or when suppuration has followed in- flammation of the enveloped viscera, tension as well as firmness disappear. They are generally, however, both present, even when the sensibility of the parietes is not much greater than natural, in chronic peritonitis with the formation of false membranes, or the agglutination of the opposing surfaces of the viscera. 15. 5th, The presence of tumours or other mor- bid growths, or the fact of their absence, has also to be ascertained by a manual examination. This information can be obtained only by this mode of investigation, carefully conducted. If we detect any degree of unusual tumefaction or hardness, we should endeavour to ascertain its exact site ; its form, size, connections ; its consistence, degree of sensibility ; and whether it is fixed or moveable, soft and yielding, or hard ; pulsatile or not. The situation of the tumour ; its size, form, and degree of fixedness, will enable us to form an idea of the part affected: whilst the absence or presence of morbid sensibility in it, of fluctuation and puls- ation, and the manner in which the nearest parts of the abdominal parietes are affected by it, will furnish important indications of its nature. When tumours or unusual circumscribed indurations are detected in any part of the abdomen, we should bear in mind that their sources and kinds are numerous : that they may be formed in the liver, pancreas, spleen, stomach, pylorus, mesentery, omentum, caecum, kidneys, uterine organs, &c.; that their nature may be extremely various ; and that they may consist either of accumulations of some fluid contained in a cyst, or infiltrated in the substance of an organ, or enclosed in its natu- ral cavity, the outlet of which has been obstruct- ed ; or of a deposition of some morbid structure, the nature of which can only be known by a com- parison of numerous symptoms, and the history of the disease. Care should be also taken that the accumulations of faecal matters occasionally formed in the caecum, and in various parts of the colon, or that an unusual anterior protuberance or curvature of the inferior dorsal or lumbar ver- tebrae, be not mistaken, as have sometimes hap- pened, for morbid growths; and that unusually large collections of the natural secretions in their cysts, as of the bile and urine, owing to temporary obstruction to their discharge, be not treated as morbid formations of a very different kind. I have known cases in which distension of the gall-blad- der, from great accumulation of the c) stic bile, was mistaken for abscess of the liver; and an enormously distended urinary bladder was viewed as dropsy. 16. 6th, The presence of fluids effused into the peritoneal sac is best ascertained by placing the patient in the erect posture. If this cannot be done, and if he cannot even sit up, the shoulders and limbs should be placed low ; and, whether in the erect or recumbent posture, the palm of one hand laid with a gentle pressure upon one side of the abdomen, whilst we tap somewhat smartly with the other hand, on the opposite side. The impulse occasioned by the stroke will occasion, if fluid be effused, a vibratory undulation or shock which will be felt by the other hand, and which constitutes the diagnostic 4 ABDOMEN—Investigation of, in Disease. symptom in diseases of the abdomen attended with efiusion. 17. 7th, Accumulation offcecal matters'mthe bowels are not unfrequently mistaken for tumours. These matters usually collect and harden in the caecum, or in some part of the colon. They seldom accumulate in the small intestines, unless they consist of certain kinds of intestinal concre- tions (see the art.); which are with difficulty dis- tinguished from tumours seated in some one of the abdominal viscera. It is indispensably re- quisite to examine the abdomen carefully in all cases of habitual or occasional constipation, par- ticularly in the region of the caecum and course of the colon ; as, when conducted with an expe- rienced tact and discrimination, these collections will generally be ascertained: and when the his- tory of the case, and numerous contingent rational symptoms, are taken into account, little risk will be run of confounding them with morbid growths. The accumulation of secretions in the gall-bladder, and in the urinary bladder, are chief- ly, particularly the latter, ascertained by manual examination. The diagnosis of those disorders is fully pointed out in another place. 18. 8th, Protrusion of some part of the abdo- minal contents, giving rise to any either of the more common kinds of Herniee, or of those winch are unusual, should never be overlooked. Inguinal, femoral, and umbilical herniae are so frequent, and, when either incarcerated or strangulated, oc- casion so serious effects, that in all cases where severe symptoms are referred to any of the viscera contained in the abdominal cavity, or in its vici- nity, or when the functions of the bowels are obstructed, this source of mischief should be par- ticularly enquired into. 19. I may observe generally, in respect of manual examination of the abdomen, that it fur- nishes valuable means of diagnosis in very many diseases, particularly when estimated in due con- nection with those derived from other sources ; but I should add,—what I shall often have to prove hereafter,—that it does not always give us exactly the same kind of information that is stated in several, and even in some very recent, works. Thus it is said to be the most certain means of ascertaining the presence of enlarged mesenteric glands, and by actually feeling these glands en- larged. Now this is not the case, and I state it from an experience of many hundred cases: for there are comparatively but few instances in which these enlarged glands can be satisfactorily detected, by the most careful manual examination. But this mode of investigation furnishes certain indications of their presence of a different kind from that which writers have laid down. It may also be remarked, that a manual examination of the abdomen is generally much more successfully made in lean subjects, in females than in males, and in children than in adults; whilst in mus- cular men, and in fat persons, it furnishes much less information, owing to the muscularity and thickness of the abdominal parietes. 20. III. Percussion has been employed as a means of diagnosis in diseases of the abdomen from a very early period of medical knowledge, but chiefly with a view of recognising tympanitic affections, or unusual accumulations of air, and dropsical effusions ; and it was not until very lately that attention was directed to it as a means of investigation in a very large proportion of other diseases of the abdominal viscera. Percussion of the abdomen as well as of the thorax is either direct or mediate: the former is that which was first ably insisted on by Auenbrugger, and brought into notice byCoRvisART, chiefly in the investigation of thoracic diseases ; the latter, both in its application to abdominal and thoracic affec- tions, is the invention of M. Piorry, who has paid great attention to its perfection, and has written ably on it as a means of diagnosis. 21. Direct percussion consists of simply striking the parts, somewhat smartly, with the points of two or more fingers united and brought to the same plane, and attending to the sounds elicited. Mediate percussion is performing the same with a thin plate of ivory, box wood, or any other hard elastic body, placed over the part to be thus examined, and striking upon it. The advantages derived from having such a body interposed be- tween the surface and the fingers are, 1st, The part is protected in a great measure from the stroke, which, although slight, yet is frequently unpleasant to delicate and sensitive persons ; 2d, It assists in the production of the sound for the obtaining which percussion is employed. (See art. Percussion.) The body on which the per- cussion is thus made usually consists of a small ivory plate of about 2£ or 3 inches in diameter: M. Piorry calls it the pleximeter, or measure of percussion. In all cases in which we wish to ex- amine the abdomen by percussion, it will be ne- cessary to use the pleximeter. The information it conveys varies according to the state of the parts underneath. If we place it o\ er the liver, per- cussion gives out a dull sound ; from the circum- stance of a dense body lying beneath that part of the abdominal parietes: if it be moved in the course of the stomach and colon, a sound will be elicited clear in proportion to the quantity of air contained in these viscera. 22. During our investigation of the abdominal contents with the aid of mediate percussion, it will be necessary to attend to certain facts:—1st, That the pleximeter will furnish, in the same person, a sound varying from dull to tympanitic as the parts over which it may be placed differ in density and the quantity of air they may enclose ; 2d, That in situations of the abdomen where, owing to the quantity of air usually contained in the bowels, mediate percussion generally gives a tympanitic sound when the plate is placed lightly on the surface, it will give a much duller, or even a dead sound, when pressed inwards so as to displace the air from underneath it, and to approach nearer to some solid body, or to bring the parts nearer to that condition by the pressure ; 3d, That the stomach and whole tract of the in- testinal canal always contain a certain quantity of air or gaseous fluid, particularly the large bowels ; and that they approach more nearly to the abdominal parietes in proportion to their dis- tension, whether with air, or with fluid or more or less solid contents ; and 4th, The quantity of air contained in the digestive tube, especially the sto- mach and large bowels, is great in proportion to the deficency of its vital energy, and the degree of inflammatory action affecting it. 23. These facts being attended to in our in- vestigations of abdominal diseases by means of | percussion, mediate or direct, the extent of the ABORTION- liver may be distinctly traced by its means ; and the degree of inflation of the bowels, or stomach, may be ascertained with tolerable certainty. When the stomach is nearly empty (for it always con- tains some air secreted from its internal surface), it retracts backwards, and recedes from the abdo- minal parietes towards the centre of the trunk; having then the colon, more or less distended with gas, placed before it. As it becomes filled with air or the ordinary ingesta it extends to the left hypochondrium, and approaches the left and an- terior parietes of the upper zone of the abdomen. In proportion to the quantity of air it contains, percussion gives out a clear sound, which is dull or dead as it is filled with fluid or solid ingesta, and as the air is displaced. When we know that the stomach must be empty of food, and yet find that a dull sound is emitted on percussion, we should always suspect organic disease. In these cases air is often secreted with great rapidity from its internal surface, but is immediately expelled, owing to the irritable state of its muscular coats, without being retained, and before any very material distension of the viscus is occasioned by it 24. The small intestines generally contain air; although, I believe, much less than is usually found in the large bowels. In a state of health, particularly a few hours after a meal, when the chymous matter is passing along them, percussion over them,—that is, over the umbilical region, and the i;n mediately adjoining parts of the surround- ing regions,—'generally yields a dull sound; which becomes clear in proportion to the quantity of air they contain, excepting in very fat persons. In a great majority of abdominal diseases, the quantity of air contained in the small intestines is increased much beyond what exists in health: this is particularly the case in several diseases of debility, as chlorosis, indigestions, colicky affec- tions, torpid states of the liver, constipation, cer- tain states of fever, hysteria, &c.; and still more bo in inflammatory states of portions of the diges- tive tube, in peritonitis, in puerperal fevers, &c. 25. When the mucous surface of the bowels or of the stomach is irritated or inflamed, the quantity of air secreted is often very great; but, excepting in the slighter states of such diseases, it is seldom retained within the sphere of the in- flammation so as to occasion that degree of dis- tension which may be detected by percussion, although it is often retained in adjoining parts of the tube, occasioning distension, great pain, tor- mina, &s. This disposition to expel the morbid collection of air arises from the irritability of the muscular fibres of that part of the intestines, the mucous surface of which is in a state of irritation; the morbid action of these fibres propelling it either upwards or downwards, where it may accu- mulate or be evacuated, but most commonly into the large bowels, or into the duodenum and stomach, where it may be detected by percussion. In diseases which paralyse the contractile actions of the muscular coats of the bowels, as the malig- nant puerperal peritonitis, the last stages of ente- ritis, rabies canina, and the advanced states of adynamic fevers, the quantity of air which is secreted and accumulated in the whole digestive tube, and the consequent distension, are often enormous. The sound on percussion, in these cases, generally becomes quite tympanitic long —Causes of. 5 before death, indicating the cause, as well as the lost tone of the muscular coat of the canal. 28. The phenomena now noticed to occur in respect of the small intestines affect, in a still more marked manner, the large bowels; flatulent distension of these being readily traced by medi- ate, or even direct percussion, particularly in the course of the colon, even when the small intes- tines, are comparatively free from it. 27. It is not merely the presence of accumu- lated air in the different parts of the digestive tube, and the important pathological and therapeutic in- dications to which the knowledge of this fact natu- rally leads, that render percussion of the abdomen a valuable means of investigation, but it is also the information it conveys of the existence of more solid formations—of fluid collections, and morbid productions. Unusual distension of the bladder ; all the forms of abdominal dropsy; ovarian dis- eases ; purulent collections in, or enlargements of, the liver; tumours of every kind, particularly when they reach a considerable size ; enlarge- ments of the spleen or kidneys, &c. ; are more readily and earlier detected by means of mediate percussion than without this aid: and, in all these, the sound emitted is dead over the diseased part, and becomes clear as the boundary of dis- ease is passed, and when the plate is placed over the hollow viscera. 28. IV. Auscultation, mediate or direct, particularly the former, is often necessary in ahdo-. minal diseases, particularly in ascertaining whether or not the large vessels are affected ; and even in tracing disease of the right side of the heart and of the pericardium. It may also be useful in those diseases of the liver which extend to the lungs through the diaphragm, particularly abscess, or hydatidic cysts of the liver breaking into the lungs. Auscultation of the abdomen has been resorted to by M. Kergaradec to ascertain the existence of pregnancy; and by M. Lisfranc, to determine the presence of stone in the bladder, when the sound is imperfectly heard to strike against it. BmLiocRArHY. Bavlini, Prax. Med. lib. iv. c. 9. | Dou'de, Semeiologie Gener ile,t. i. p. 333.— Cruveilhier, Diclionnaire de Med. et Chirurg. Prat. t. i.—Piorry, De la Percussion Mediate, Paris, 182d; et Piocede Opera- toirs dans 1'Exploration des Organespar la Percussion Mediate, Paris, 1630. ABORTION. Syn. Abortus, aborsus, affluxio. Jia moptysis, with violent paroxysms of cough and threatened abortion, occurring in a plethoric lady at the fourth month of pregnancy. Full venae- section was performed, chiefly on account of the severity of the pulmonary disease; the col- chicum was directed with an anodyne; and the patient left under the care of the family practi- tioner. Abortion took place, and was attributed chiefly to the sickness, retching, and depression occasioned by the colchicum; it having been un- remittingly administered until my next visit, on the third day from that on which it had been pre- scribed, notwithstanding the discretionary power with which the practitioner had been invested. (See also, on this subject, the Treatment of Hae- morrhage from the Uterus.) 39. III. The remeiial treatment of abortions is next to be considered. It occasionally happens that the retention of the ovum, or of a portion of the appendages of the embryo, produces much constitutional disturbance, particularly nervous symptoms, and irritative fever, which sometimes assume serious features, with disorder of the bow- els, typhoid or ataxic signs, and an offensive vagin- al discharge. The decoction of cinchona and muriatic acid, or this decoction with the liquor of the acetate of ammonia, or the following, will prove extremely serviceable :— No. 1. R Mist. Camphors 5 j.; Liq. Ammon. Acet. gijss , Acidi Acelici Pyrolignei 17} xxv.; Syrup. Zingiberis. 3sa M. Fiat haujtus ter quaterve in die sumendus. No. 2. R Camphorae rasa?, gr. ij.—iij. ; Extr. Cinchon. Resin, gr. iij.—v.; Conserv. Eos. q. s. ut fiant Pilulseij^ ter die capiendae. In cases of this description a turpentine enema, administered every second or third day, is ex- tremely beneficial : and advantage will be derived from injections of a solution of the chloruret of lime, or of Labarraque's liquor, per vaginam. No. 3, R Liq. Labarraquii Chloro-Sod. gjss.; Mist. Cam- phors, ^vij.i. M. Fiat injectio. 40. When troublesome diarrhoea is present, in cases of this description, the chloruret of lime, either in the form of pill or solution, is extremely efficacious. I have prescribed it as follows :— No. 4. R Chlorureti Calcis gr. viij.—xvij. ; Pulv. Traga- canth. Comp. Jjss.; Syrup, q. s. M. Fiant Pilulae xxiv., quarum capiat binas ter quaterve in die. No. 5. R Chlorureti Calcis gr. vj.—xij. ; Tinct. Calumba ^ iij. ; Aq. Menth. Virid., vel Aq. Carui, vel. Aq. Ane- thi, Jvj.— §vijis. Fiat Mist., cujus sumat coch. j. velij. larga ter quaterve quotidie. The chloruret of lime may aLso be administered in water gruel, as an enema, in doses of viij. to xij. grains, once or twice daily. 41 The debility occasioned by abortions re- quire the use of tonics, with mineral acids, nour- ishing but light diet, a wholesome air, gentle exercise, and the tepid or cold salt-water bath :— the mineral waters of Bath, Bareges, or Tun- bridge; those of Ems, Spa, Pyrmont, and Geil- nau; or the artificial mineral waters of the last- named places, are also beneficial. When nervous or hysterical symptoms supervene, the exhibition of antispasmodics, with gentle tonics, and the oc- casional use of cooling aperients, are required. The treatment of the effects of abortion is, in every respect, the same as that recommended in 12 ABSCESS —Pathological Doctrine of. the articles on Hemorrhage from the Uterus, in the unimpregnated and puerperal states. Bibliography. F. Alliums, Diss, de Abortu, Franc. 4to. 1699. — Stahl, Diss, de Abortu et Foetu Mortuo, Halae, 1704.— Vide Halter, Disser. Collect., t. iv. No. 139.— Stall, De Abortu, in Diss. Med. edit. Egerel, t. iv. — Detharding, De Foetus immaturi Exclusione, Rost. 174S. — Jasserini, De Abortu, Vien. 1777.—Mayer, Aphorismi de Causis Abortum provocantibus, 4to. Franc. 1780.— Becker, De Abortu, Got. 1798.— Chregorini, De Hydrope Uteri et Hydatidibus, Hal. 1795. — Le Roy, Sur les Pertes de Sang pendant la Grossesse, et sur les fausses Couches, Paris, 1801. —Stewart, On the Causes which destroy the Foetus in Utero, in Medical and Chirurgical Transactions, vol. 7. p. 144 — El. v. Siebold, Von den Fruhgeburten in dessen Handb. zur Erkeuntniss und Heilung der Frauen- zimnier krankheiten, ii. b. u. 2., Frank. 1823. — Professor Desormeaux, art. Avortement, Diction, de Medicine, t. iii. p. 177.; et art. (Euf., ibid. t. xv. — Dr. Blundell, Lectures on Midwifery, Sic. Lancet, vol. xiii. — Good, Study of Medicine, vol. v. p. 174. — Els. v. Siebold, art. Abortus Encyclop'4disch'es Worterbuch der Medicinischen Wissenschaften, 6ic. erster Band, Berlin, 1828. — Ryan Manual of Midwifery, 12mo. Lond. 1831, 3d ed. Duges, in Revue M&licale, 1824, t. iii. p. 74. ; et Manuel des Ac- couchemens, Paris, 1830.—Audry, Sur le Maladies du Foetus et ses Annexes, in Journ. des Progres des Scien. Med., 2d ser. t. i. p. 126. ABSCESS. Syn. Abscessus (from abscedere, to depart, to separate), Apostema, Abscessio, Vo- mica, Imposthuma, Auct. Lat. Anoari;iia Gr. Abces, Fr. Die Eiterbeule, Ger. Ed- derbyld, Dan. Bulning, Swed. Ettergezwel, Dut. Ascesso, Ital. Abscesso, Span. Absces- so, Port. Abscess, Imposthume, Eng. Classif. — See Inflammation. 1. Defin. A collection of purulent matter formed or deposited in the structure of an or- gan or part. 2. An abscess is never an original disease, but is constantly the effect or termination of inflamma- tory action, in some form or grade, or of irritation of the part in which it is seated. This may not seem to be in accordance with certain phenomena connected with the formation of purulent collec- tions, in parts at a distance from those in which inflammatory action originates, and where pus is originally formed: but I shall have occasion to show that it is not opposed to sound views as to this topic, or, at least, that the exceptions to it are few. 3. Without noticing further than to enumerate them, the older distinctions of abscesses into the warm, phlegmonous, or inflammatory, the cold or congestive, and the acute and the chronic, I shall have to show that, instead of proceeding from different sources, they are equally the result of a certain state of inflammatory action, modified into a variety of forms according to the degrees of vital energy and action of the part, and of the system generally, the organization of the part af- fected, and the peculiarity of constitution and diathesis. In the present article, a general view will be taken of the pathology and medical treat- ment of abscess, the consideration of the different kinds of abscess; their various seats, and relations to other diseases, fall under different heads, where they are more advantageously discussed. 4. I. Of the Pathological Charac- ters of Abscess. 1st, Of abscess proceeding from acute inflammation, with integrity of the constitutional energy. When a part becomes inflamed, the vitality of which has not been previ- ously injured, as respects either its individual state or constitutional relations, its temperature becomes increased, and its vessels are injected with a great- er quantity of the circulating fluid than in health, and generally in proportion to the violence of the irritation upon which this afflux of fluid depends. I At first the fluid does not extend beyond the vessels 1 in which it has passed : but, in proportion as it dis- tends them so as to exhaust their tone and power of reaction, and as the vital cohesion of their ex- tremities, and of the tissues which they supply, is weakened, a portion of the more fluid constituents of their contents escapes into the texture of the part affected; infiltrates, and combines with, its constituent elements; and renders it, at first, more compact and dense. But, at the same time that the inflamed part undergoes this change, it looses its vital elasticity, is more friable or lacerable, so as to break down more readily from foreign press- ure, or upon the application of a firm ligature. 5. If the inflammatory action stops not here, the tissues affected by it undergo further changes. They pass, more or less rapidly, from a dense but friable state to that of softening; and this quickly but insensibly assumes a pulpy condition, owing to its continued and increasing infiltration with the more fluid parts of the blood, and even with more or less of its coloring particles; the mole- cules composing the tissues of the part being so combined with, and separated by, the infiltrated fluid, that all distinct traces of proper organiza- tion are lost. From this pulpy state, to which the central portion of the inflamed structure is reduc- ed, the transition to pus proceeds rapidly. But it is not to be understood that the tissues them- selves are converted into this fluid. The fluid poured out from the extreme capillaries gradually distends the surrounding parts, and partially dis- solves the softened and disorganized tissues in which it is effused. The coagulable lymph, which the tonic or unexhausted vital energy of the ad- joining vessels form in the surrounding texture, confines the effused fluid, and prevents it from extending beyond the barrier it opposes; whilst the impaction of the cellular tissue, occasioned by the increasing quantity of purulent effusion, and the pressure it produces in all directions, with the thickening, and the continued deposition of lymph in the parietes of the abscess, tend still further to fulfil this end, and thus to limit the mis- chief, and to prevent the contamination and dis- organization of the adjoining structures; conse- quences which not unfrequently supervene, when the vital energies of the frame and the state of lo- cal action are insufficient to admit of the formation of coagulable lymph and to throw up this barrier against the extension of disease. 6. The first step of the suppurative process is the dissemination, particularly in the softest, in the first and most intensely inflamed part, of minute collections of a sero-albuminous or sero-sanguine- ous matter. By degrees, this fluid becomes more abundant. These minute collections enlarge, ap- proach each other, and, at last, the partitions of softened tissue between them are altogether dis- organized and disappear; the whole, at last, forming only one cavity of variable extent. As this process advances, the effused fluid changes from a tluii albuminous lymph into pus; which be- comes more thoroughly elaborated, losing its col- oring matter which it had derived from the blood; and dissolving the shreds or dibris of the disor- ganized tissues in which it had formed : and when the suppurative process is matured, the pus forms an homogeneous fluid, presenting certain charac- ters distinguishing it from all other animal fluids. ABSCESS—Acute, its Pathology. 13 7. Pus, taken from a matured abscess of the description now exhibited, is generally a whitish or cream-like fluid ; friable, homogeneous, soft, and smooth to the touch ; somewhat heavier than water, in which it is only partially soluble ; with- out any disagreeable smell, and producing of itself no irritating effects upon the tissues enclosing it as long as it is excluded from the action of the atmosphere. Upon a closer examination, it is found to consist of minute colourless globules, resembling the colourless globules found in the blood, floating in a thin albuminous fluid. 8. It is often a matter of importance to distin- guish pus from the mucus secreted by a mucous membrane in a state of irritation ; and, accord- ingly, various attempts have been made to esta- blish some specific character. The circumstance of pus sinking in and partially mixing with water, whilst mucus remains at its surface, has been taken as a common test; and in many cases will be sufficient, with the history of the disease, and various concomitant phenomena, to enable us to decide : but it should be recollected that the mu- cus, which is frequently secreted in great abund- ance by the internal surface of the bladder, and which is very remote from pus in its characters, always sinks in water. Besides, mucous surfaces, when in a state of inflammation, secrete a fluid varying from a thin watery or frothy matter; and in some cases, from a thick albuminous and vis- cous mucus to a friable cream-like pus ; but most commonly, a muco-purulent liquid, which pre- sents more or less of the characters of both pus and mucus. The appearance exhibited by pus, when pressed between two plates of glass, which are afterwards separated, is often distinctive: this fluid attaching itself to their surfaces, without the viscous adhesion of mucus, and partly consisting of small globules. The viscous elasticity of mu- cus, of which character pus is entirely deprived, distinguishes the one from the other more com- pletely, and in a more intelligible manner, to the practised eye, than any other feature they present. In addition, however, to this, it may be added that, when water is added to a solution of pus in dilute sulphuric acid, a more or less abundant precipi- tate is formed ; whilst, with a solution of mucus in the same acid, whitish filaments form on the surface upon the addition of water. 9. As the partitions of softened tissue placed between the incipient purulent collections, in a part undergoing the early process of suppuration, lose their vitality, and become broken down in the effused fluid, the vessels and nerves, as well as the more solid tissues passing through the part, continue to resist the disorganising process for a longer period, so as to form isolated bridles, and communications between the separated parietes of the abscess. 10. The interior of the parietes of the cavity is generally more or less reddened, tomentous, and very close in its texture, owing to the impaction or distending power exercised by the accumulat- ed fluid and the effusion of lymph; so that the fluid contained by them is completely isolated from the surrounding structures. The membrane thus formed presents all the characters of a mu- cous surface, particularly when the grayish pellicle which usually covers it is removed. Its interior surface is in contact with the purulent collection ; whilst, externally, it adheres intimately to the 2 surrounding tissues, and is confounded insensibly with them. It approaches more nearly to the cir- cumference of the inflamed part, the more com- plete the softening of the tissues, and the more the abscess has advanced to maturity. Its dens- ity and thickness are generally in proportion to the slowness of its formation and the length of time it has existed. 11. In parts abundantly supplied with cellular tissue, the membrane proper to abscesses acquires a great degree of resistance and density, forming thick cysts; whilst in very soft organs, or in those but scantily provided with cellular tissue, as in the brain, it remains long in the state of a vas- cular pellicle, scarcely distinct from the healthy structure with which it is connected. It is in general rare that we find a thick or firm cyst in the acute abscess now under consideration; for it forms too rapidly to admit of the thickening and condensation usually occasioned by inflammatory action of some duration. In some very acute abscesses, as in those which sometimes form in the liver of Europeans residing in India, after in- tense inflammation of the internal structure of the organ, no cyst, membrane, or even pellicle can be detected on the internal parietes of the ab- scess; the whole surrounding structure being in- flamed, softened, and sometimes portions of it hanging or floating in shreds in the midst of the purulent collection. In these cases the purulent collection, although existing as a circumscribed abscess, more nearly approaches the diffused ab- scess next to be noticed. 12. The functions of the membrane lining ab- scesses are not confined to the containing and isolating the purulent matter, so as to prevent the contamination of the adjoining structures. Owing to the absorption and exhalation proceeding in its surface, the contained fluid is continually renewed, its qualities are modified, and its decomposition prevented. It is not altogether removed from the influence of life, but participates in the vitality of the surrounding textures, as all fluids accumu- lated in organized parts do, though in a feeble and obscure degree. M. Dupuytren remarks, that it is through the medium of this living envelope that the matter containedin abscesses is augmented and diminished in quantity; is thickened, or ren- dered more fluid; or is occasionally changed by substances absorbed or injected into the circulation. It is because the cysts of abscesses are connected by an intimate sympathy with the chief centres of vitality that the excitation of the more impor- tant viscera affects them in so marked a manner; and that remedies, judiciously applied to these viscera, often tend to promote the absorption of the matter they contain. 13. 2d. Of Abscesses proceeding from acute inflammation in a cachectic habit of body, defi- cient vital resistance, and with a tendency to spread; or Diffuse Abscess. In debilitated and vitiated habits of body; in persons of exhausted vital energy, whose assimilating and secreting organs are torpid; and owing to the operation of certain nox- ious and intense causes, particularly those which contaminate the structure to which they are ap- plied, as various animal poisons, animal and vege- table matter in a state of decomposition, or what- ever produces, from its local or constitutional action, a sceptic effect upon the living textures: from these circumstances especially, inflammatory action is 14 ABSCESS — Diffuse, its Pathology. not limited to a particular part, or within distinct bounds; and the fluid which is poured out from the inflamed vessels is not circumscribed, or con- fined to the centre of the inflamed part. The inflammation which produces this unhealthy and imperfect form of abscess is always characterized by that state of asthenic or ataxic action, local and general, which is incapable of producing co- agulable lymph from the blood, that may limit both the morbid action and the effused fluid, i (See art. Inflammation.) 14. The present kind of abscess not unfre- quently forms in erysipelas ; or after wounds, in- juries, and punctures ; and from the inoculation of an animal poison. The character of the suc- cession of morbid actions it presents is want of vital power and resistance, and a speedy solution of the vital cohesion of the affected tissues. It would seem that the influence of the ganglial nerves supplying the capillaries of the part is ra- pidly, or almost instantly, destroyed by the cause of the disease ; and that the vessels, thus deprived of a great proportion or the whole of their vitality, allow the escape of the more fluid parts of the blood, and the infiltration of the tissues. The vessels pass rapidly, and without the previous grades of healthy inflammation, into that state which admits of the effusion of a watery or puri- form sanies. The state of vital energy, and the deficient crasis, or unhealthy condition of the blood itself, probably contributes to this result; and, with the effect of this effusion on the diseased part, promotes the rapid exhaustion of the remain- ing action of the capillaries. 15. Diffusive abscesses generally commence in, and spread rapidly in the direction of, the cellular tissue. They affect also, in a very marked man- ner, the other structures placed in their way. They seldom commence in the internal viscera, as the liver, lungs, &c. ; but when they do thus originate, as is occasionally observed in the latter stages of malignant or ataxic fevers, in exhaust- ed states of the frame, &c, they nearly approach the characters they assume in the cellular struc- ture. In almost every case of this disease, the constitutional disturbance is very remarkable ; and the powers of the nervous system, particu- larly that presiding over the organic and assimi- lating functions, uncommonly depressed. Locally, the effusion of a watery, or sero-albuminous, or a sero-sanguineous fluid is nearly coeval with the affection of the cellular tissue and congestion of its capillaries. The vital cohesion of the inflamed texture is rapidly dissolved ; and the fluid, abund- antly poured out in its areolae or cellules, distends the part, diminishes its vital functions to the lowest grade, and, at points, lacerates its tissue, thereby partially cutting off its connection with the adjoining structures. Thus the fluid is effused from the congested capillaries of the affected part in numerous places : in some, forming consider- able collections; in others, mere infiltrations. Parts of the cellular tissue itself, and, in rare in- stances, as the mischief proceeds, portions of ad- joining or intermediate textures, are deprived of all vitality, sphacelate, and mix with the fluid effused. 16. In many cases the integuments participate but imperfectly, and often not at all, in the mor- bid actions, whilst the process, as now described, is going forward ; and the great effusion into, and partial destruction of, the cellular tissue, have enormously distended the limb or part in a dif- fused manner and to a great extent, and given it a boggy or imperfectly fluctuating character. At a later period, parts of the more attenuated or dis- coloured integuments vesicate, ultimately burst, and give issue at first to a discoloured puriform secretion, which afterwards becomes offensive and otherwise modified. When the skin is affected, it generally presents a dark or livid hue: its tem- perature is seldom above (excepting, sometimes, at the very commencement of the antecedent in- flammation), and frequently sinks below, the na- tural standard. 17. With respect to the appearance of the se- cretion in this form of abscess, I may state, that it not only varies remarkably in different cases, but also at different stages of the same case. At first, the fluid effused and infiltrating the cellular structure consists chiefly of a limpid, reddened serum, which readily flows from the divided struc- tures ; in a more advanced stage, the effused mat- ter is less fluid, often high-coloured, but without the whiteness and opacity of purulent matter. Afterwards, the cellular membrane is engorged with a white semi-fluid matter, which separates the particles of fat and cellular tissue at an unusual distance from each other. In subsequent stages it continues opaque ; but often becomes reddish, greenish, and more fluid. At a still more advanced period, the infiltrated cellular and adipose tissue are entirely broken down, and the sphacelated portions hanging into, or mixed with, the puriform matter; which sometimes now presents the appear- ance of a brownish, purulent sanies, sometimes a greenish pus, and at other times a sero-purulent matter of various shades of colour and degrees of consistence. At no period of the disease is the matter contained in any circumscribed cavitv, but is gradually and irregularly lost in the surround- ing cellular tissue; without any demarcation, or appearance of coagulable lymph about the circum- ference of the diseased part. In general, the purulent secretion speedily assumes an offensive odour, and its sensible qualities are otherwise al- tered, and often variously, upon the admission of air to the diseased surface. 18. The muscular structure, and other parts in contact with the puriform matter, and in the way of the spreading disease, is generally much discol- oured, softened, easily torn, and sometimes par- tially destroyed. In some cases the muscles are paler ; in others, darker, and more livid than na- tural. In rarer instances, the adjoining bones and more resistant structures are also affected. (See Inflammation, Diffusive.) 19. 3d. Abscesses consequent upon inflamma- tion of lower grades of intensity.—.The more slow and obscure the progress of inflammation, the less marked are the signs of irritation preceding and accompanying abscesses. It is not uncommon to observe, in lymphatic and phlegmatic tempera- ments, fluctuating tumours of various sizes, both superficial and deep-seated ; without any consider- able pain or increase of animal heat, either ante- cedent or subsequent to their formation. Purulent collections, of a chronic and indolent character, generally proceed from a low but continued state of irritation, or from reiterated excitation of so low a grade as scarcely to influence the sensibility of the part; and occur in. constitutions of weak vital ABSCESS—Chronic, its Pathology. 15 resistance and defective restorative energy. On the other hand, the abscesses described in the pre- ceding sections result from inflammation of a more or less acute character, occasioned by active stim- ulation or deleterious agents, and generally affect the system in a more or less active manner. 20. Owing to the low grade of irritation in the affected part, the vessels are but little, and often scarcely perceptibly, injected. The abscess, in place of commencing with a number of distinct centres or foci, appears at first as a single isolated collection in one or more of the cellular areolae, and presenting, from the commencement, a mani- fest fluctuation. In some cases, this appearance of the affected part is less that of true phlogosis than of a deviation from its nutritive actions. The tissues, instead of attracting, in virtue of their vital endowment, the nutritive particles ; and the vessels, instead of imparting them in an appro- priate condition, and exhaling a fluid suitable to the healthy state of parts, are so far changed as to fail in the performance of these actions ; the ves- sels furnishing a fluid of a certain kind, apparently composed of the particles or globules which, under the influence of healthy vital endowment, would have been separated from the circulating fluid for the nourishment or growth of the tissues, and of the watery exlialation destined to lubricate them, and render them fitted for their functions. 21. In the chronic varieties of abscess, the pus, being secreted under the influence of a lower grade of excitation, differs from that previously described (§7, 8.). It is frequently yellowish, serous, trans- parent ; containing flocculi of an albuminous or fibrinous nature, and whitish, opaque appearance : sometimes it is mixed with minute shreds of cellular-like substances. In other cases it is near- ly analogous to mucus, from its thickness and vis- cosity. In some subjects, when very slow in its formation, it assumes a greater consistence and opacity, resembling half-congealed lard or liquid honey ; and the tumours which it forms seem to constitute a connecting chain between pure ab- scesses and melicerous or steatomatous cysts. These latter differ in no respects from abscesses devoid of active inflammation, but in the greater consistence of the matter they contain : and in some cases, as M. Dupuytren remarks, it is difficult, if not impossible, to distinguish between them. 22. Owing to the extreme slowness of their formation, and the absence of acute inflammatory action, the parietes of the present kind of abscess have a more distinct organization than those of the first species. Vascular injection and redness are here seldom observed exteriorly to the cyst enclosing the purulent collection. The skin cover- ing the tumour, and through which the fluctuation is readily felt, is generally free, moveable, and unaltered. All the morbid action seems concen- trated in the diseased membrane enclosing the matter. This membrane or cyst is, internally, of a reddish gray tint, and more or less intimately connected with the surrounding structure. It is in some cases soft, thin, and cellular; in others,thick, strong, and of a cellulo-fibrous, or even fibrous structure. The slower the tumour is in enlarg- ing, the more liable is the cyst to undergo change, and to modify the state of the matter it contains : and, hence, abscesses of a very slow or chronic j kind often approach slowly but nearly to the characters of several other encysted tumours. 23. The purulent collections which form around foreign bodies, that occasion but little irritation, generally belong to the present kind of abscesses! They are always lined with a firm cellular cyst, analogous to that enclosing the foreign body itself! The abscesses which proceed from bodies occasion- ing great irritation are preceded by great pain and inflammation, and belong to the preceding kind of abscess. 24. 4th. Of symptomatic abscesses, or collec- tions of matter at a distance from the places where the pus is first formed. In the foregoing sec- tions I have considered the formation of abscesses in, and their limitation to, the primary seat of irri- tation : but if the parts affected are surrounded by a loose areolar cellular tissue, readily permeable by the matter as it is formed; and especially if the state of vascular action and vital energy of the frame are insufficient to the production of coagulable lymph around the inflamed centre ; the matter gradual- ly finds its way in the course of the cellular structure to adjoining parts, particularly to those which are more dependent, infiltrates them, and forms, more or less distinct and fluctuating, tu- mours at a distance from the primary seat of in- flammation. Instances of this kind of abscess are furnished us in diseases of the hip-joint, and in cases of inflammation commencing in some or one of the vertebrae, or their fibro-cartilages. In this latter case, if the disease commences in one of the dorsal vertebrae, the purulent fluid may ac- cumulate under the pleura, infiltrate the adjoining cellular tissue, and, following the direction of the ribs, appear at some part of the side or back, or even near the sternum, far from its origin. When the inflammation attacks one of the dorsal or lumbar vertebra;, or intervertebral structures, it may travel in a similar manner behind the pillars of the diaphragm, proceed in the course of the psoas and iliac muscles, following the cellular tissue behind the peritoneum, and appear ex- teriorly, most frequently under the crural arch, but sometimes through the inguinal ring. In other cases it proceeds to a shorter distance, and points at the sacro-iliac symphysis, or in the angle bttween it and the spine : or it may extend down the pelvis in various directions, following the cellular substance surrounding the vessels and nerves. rl hus it may pass through the ischiatic notch, forming an abscess at the internal part of the gluteal muscles ; or along with the great sciatic nerve, and point on the superior and pos- terior part of the thigh ; and, lastly, it may find an issue in the perineum, at the margin of the anus, or into the rectum, or even into the vagina. In some rare instances a double tumour and open- ing are formed. In the case of a female by whom I was consulted, the matter had found its way to the integuments of the sacro-spinal angle of the loins, where it was punctured by a surgeon, and yet had also burst its way into the vagina. In the case of a groom whom I attended, a tumour formed at the sacro-iliac symphysis, below the crural arch, producing the most violent and pain- ful tumefaction of the limb, owing to the pressure of the matter on the nerves and veins ; and the matter afterwards burst into the lower part of the sigmoid flexure of the colon. 25. The matter proceeding from abscesses symp- 16 ABSCESS —Consecutive, its Pathology. tomatic of inflammation and ulceration of bones or cartilages is generally grayish, thin, mixed with albuminous flocculi, minute clots of blood, and portions of phosphate of lime. It exhales a nau- seous odour : but this characteristic is present only after the opening of the tumour, and when the air has access to the cavity. 26. If we examine the cavities of symptomatic abscesses, and trace them from their origin to their outlet, we shall find, in the former situation, the cartilages and bones profoundly changed the bones are softened, friable, changed to a grayish black, partially absorbed and carious, and their periosteum destroyed. From this origin of the disease is formed a channel or sinus, traversing the cellular structure frequently in the course of the large vessels or muscles, and terminating with the external outlet of the tumour. The whole of this canal or sinus is usually surrounded by a softened, friable, or lardaceous state of the tex- tures; and lined with a smooth, thic'<, firm, cel- lular, or fibro-cellular membrane, which in some cases is of a fibro-cartilaginous structure. At the lower part, the canal generally dilates into a con- siderable cavity, sometimes irregular or sinuous in its form, and lined with the membrane usually found in the more chronic kinds of abscesses. 27. 4th. Of consecutive abscesses; or collec- tions of matter found in situations consecutively to its formation in distant p%rts, between which there exists no communication. It has been not infrequently remarked, that inflammation of a part has taken place, and has gone on to suppuration ; that the matter thus formed has been absorbed ; and that it has subsequently formed in some other viscus, generally in an internal organ. The nature and procession of the morbid phenomena now enounced have led to some enquiry, particularly in recent times. The circumstances in which consecutive abscesses occur in practice are the following: — Inflammation of the internal surface of the uterus, or of its veins, or of both the substance of the uterus and veins, occasionally ta'-ces place after child-birth, and terminates the life of the patient. On dissection, purulent infiltrations or distinct collections of pus are found, in one case, in the lungs ; in another, in the liver ; in a third, in the substance of the brain ; in a fourth, in the capsules of the joints ; and, in a fifth, in both the lungs, liver, and perhaps, also, in the joints. A man, from injury of the head, has in- flammation of the sinuses of the brain, followed by all the symptoms of a vitiated state of the cir- culating fluid, terminating in death : after which, abscesses, or purulent infiltrations, are found in the liver or lungs. A similar procession of pheno- mena occasionally results from phlebitis conse- quent on blood-letting, or other causes ; also during the suppurations following amputations, par- ticularly when the matter is confined on the face of the stump, by the adhesion of the integuments which had been drawn over it. A child is seized with severe or confluent small-pox ; and during, or subsequently to, the secondary fever, fluctuat- ing tumours form in the joints from matter accu- mulated in their capsules. Upon dissection, the cartilages are found eroded ; and, in other rare cases of this kind, purulent collections are found in the internal viscera. In other instances, ab- scess disappears from external parts; the patient sinks with low fever ; and, upon dissection, collec- tions of pus are found in internal organs. In cases of this description, the following require notice: — 1st The state of the vital energies preceding or during the occurrence ; 2d, The symptoms char- acterizing the progress of the phenomena ; and, 3d, The nature of the results. 28. 1st, The energies and vital resistance of the system are generally greatly impaired, either from pre-existing or concurring causes, in cases where consecutive abscesses form. (See article on In- flammation of Veins.) 2d, The depression of the powers of life increases as the disease advances. The nervous s\ stem is seriously affected ; the cir- culating fluid betrays change in its appearances after its emission, or after death ; the soft solids lose their vital elasticity and cohesion; the surface of the body and countenance become dus'ty and livid ; and low delirium, rapid and weak circula- tion, &c. take place. 3d, The purulent matter is generally either infiltrated into the parenchyma- tous structure of some organ, or collected into one or more distinct abscesses, or it is effused into the cavity of one or more joints. When the mat- ter is infiltrated into the texture of an organ, the infiltrated structure is very frequently also soft- ened. The purulent collections that are found in other casas generally have no distinct cyst, and the surrounding substance of the organ seldom presents any marked redness or injection of its vessels, or indeed any remarkable change, ex- cepting in some instances a slight softening. The matter is usually found in several distinct ab- scesses or collections, varying from the size of a small seed to that of an egg, or even larger. Sometimes the immediately surrounding structure seems impacted around the abscess, but not other- wise changed. The purulent matter itself varies but little from that which is observed in the ab- scesses described in the first section. (§§ 6, 7, 8.) It is occasionally of a darker or greenish hue, particularly when found in the liver. 29. As to the Origin of these purulent collec- tions, some doubts may be entertained. That they are very intimately connected with the primary inflammation and formation of matter in other parts of the system, cannot be doubted, but in what way cannot be so readily stated. It seems to me extremely probable, from the attentive ob- servation of the progress of a number of such cases which have come before me in practice, that, owing to depressed vital energy, and defi- cient resistance of the frame, purulent matter passes into and vitiates the blood; that the morbid condition of the circulating fluid, thus induced, depresses still lower the already weakened nervous powers ; and that the irritating matters carried into the circulating current change the state of the capillaries of parenchymatous and some other organs, so that they secrete purulent matter with- out any evident sign of previous or accompanying inflammation. Several French pathologists sup- pose that the purulent matter conveyed into the blood circulates without combining with it, and is merely deposited by the capillaries, or separated by them, from this fluid in parts ; the vesse's and texture of which are most disposed to permit its elimination, or the best constituted to admit of its deposition. It is difficult to deter- mine in which of those ways the consecutive abscess is formed. Indeed, both may approximate ABSCESS —its Progress. 17 the truth, the consecutive formation of pus arising, in one case, from the irritation occasioned by the presence of morbid matters in the blood; and, in another, chiefly from the separation or secretion of it in the parenchyma of an organ, without any previous or attendant irritation. 30. II. Of the Progress and Termin- ations of Abscesses.—At any period of its existence, the inflammatory action in an abscess may cease, and the matter which has been formed be absorbed. In these cases the purulent matter is carried into the circulation; and, whether the in- flammation is primarily and gradually extinguished in the abscess, or whether intense pain and inflam- mation, developed in some other organ, exercises on the first centre of mischief a true revulsion, the absorption of the pus is only consequent upon the subsidence of the local signs of inflammation and congestion. The part looses its turgescence, redness, increased heat, and tumefaction, and is restored to its healthy state without any deformity or cicatrix. In these cases the absorbed matter is eliminated from the circulating mass, without accumulating in it to a hurtful extent, by the ac- tive or unimpaired functions of the various elimi- nating organs, particularly by the kidneys, and mucuous surface of the intestinal canal,—the matter, in some cases, being apparent in the urine, and in the others exciting a temporary diarrhcEa. 31. In other instances, the inflammation pro- ductive of suppuration being but slight, or being less completely dissipated, and the solid tissues, and particularly the firm and thickened cyst, op- posing the extension of the abscess, it occasionally rests long stationary. In this case the pus remains inactive and inoffensive in the part, like a smooth and inert body lodged in a cyst. Abscesses will sometimes continue for a very long time unchang- ed, and without occasioning much disturbance to the economy, particularly when deeply seated. In such cases the cyst becomes more and more firmly constituted, thickened, and changed from the state of the surrounding parts; so that the pus is in some measure isolated from the adjoining structures : in this state it may remain, as in the brain and liver, for a considerable time, without any very marked symptoms, until some accident or exciting cause occurs to affect it and the adjoin- ing parts, when the usual course of the disease will be resumed. 32. The foregoing changes are comparatively rare. In the great majority of cases, pus dis- tends, compresses, and obscurely excites, the parts in which it is lodged. Instead of being diminished, the abscess is increased in size, and tends to find an external outlet, uniformly in the direction of either the cutaneous or one of the mucous surfaces. Purulent matter is thus submit- ted to the general law of the economy ; the vital resistance, opposed to all substances calcu- lated to excite or otherwise injure the textures, detruding it by a regular procession of pheno- mena, as long as the energies of the system are not entirely overwhelmed, to the nearest or most unresisting part of the surface, and at last expel- ling it altogether from the body. 33. The succession of morbid phenomena oc- casioning the deliverance of the system from col- lections of matter, is of great importance to the practitioner, particularly as respects deep seated or internal abscesses. Generally the quantity of 2* matter is continually increasing, owing either to the extension of suppuration in the inflamed part, or to a continued secretion from the internal sur- face of the abscess, or to the concurrent operation of both causes. In consequence of this increase of quantity, the parietes of the abscess are dis- tended and applied more closely to the surround- ing parts, which are pressed outwards by the accumulated matter. This distending power is equally exercised from the centre to the circum- ference. But, as all the adjoining parts do not exercise the same degree of resistance, the abscess extends in the direction of the external or free sur- faces; its more deeply seated parietes being sus- tained by all those parts which are placed beneath them; whilst the tissues which are exterior to it, being deprived of aid, are readily elevated and distended by the increased effusion. 34. As to the nature of this effusion, and the changes it undergoes, certain questions have been urged. It has been supposed that the matter found in abscesses is not secreted in the state in which it exists at the period of maturation : but that the fluid effused is in a state which may be called albuminous serum; which, owing to the continued exhalation and absorption taking place in the internal surface of the abscess, is changed into what is called well-digested pus. Others suppose that the purulent fluid is secreted in the state of pus, or nearly approaching to it, by the membrane forming the cyst, and which, as it pre- sents many of the characters of mucous membrane, may, like this membrane, when highly inflamed, secrete a purulent fluid. It is extremely proba- ble that both views may be in a great measure correct: for attention to the maturative process in recent abscesses shows that the fluid first effused is not pure pus; and it is undeniably proved that the matter contained in the different kinds of ab- scesses is variously modified according to their duration, their situation, and the circumstances attendant on their progress. Whilst, on the other hand, it must be conceded that the internal sur- face of an abscess, particularly in a high state of inflammation, or when irritated by the contact of the air, will secrete a purulent fluid, or a matter which very rapidly assumes the puriform charac- ter; the vessels terminating in it giving issue not only to the watery part of the blood, but also to many of its smaller globules, so as readily to form a pure pus, which quickly becomes thick, upon the evaporation or absorption of a portion of its more fluid constituents. 35. Another important matter, relative to the progress and external pointing of abscesses, is the fact, that inflammation generally seizes upon the adjoining structures as the internal membrane is more closely applied to them. The parts most distended and stretched by the contained fluid have the inflammatory action extended to them from the parietes or membrane of the abs- cess. To the inflammatory irritation thus induced in the surrounding textures succeed their adhe- sion to the parietes of the abscess; absorption of their solid efcments, with attenuation; and, lastly, ulceration,—the integuments merely often resist- ing for a considerable period the discharge of the fluid. 36. If we take as an example the not unfre- quent occurrence of abscess in the substance of the liver, and trace its progress in one of those 18 ABSCESS — its Progress. directions which it sometimes follows, namely, through the diaphragm and lungs, until it empties itself into the bronchi, we shall find the following to be the course of the morbid phenomena:— As the inflammatory action and the secretion of purulent matter proceed, the abscess which has been formed, generally in cases of this kind in the convex part of the organ, advances towards the surface; the inflammatory action extends to this part; and lymph is tlirown out, which, with the pressure of the swelling and pointing of the ab- scess, irritates the peritoneal surface of the dia- phragm, inflames it at the part opposite, and oc- casions its agglutination at this situation to the parietes of the hepatic abscess. As the tumour points upwards, the inflammatory action advances in the same direction; extends to the muscular structure of the diaphragm, which is softened and attenuated, assuming at the same time a dark or bluish tint; and invades the diaphragmatic pleura, where it throws out coagulable lymph. This secretion occasions irritation and inflamma- tion in the opposite part of the pulmonary pleura, and the cohesion of the lung to the diaphragm at the part where the collected matter is advancing prominently upwards. As the parts thus succes- sively involved undergo the softening process con- sequent on inflammation, and yield before the pressure of the accumulated fluid, owing to their diminished vital cohesion, absorption commences and proceeds in the central or prominent part of the tumour; and the matter thus finds its way in the direction which is most yielding, where the inflammatory action most readily advances, and where the resistance to it is thereby still further diminished. I have had frequent occasion to trace the above phases of the progress of large and deep-seated abscesses; and to satisfy myself that they proceed in a similar manner, whether they advance to the external surface of the bodv, or open upon a mucous surface, or into a shut cavity; which last is a rare occurrence. 37. It is of importance to observe the proces- sion of phenomena now stated; inasmuch as the successiver eddening, inflammation, adhesion, soft- ening, and absorption of the various structures, as the tumour advances exteriorly, are the guides to a very important part of the treatment of these formations. Thus, when we observe marks of inflammatory irritation of the skin take place in the situation of an internal abscess, we may infer that the ulterior phenomena now enumerated, par- ticularly adhesion, have taken place in the parts beneath, and we may safely decide upon carrying an incision from the centre of the inflamed integ- uments to the seat of abscess. 38. It must not be overlooked, that various aberrations of purulent collections take place, in their progress to the surface, and that they often proceed in a direction opposite to that of gravita- tion, owing to the resistance of bones, fasciae, and aponeuroses ; which last oppose them in a most remarkable manner, and cause their extension in various directions, giving rise to the most severe local and constitutional sufferings. • 39. Abscesses, besides, cause the inflammation of parts placed between them and the centre of the system, as respects the direction of the cir- culating vessels, as well as of those parts situated exteriorly to them, although in a much less decree, and followed by very different results; for, in- stead of the thinning, erosion, and ulceration of the exterior parts, tending to advance them to the sur- face, the inflammation of the parts behind, or more deeply seated than they, is frequently ac- companied with thickening, and increased density of structure; whereby the system is, in a great measure, protected from their extension to more internal and vital parts. Numerous instances oc- cur, where the periosteum or the peritoneum, the pleura, the fibrous and synovial capsules, undergo a marked thickening, opposing thereby an in- creased obstacle to their extension in that direc- tion, when abscesses form in the vicinity of those membranes. When, however, the energy of the system and its vital resistance are deficient, ex- ceptions sometimes occur to this rule, and ab- scesses find their way, when situated favourably to this mode of termination, into important cavi- ties and organs. Thus, an abscess seated deep in the parietes of the chest or abdomen, may open into these cavities, as in the case of the son of the eminent M. Petit; or an abscess in the liver may find its way into the pericardium. But any disposition to its opening internally, is opposed not only by the thickening of the serous and other membranes, &c, as here instanced, but also by the support of the viscera underneath, which resist the pressure and extension of the tumour in this direction. 40. The progress and spontaneous opening of abscesses, advancing in the manner now explain- ed, terminate with the erosion ef the integuments, which, having been reduced to a pellicle, have their epidermis elevated in the form of a plilyc- tena, which soon breaks, and gives issue to a por- tion of the contents of the abscess; and the dis- charge is renewed at intervals, by the gradual retraction of the parietes of the cavity upon the re- accumulated secretion. The successive evacua- tions occasioned by the reaction of the parietes of the abscess, are particularly favourable in cases of large abscess, by preventing any vacuity. In cases of empyema, for instance, where the ar- tificial opening is often fatal, a favorable result not unfrequenlly follows a spontaneous and suc- cessive evacuation of the purulous collection: for it is chiefly by imitating the natural process in those cases, that we secure the greatest advanta- ges to the patient, where we find it requisite to open symptomatic abscesses, as those usually call- ed lumbar; and not by making large incisions, and producing a large evacuation, whereby the air has access to their cavities, but by successive punc- tures, the margins of which are immediately clos- ed, upon the evacuation of that part of the contents which are first expelled by the reaction of their parietes. 41. The passage of air into the cavities of ab- scesses is always followed by an increased state of irritation of their lining membrane. The hurt- ful effects of this communication have been de- monstrated by M. Dupuytren, and other env inent men, although denied by others, but without either the satisfactory proofs of experience or of reasoning. In some cases the accession of in- flammatory action in the part, upon the access of air, is very remarkable. In cases of small chron- ic abscesses this effect is often beneficial; but in large and acute abscesses the irritation thus in- duced may be too great for the powers of the system to withstand. ABSCESS—Diagnostic Symptoms. 19 42. Under the most favorable circumstances, the effects of the admission of air into the cavity of an abscess are counteracted by the accompa- nying treatment; and the discharge soon assumes a different appearance from that of the matter first evacuated : it becomes less white and con- sistent; and, subsequently, when the parietes commence forming the adhesions which precede cicatrisation, it is merely a more or less copious citron-colored serosity. After the opening of slow and indolent ab- Bcesses, the serous, thin, and flocculent pus with which they are filled, is replaced by the discharge of a more digested, homogeneous, and cream-like fluid, indicating a more intense state of action in their parietes. 43. Upon examining the interior of abscesses which have been opened, it will be seen that their parietes gradually discharge themselves; that they cast off" the grayish and flocculent pellicle which covers them; and that they become cov- ered with cellular and vascular granulations, of a lively red and solid appearance, formed from co- agulable lymph thrown on the inflamed surface, into which new capillary vessels shoot, and re- sembling the granulations on the surface of wounds, from which is exhaled the matter which succeeds to that first discharged from them. The parietes thus cleansed contract towards their cen- tres, and in the direction of their most deeply seated parts. They afterwards unite; so that the cavity, which has been thus circumscribed, at last disappears. In the situation of the abscess nothing is found but its cicatrix; at first consisting of a cellular lamina, or plate, of various thickness and density, penetrated by coagulable lymph, and subsequently converted into a scarcely apparent cellular line, which sometimes, at last, entirely disappears. 44. But the progress of abscesses after they have been opened, is not always so favorable. It may be premised, that the irritation proceed- ing from the contact of air with the internal sur- face of an abscess is, in general, in proportion to its volume, and the unyielding state of its parietes. When the abscess is small, the resulting irritation is but faintly marked: but if the parietes be of a large extent, and if the abscess is deeply seated, particularly if it be in any of the viscera, the in- flammatory excitement occasioned by the air not only increases all the local phenomena, but also gives rise to serious constitutional disturbance, often terminating the life of the patient. The yielding state of the parietes, and their apposition, are sometimes calculated to counterbalance the bad effects occasioned by their extent. When the diseased surfaces have been freed by the complete discharge of matter, and admit of being closely applied to each other, the admission of air is in a great measure prevented, and adhesions frequently proceed rapidly. Where, however, the parietes cannot be brought closely together, and the cavity can be obliterated only by means of granulations formed to an extent that may fill it, the duration of the suppuration is prolong- ed, and the effects produced on the constitution by the extent of the discharge are often serious. 45. But this is not all the mischief resulting from the access of air to the cavity of an abscess: the pus which still remains, particularly in deep- seated abscesses, is more or less changed by it, and exhales an infected or putrid odour, proceed- ing from decomposition occasioned by the tem- perature to which it is subjected, and its contact with atmospheric air. It is also often observed, that when large abscesses are opened, and air gains access to them, the morbid excitement thereby occasioned in their parietes, re-acts upon the principal vital centres; the nervous systems, the digestive organs, and the circulation suffering from and participating in it, and the suppurative process is thereby greatly increased; at the same time the constitutional powers are much de- pressed, the matter is rendered much more of- fensive, and otherwise changed, according to the seat of the abscess. As the powers of life sink under the disease, the fluid secreted is more offensive and disposed to decomposition, until it is often doubtful whether the change proceeds more from the access of air, than from the low state of vital energy. Indeed, in many cases, the latter cause seems much more influential towards pro- ducing this state of the discharge than the pre- sence of air ; for we not infrequently observe, that as long as the constitutional powers remain but little depressed, the access of air has but little effect, the discharge exhaling no offensive odour; but as soon as, owing either to the increase of inflammation in the cyst, or to other concurrent causes, the febrile commotion is increased, and the nervous system and digestive organs evince serious disturbance and loss of energy, the dis- charge becomes rapidly offensive and increased in quantity; the matter often changing from a more or less pure pus to a state approaching to putrid sanies. 46. III. Of the Diagnostic Signs of Abscess. When inflammation has attacked a cellular structure, or viscus, in which this tissue is a prominent constituent part, and particularly if it be intense in degree, rapid in its progress, and ac- companied with a pulsative pain, we may with confidence decide upon suppuration being about to take place. This result is announced by a dimi- nution of the pain, which changes to a pulsatory sen- sation isochronous with the pulse; by a feeling of weight and tension in the part; by a diminution of the febrile action, succeeded by a large, broad, open, soft, or undulating pulse; and by irregular chills or rigors, which extend, after various inter- vals, along the back, loins, and sometimes the lower extremities. If the matter is not soon afterwards evacuated, the symptoms of chronic irritation succeed; especially small and frequent pulse, heat or burning of the palms of the hands and soles of the feet; irregular fits of perspiration, and night sweats; loss of strength; and all the characteristics of hectic fever, which makes more or less rapid progress, and is sooner or later fol- lowed by colliquative diarrhoea, according to the seat and extent of the abscess, the constitutional powers of the patient, and the treatment employ- ed. The above symptoms indicate that a per- manent cause of irritation, and of constitutional contamination, has succeeded to the state of active inflammation. 47. The tumefied state which characterises sthenic or phlegmonous inflammation, is greatly modified after suppuration has advanced. It be- comes less diffused, is much lessened in the cir- cumference of the periphery of the tumour, and seems more and more concentrated. Hence it 'rognosis of. 20 ABSCESS —P becomes more elevated, prominent, and softened at the centre of the surface. The redness and tension undergo a similar change. The circum- ference of the inflamed surface is restored in some degree to the natural state; but the more promi- nent part acquires a dark red tint, afterwards a bluish hue, and yields more and more to the pres- sure of the subjacent pus. For some time previ- ous to this stage the tumour evinces a more or less distinct fluctuation when suitably examined, and this sign becomes more manifest as the ab- scess advances to the surface. 48. When an abscess forms in deep-seated parts or viscera, particularly those protected by solid envelopes, or by thick and unyielding structures, the diagnosis rests entirely upon the natirre of the constitutional disturbance, and the disorder in the functions of the affected organ or part, and here the physician should seize and appreciate the slightest difference taking place in the pulse, the animal heat, and the state of all the natural and organic functions. In these cases he requires the most exquisite tact for examination, in order to arrive at an accurate opinion. The symptoms which should guide him in cases of this descrip- tion will be stated when I treat of the diagnosis of the different kinds of visceral abscess. I may, however, remark at this place, that, even in parts much less deeply seated, when the cyst of an ab- scess is greatly distended and very tense, fluc- tuation of its contents are generally extremely obscure, or even not to be felt, although its con- tents may be very fluid. Also, when the purulent matter is contained in no distinct cyst, but is dis- seminated through the textures, or infiltrated be- tween fasciae or muscles, or is confined beneath aponeuroses, great incertitude may exist as to its formation. The parts in such cases present more of a diffused oedema than of a fluctuating tumour; and if fluctuation can be at all felt, it is only ob- scurely. 49. It must be evident that the more feeble and latent the phenomena of the precursory in- flammatory irritation, the more difficult is it to de- termine the period at which the elaboration of pus commences. We frequently observe in practice, particularly after phlebitis, injuries of the head, fractures, and capital surgical operations, abscess- es form in the liver, mediastinum, lungs, kidneys, or ovaries, preceded merely by obscure and occa- sional pain, and furnishing no certain symptoms of a local kind, by which we can decide as to their formation, until the time that they appear exter- nally, or are detected upon post mortem examin- ation. In cases of this description, the constitu- tional symptoms are our chief guides; but even these are often so uncertain and so imperfectly developed as to leave us in doubt. The accession in this obscure manner of internal abscess is par- ticularly remarkable as respects those which su- pervene to inflammatory disease existing in other parts, particularly to phlebitis, and which I have denominated consecutive abscesses. (See Veins —inflammation of.) 50. Symptomatic abscesses generally escape detection until they advance externally. Previous to this, pain, uneasiness, tumefaction, &c. are only felt chiefly in the part originally affected. But the symptoms already noticed (§ 46—48.), espe- cially the unhealthy aspect of the surface, the state of the febrile action and of the pulse, the night perspirations, the disorder of the respiratory and alvine functions, will generally serve, in con- junction with the changes in the part to which symptomatic abscesses extend, to indicate the na- ture of the mischief. 51. It is important, as M. Dupuytren has very justly remarked, to take into account, when determining the existence of abscess, the greater disposition inherent in some constitutions to form purulent matter. In some persons, the least irri- tation is followed by the suppurative process. This is particularly the case in persons of a pale visage, of a soft flaccid state of the different structures, and of the lymphatic temperament It is also remarkable in those whose vital ener- gies have been lowered by previous disease ; by chronic affections of the digestive mucous sur- faces; and by those diseases which require the performance of amputation, or other important surgical operations. When the suppurative pro- cess has continued for some time, and has after- wards been suddenly stopped by an operation, or any other active treatment, the disposition to form abscesses is generally remarkable. A similar re- mark may be extended to the sudden suppression of any accustomed secretion or discharge. The most familiar instance of this kind is noticed in the breast of nurses, which are extremely liable to suppuration upon interruption to the secretion of milk. These considerations should have their due weight with us when estimating the signs of the existence of internal abscess. Those symp- toms which are peculiar to collections of matter formed in each of the internal viscera are pointed out in their respective articles. 52. IV. Of the Prognosis of Abscess, The danger from abscess is in proportion, 1st, to the extent of their internal surface ; 2d, to the depth at which they are seated; 3d, to the indo- lence of their action, or the deficiency of vital ac- tion accompanying them; 4th, to the severity and danger of the disease by which they have been occasioned; 5th, to the sinking or deficiency of the constitutional powers under them; and, 6lh, to the severity of the symptoms accompanying them, or produced by them. These positions are so obvious, that no remarks need be offered in support of them. I may, however, observe, that abscesses seated in internal viscera are always attended with danger; but the degree of danger will depend upon numerous circumstances con- nected with their seat, the direction which they take, the state of the vital energies of the frame during their progress, the chances of their evacua- tion, and the means of reparation and renovation the constitution may still possess. 53. The prognosis of chronic, symptomatic, and consecutive abscesses depends as much upon the nature of the preceding disease, as upon the state of the abscess itself. In chronic abscess, the danger is in proportion to the extent of the surface of its parietes, and to the grade of consti- tutional vice. In symptomatic abscess, the danger depends almost wholly upon the nature and extent of the original disease, of which it is the conse- quence, and upon the largeness of surface extend- ing thence to the ultimate limits of suppuration. In consecutive, abscess, the danger is extreme; owing, in many cases, to the nature of the prima- ry disease, the depressed state of the constitution- al powers, and to the vitiation of the circulating ABSCESS —Treatment of. 21 fluid and soft solids of the body, with which it is connected. 54. V. Of the Medical Treatment of Abscess.—The indications of cure which we propose in abscess is, 1st, to remove the purulent collection from the part containing it; and, 2d, to procure the obliteration of the cavity in which it was lodged. The first intention is accomplished either by procuring the absorption of the purulent matter, and its elimination from the body; or by opening the parietes of the abscess, and thus giving a direct outlet to the contained matter. When the means used to accomplish the absorp- tion of the purulent matter fail, or when the cha- racter of the abscess and state of the frame forbid the employment of these means, opening the ab- scess must be resorted to when the proper period for having recourse to the measure arrives. 55. 1st, Means which may be resorted to, in order to procure the absorption of the purulent matter, and its elimination from the frame.— Numerous instances have occurred of the rapid absorption of the matter contained in an abscess, and of its discharge from the circulation, 1st, by the urinary organs, the urine becoming abundant, and containing either a puriform secretion, or being otherwise altered; 2d, by the mucous sur- face of the bowels, attended with diarrhoea; and, 3d, by the cutaneous surface, in the form of a co- pious, thick, or viscid, and offensive perspiration. These are the most common channels of elimina- tion of the purulent secretion, when absorbed into the circulation from the cavity of an abscess. The purulent collection may, also, disappear in conse- quence of other critical or accidental evacuations; but this result is of rare occurrence, and is a much more remote contingency than those enumerated. Experience having shown the possibility, and the great advantages, of removing the matter contain- ed in an abscess by exciting absorption, the means most effectual in attaining this end should be first put in practice. 58. With this view drastic purgatives may be prescribed, when the state of the patient admits of them; and next to them, such diuretics and diapho- retics, as may be appropriate to the circumstances of the case. Contemporaneously with the use of those internal derivatives, external applications should be employed, particularly those which pos- sess discutient, resolvent, and styptic properties. Frictions with stimulating substances, as ammoni- acum, iodine, hydriodate of potash, &c. ; cold, warm, or tepid affusions on the part, either of simple or mineral waters, of sulphureous or saline, natural or artificial, may likewise be tried con- jointly with the internal means. But this ener- getic plan of treatment,—this combination of the revulsive and discutient practice,—this metho- dus perturbatrix, is not applicable to all cases. There are many circumstances connected with the seat and condition of an abscess, and with the state of the different functions, that either alto- gether forbid its employment, or require impor- tant modifications and adaptations of it. 57. Thus, abscesses preceded by acute or ac- tive inflammation, are rarely susceptible of being absorbed; the opening of them, therefore, is al- most inevitable. Chronic abscesses, which are generally provided with thick cysts, also admit not of removal by this practice ; it being generally requisite to excite a new action in their parietes, which may modify their texture, and render them susceptible of contracting the adhesions requisite to their obliteration. Ihe majority of purulent collections which are removed by absorption, is such as form rapidly, without much previous in- flammation, and in debilitated habits, or in those weakened by pre-existing disease. In persons of this description, the excitement or irritation of the kidneys, or of the mucous surfaces, will often over- come the irritation existing in the seat of abscess, and consequently promote the absorption of the pus it contains; at the same time that the fluid abundantly secreted by the parts artificially ex- cited will assume, in consequence of the state of the patient, a puriform character. (Dupuytren.) But, in the majority of instances of this kind, it is necessary that the artificial irritation or excitement shall be greater than that previously existing in the seat of abscess, and that the organs or parts in which it is induced be in a sound state; otherwise the revulsion cannot be either successfully or safe- ly practised. However we may explain the mode of action of revulsants on abscesses of this kind, there can be no doubt that it is almost entirely in them, and particularly when they are seated in lymphatic glands, that we can hope successfully to employ this plan of cure. 58. When the evacuations procured from the first passages, and from the kidneys and skin, have no effect upon the tumours, and particularly if the stomach and bowels seemed to support their action with difficulty, they must be aban- doned, and recourse be had chiefly to the more direct means of cure. The local excitants, as iodine, the sulphureous douches, frictions with mercurial, camphorated, and terebintbinated lini- ments, and the repeated application of blisters for a short time, are only suited to the chronic kinds of abscess, where little or no inflammatory action exist. But these remedies should be watch- ed, lest they increase the heat and inflammato- ry action of the external or superficial part of the tumour, and thus occasion their external open- ing- ... 59. In the majority of abscesses, it is requisite to keep three facts in recollection: 1st, that the inflammatory action in their parietes does not cease on the formation of the purulent collection; 2d, that an abscess is generally a complication of this inflammation, and of the retention of purulent matter in the inflamed parts which formed it, the inflammatory action being still present, although in a somewhat modified state and grade, and still continuing to form this matter; and, 3d, that the existence of pus does not necessarily or materially change the nature of the action which produced it. The therapeutical indications to which these facts necessarily lead are important, particularly as they show, what, indeed, has been proved by expe- rience, that antiphlogistic remedies, especially those of local application, should not be laid aside with the supervention of suppuration. In the majority of cases, and particularly when increased heat of the part still continues, this class of local remedies should be employed with an energy in proportion to the activity of the local symptoms. As long as pain, redness", heat, and tension remain around the abscess, so long should leeches, or other modes of capillary depletion, directed to its vicinity, be had recourse to, particularly if the state of the patient offers no urgent indications against the practice. REATMENT OF. 22 ABSCESS—Ti Emollient and astringent applications should also be constantly employed. These will generally reduce the inflammation of the surrounding tissue, favour the resolution of the parts not yet suppu- rated, limit the quantity of the morbid secretion, and favour the maturation of the abscess, so that it may be opened with the best hopes of success. In some cases, the use of these antiphlogistic mea- sures will give rise to the absorption of the puru- lent matter, even after this had been attempted to no purpose by means of revulsives. 60. It should be recollected that the surfaces of abscesses are the constant seat of two kinds of action ; one of exhalation or secretion, the other of absorption; and that whatever excites or irri- tates them increases the former, and whatever soothes or diminishes this irritation lessens it, and favours the latter action. This consideration should lead us strenuously to adopt a continued antiphlo- gistic and soothing treatment of the affected part, until the thinning of the skin at the most promi- nent part of the tumour indicates the necessity of opening it. 61. In symptomatic abscesses, the treatment should chiefly be directed to the primary seat of disease; for as long as the mischief continues or advances there, the purulent collection increases, and diminishes as it subsides. Thus, the abscesses that point near the anus or crural arch, in conse- quence of disease of the vertebrae, will sometimes disappear after the use of active means directed to the original malady, and judiciously adapted to the state of the patient. 62. Consecutive and spreading abscesses re- quire a very different management from that now pointed out. These generally occur in persons of an unhealthy habit of body, or who have been weakened by acute disease ; or they are the result of an adynamic or ataxic and spreading inflammation occasioned by a specific or poison- ous agent; and they are not infrequently the consequence of the inflammation of veins, or of the presence of morbid secretions or purulent matter absorbed into the circulation, (§§ 25—28.), or of the transfer of irritation from a distant part. But from whatever cause they may proceed,—and they may, and occasionally do, proceed from either of those sources,—deficient constitutional energy, and vital resistance to the influence of the exciting cause, with a marked disposition of the structures to be invaded by it, and to partici- pate in the morbid action it excites, are their con- stant concomitants; requiring the energetic use of those means which are the best calculated to rouse the powers of the frame, to restore the de- ficient tone of the capillary vessels, and to thus enable them to form coagulable lymph, by which the spread of the local mischief may be limited. Instead, therefore, of having recourse to antiphlo- gistic remedies, the state of local action, and of constitutional power, requires a tonic, stimulat- ing, and restorative treatment; conjoined with the means best calculated to promote the functions of all the abdominal viscera, so that morbid matters may be eliminated from the circulating current, and healthy nutritious elements conveyed into it; and with a pure air to perfect the changes which it undergoes during respiration, and which are requisite to the continuance of the functions of life. The treatment necessary in such cases is fully detailed in the articles on Inflammation of Veins, on Spreading Inflammation of the Cellular Tissue., and on the treatment of Animal Poisons. 63. 2d. Of opening abscesses.—When we fail in procuring the absorption of the puriform mat- ter, its artificial discharge will, sooner or later, be required, when this can be accomplished. Certain abscesses require a more immediate performance of this operation than others, and more particu- larly the following :—1st, Abscesses proceeding from the escape, into the substance of any organ or part, of irritating secretions or excrementorial matters, as the urine, or faecal substances. 2d, Abscesses preceded by very acute inflammatory action, and occurring in cellular or adipose struc- tures, as the margin of the anus, the sides of the neck, or the groins. 3d, Purulent collections deeply seated, or confined under fasciae or aponeu- roses. 4th, Abscesses formed in the parietes of the splanchnic cavities, in order to prevent the chance of their breaking internally. 5th, Ab- scesses formed in parts through which large nerves and blood vessels pass, and on wliich the puru- lent matter occasions a painful and injurious pres- sure ; as abscesses in the neck, and underneath the sterno-mastoid muscle, at the top and inside of the thighs and arms, &c. 6th, Abscesses which embarrass the respiratory organs, and which press upon the larynx, pharynx, or trachea, or which endanger the integrity of those parts. 64. In all these the strict antiphlogistic treat- ment will be requisite, unless they are of the dif- fusive or consecutive kinds, with emollient appli- cations, in order to limit the extent of the inflamed parts, to diminish their size, and to hasten their maturation ; and in many cases this mode of treatment must be continued for a considerable time after the discharge of the matter, in order to limit or prevent its re-accumulation, and to pro- mote the collapse and diminution of the parietes of the abscess. The cases where it will be fre- quently necessary to retard the period of discharg- ing the purulent collection, are chiefly those in which it is formed in the internal viscera, as the liver, spleen, kidneys, lungs, &c. ; respecting which I have treated fully under their appropriate heads. 65. Chronic abscesses should be opened as soon as it is shown that their absorption cannot be accomplished ; or when they augment in bulk under the discutient and derivative treatment. Symptomatic abscesses also require to be opened, when we find that the means which we have di- rected to the original seat of disease fail of limit- ing their extension, or lessening their bulk. Con- secutive abscesses require to have their contents immediately discharged, when their situation ad- mits of this being done ; for the morbid state of the matter they sometimes contain, and the weak vital resistance opposed by the surrounding parts, and by the constitution, favours the contamination of the adjoining structures, and, indeed, of the whole frame. But this intention can seldom be fulfilled, owing to the seat of the purulent collec- tion ; and, when it is put in practice, it should be followed by as complete an exclusion of the at- mospheric air as possible. 66. It does not come within the scope of this work to notice, at this place, the different modes of opening abscesses, and the treatment with which the operation should be accompanied and ABSORPTION —as followed. This necessarily differs in every case ; but that part of it which belongs to my province is stated at the place where abscesses in the dif- ferent viscera are discussed, and the means which may be employed to procure the obliteration of their cavities, the second intention of cure, are noticed, with reference to abscess of each of the important viscera and structures in which it is liable to form. Bibliography.—Stahl, De Abscessu et Furunculo, Halae, 1714.— Ludwig, De Abscessu Latente, Lips. 1758, 4to. — Meyer, De Abscessu in Febribus, &.c, Got. 1759. —Schroeder, De Pun's absque praegressa inflammatione Origine, Got. 1766.—Bordenave, De Abscessu Abdominis, fee, Paris, 1774.—Frey, De Apostematibus, Lips. 1775. — Darwin, Experiments on Mucilaginous and Purulent Matter, Litchf. 1760.—Salmuth, De Diagnosi Puris, Got. 1783. — J. Hunter, On the Blood and Inflammation, Lond. — Home, Dissert, on the Properties of Pus, Lond. 1783. — Justamond, Versuch. lib. d. Entzundung. &.c, Leip. 1790. — Widekind, Allgetn. Theorie d. Entzundungen, Leip. 1791. — Dupuy, Sur les Abces, ou Tumeurs pu- rulentes, Paris, 1804.—Lassus, Pathologie Chirurgi- cale, t. i., Paris, 1809, 8vo. —Pearson, Observat. on Pus, Philosoph. Trans., Lond. 1811. — Rust, Uber Absoesse, in dessen Magazin, b. i., Berl. 1816. — Thomson., On Inflam- mation, Edin. 1823, ch. 9. — Heurtltloup, In Dictionnaire des Sciences Medicales, t. i. et t. viii. p. 431.—Richter, art. Abscess, Encyclop'ad. Worterbuch der Medicinischen Wissenschaften. b. i., Berl. 1828.—Roiuc, art. Abces, in Dictionnaire de Mfidecine, t. i p. 4. — Dupuytren, art. Abcet, in Dictionnaire de Mfedecine et de Chirurg. Pra- tiques, t. i.,Paris, 1829. ABSORPTION. Syn. Absorptio, Lat. Absorp- tion, Fr. Die Einsaugung, Ger. Assorbim- ento, Ital. Classif. General Pathology and Therapeutics. This is one of the most important functions in the system, and one of the most frequent channels through which disease is caused, perpetuated, or removed. As to each of these relations it requires a brief notice. 1. Of Absorption in relation to the Causation, Perpetuation, and the Re- moval of Disease. — The importance of en- tertaining accurate ideas as to the channels through which noxious agents affect the system, must be manifest. Without them, many of our pathologi- cal doctrines must be erroneous, and the thera- peutical indications founded on them worse than useless: on the other hand, just views as to the nature and extent of the causes which operate through this medium, give rise to the most im- portant inductions, —the chain of morbid causa- tion is traced without interruption, the nature of pathological conditions is more accurately ob- served, and ultimate effects are recognised in due connection with remote causes. The prac- tical advantages which accrue are great: pro- phylactic measures are based on sound princi- ples; remedial agents are directed with precision; and the physician prescribes in a spirit of rational induction, instead of blind empiricism. 2. The agents which affect the system inju- riously through the medium of absorption consist, first, of those which are external and foreign to the body, and act upon it only occasionally, or under certain circumstances; and, secondly, of those which are generated in the body itself, and, when carried by means of absorption into the current of circulation, produce very important effects. The former rank among the primary causes of disease; the latter are themselves the result of disease, but become important secondary causes, perpetuating and generally increasing its jductive of Disease. 23 severity. The first class invade the system on the mucous and cutaneous surfaces, — the skin, the lungs, the alimentary canal, &c: the second class form in the parenchyma or texture of organs and parts, or are generated on secreting surfaces, whence they are absorbed into the circulation. On each of these I shall offer a few remarks. 3. 1st. Of absorption on the skin in relation to the production and removal of disease. — a. That disease frequently proceeds in this way is evinced by certain contagious and chronic affec- tions of the skin itself: that it is possible to produce various derangements, by applying to it several active agents, which affect this surface no further than in being absorbed from it, may be proved by direct experiment. But it is chiefly when the skin is deprived of a portion of its cuticle, how- ever minute, that we perceive affections produced through the medium of cutaneous absorption. Several eruptive and contagious diseases are familiar examples of this; and the majority of deleterious agents produce a most decided effect when applied to the skin thus exposed. 4. b. The same channels through which dis- ease invades the system, are often the most suitable through which to counteract or remove it. This is shown by the treatment of syphilis; by the use of baths, lotions, fumigations, and inunctions in cutaneous and visceral affections; and by the employment of various remedies to the skin, which are partially absorbed from it into the system. When the skin is deprived of a portion of its cuticle, it absorbs rapidly many of the most active agents employed in medicine; and it is thus ren- dered one of the most eligible situations to which we can direct our plan of cure. Thus, when the stomach will not retain the sulphate of quinine, it may be efficaciously administered to the de- nuded cuticle; or when we wish to produce an anodyne effect upon the system, or to assuage violent pain, the preparations of morphine, as the acetate, may be applied in this way. And in various diseases, when the function of deglutition is lost, or the mouth cannot be opened, certain active remedies may be thus administered; more especially those which operate their effects after having been absorbed into the circulation. Even purgatives, as the croton oil, and elaterium, some preparations of iodine, strichnine, prussic acid, tartar emetic, &c, if judiciously employed in this way, will be often productive of advantage, and are not infrequently required to be thus pre- scribed. 5. 2d. Of absorption from the lungs in rela- tion to the causation and removal of disease.— a. There are very few, if indeed any, of the nu- merous maladies which are usually denominated in- fectious, that are not caused through the medium of the lungs. And, though the greater proportion of them are most probably induced from the morbid impression which then- exciting causes make upon the nerves supplying this organ, yet several of them are also, more or less, occasioned by the absorption of the cause itself into the cir- culation, and by its influence upon the blood, and the nervous and vascular systems. Probably, also, certain other causes of disease, of no mean importance, particularly marsh miasmata, and noxious animal exhalations, act directly upon the organic nerves of the lungs, and on the blood itself, through the medium of absorption. We 24 ABSORPTION—.its Pathological Relations. have reason, moreover, not only to infer that the more material causes of disease are absorbed from the surface of the lungs, when inhaled into them with the atmosphere, in the moisture of which they are dissolved, or otherwise combined ; but also that the foreign gases, which sometimes mix with the air, act in some measure through the same channel. 6. The organization of the respiratory surfaces, the nature of the circulating functions on these surfaces, and the more immediate relation subsist- ing between the air in contact with, and the blood circulating in, them, will readily explain the rapi- dity with which foreign matters floating in the atmosphere are frequently conveyed into the cir- culation. Besides, we have strong reasons to infer that several of the gases, and of the soluble sub- stances which float in the air, are carried directly into the blood from the surface of the lungs, with- out passing along absorbent vessels. The experi- ments of Professor Mayer, and of Drs. Law- rence and Coates, as well as those of MM. Segalas, Fodera, &c, fully confirm this in- ference; whilst those performed by MM. Magen- die, Seiler, Ficinus, Tiedemann, Gme- lin, and several others, show, that even in the al- imentary canal, and especially when capillary ves- sels are divided in any of our tissues, the function of absorption is not confined to lacteal or lymphatic vessels, but is frequently extended to the venous capillaries, which, in respect of certain substances particularly, chiefly perform this function. Hence I may conclude that foreign substances dissolved in, or combined with, the moisture of the air, or mixed with this fluid, may, when inspired, be car- ried from the surface of the lungs into the blood, independently of the absorbent vessels ; although, doubtless, these vessels perform their appropriate functions in this as in other parts of the body. 7. b. The rapidity of absorption in the lungs, and the ready access to the blood which foreign mat- ters find through them, are sufficient to vindicate their importance as channels through which to convey our means of cure, not only in those ma- ladies to which they are liable, but also in a num- ber of diseases affecting the whole frame, or par- ticular parts of it. General suggestions on this subject are all that can be advanced in this place : the particular recommendations for its use are given in their appropriate places. Those gaseous bodies which possess active medicinal powers: all those remedies which are more or less volatile, or are soluble in aqueous vapour; and many medical substances which may be rendered volatile or soluble in water, when combined with other bod- ies that do not destroy altogether their remedial powers, maybe prescribed advantageously through the medium of the lungs. Chlorine, the nitrous oxide, dilute oxygen gas; the vapour of iodine, or the sulphuret of iodine; the vapour of turpentine, camphor, of the common, the aromatic, or the pyroligneous vinegars; tar vapour; the chlorides or chlorurets of lime or of soda; aqueous vapour hold- ing the active principles of opium, henbane, hem- lock, belladonna, digitalis, colchicum, &c. in so- lution ; the volatile principles of various salts, the aroma of a number of vegetable bodies,—all exert powerful effects upon the system when ad- ministered in this way. 8. c. Through this channel a number of fevers, especially those which are characterized by great j depression of the powers of life, or which rapidly pass into this state ; various chronic afiections of the lungs themselves, which are unattended by acute inflammation, but consist chiefly of a mor- bid state of the respiratory nerves, and are accom- panied with spasm, and a morbidly increased secretion; the different kinds and forms of as- phyxy; the diseases which threaten life by inter- rupting the respiratory functions; and various maladies in which the blood is vitiated, and where it becomes important to act in a direct and de- cided manner on this fluid, and on the circulat- ing organs generally, may be successfully com- bated. 9. d. The knowledge that we thus acquire re- specting the channels, through which the causes of many diseases invade the system, and the re- medies for removing them may be efficaciously administered, furnishes us with important indica- tions as to the employment of prophylactic mea- sures, and rational plans of regimen and hygiene. Miasmal or contagious fevers furnish us with nu- merous opportunities of proving the justness of these views. Observation shows us that the causes of this class of disease act upon the system chiefly from their presence in the air we breathe: I it further enables us to decide that these causes invade the system chiefly through one of two, or perhaps by both, routes; viz. by the nerves sup- plying the respiratory organs, or by the partial absorption of the causes themselves, from the pulmonary mucous surface, into the circulation. From the same source, or from the collateral evi- dence of experiment, we know that foreign sub- stances do not so readily enter the circulation, when its functions proceed with energy, and the vital resistance is perfect, as when they act feebly and imperfectly; and that the depressing causes of disease have less power over the nervous in- fluence of the respiratory organs, and of the system in general, when the vital actions which take place in the lungs are performed with due acti- vity. The same sources of observation make us acquainted with the important facts, that the dilu- tion of the atmosphere, which contains the causes of febrile diseases floating in it, by free ventil- ation; that the destruction, or neutralization, or counteraction, of these causes, by the evaporation of certain disinfectant and stimulating agents; and that a due energy of all the vital and secreting functions, with an equable state of the mental powers and manifestations, and with a steady con- fidence; are the most successful means of prevent- ing the attack and diffusion of those maladies. 10. By combining these facts as to the source, mode of operation, and methods of counteraction, of the chief causes of a most important class of maladies, and by directing the measures they sug- gest as far as may be according to the peculiari- ties of individual cases and diseases, we are thereby enabled to furnish persons, and even whole com- munities, with instructions and means calculated either to counteract or to lessen the dangers to which they are exposed. 11. 3d. Of absorption from the alimentary ca- nal, in connection with the causation of disease — a. It may be received as a pathological axiom that the rapidity and extent with which deleterious matters are absorbed from the digestive mucous surface, as well, indeed, as from the respiratory, a::d other organs of the body, are nearly in pro- ABSORPTION —its Relations to Disease. 25 portion to the depression of the nervous ener- gies and vital resistance of the system. The truth of this is evinced in respect not only of the actions proceeding on the mucous surfaces, but also of those taking place in the different organs and structures. It is necessary to allude here to the numerous agents which cause, coun- teract, or remove disease, by their being absorb- ed from the alimentary canal. Whilst many agents produce their effects chiefly by modifying the states of the nerves and mucous tissue of thjs canal, others act principally from being ab- sorbed, either by the lacteals, or by the venous radicles, and carried into the circulation ; and a still more numerous class seem to operate through both channels, impressing immediately the nerves and tissues to which they are applied, and subse- quently being absorbed into the blood, where they produce important effects not only upon this fluid, and on the vascular system, but also upon the functions of various secreting organs, especially those by which they are eliminated from the body. 12. A very large proportion, therefore, of the ingesta, whether alimentary, medicinal, or poison- ous, thus acting upon the system chiefly through the medium of absorption, the importance of di- recting a considerable portion of attention to this function in our pathological investigations, as well as in the appropriation of medicinal means, must be apparent. Besides these more obvious rela- tions of the subject, there are others which have been either imperfectly investigated or entirely overlooked. To these I can merely allude: but amongst the most interesting are the absorption of unwholesome and imperfectly digested chyle from the intestinal surface ; the absorption of a portion of the vitiated secretions which occasionally accu-, mulate in the alimentary tube, particularly in the ccecum and cells of the colon ; the absorption of some part of the faecal matters, when they are long retained in the above situation, as evinced by the sensible qualities of the perspiration, foul state of the skin, &c, or of the obstructed and accumu- lated urinary secretion, as proved by similar phe- nomena ; the passage of bile into the circulation, when it has been retained in the liver, the biliary ducts, or gall-bladder, from torpor or obstruction of these parts, or when it is secreted in large quantity, and does not readily pass off with the egesta. All these are very fruitful sources of disease ; and, although generally connected with some degree of pre-existing disorder, or of torpid function, they are often the chief aggravating causes of many of the maladies we are called upon to treat, from the constitutional and visceral disturbance they occasion and perpetuate. 13. There are few disorders which implicate the digestive and chylopoietic organs, and very few febrile diseases, which do not, at some period of their course, evince signs of the absorption into the circulation of a portion of the morbid secre- tions or faecal fluids retained in the alimentary canal, when due evacuations are not practised. Therefore, besides the other effects produced by medicines of this class, the due evacuation of these secretions and faecal matters from the prima via is one of the best offices they perform. 14. b. It is unnecessary to do more than to allude to the advantages that accrue to the scien- tific practitioner from some knowledge,—although, in the present state of medicine, necessarily im- | perfect,—of the remedies which act by beino- ab- sorbed, either altogether or in part, from the ali- mentary canal. Most of those substances which are found by experience the most efficacious in promoting the actions of the different secreting viscera, and in producing a marked and perma- nent change of the general state and functions of the economy, operate after having been absorbed into the circulating current, and conveyed through this channel to vital and secreting organs; and, although, during the healthy performance of the secreting functions, or whilst the vital energies are not far reduced, these substances seldom accu- mulate in the blood so as to be detected in it by chemical analysis, owing to the balance which is preserved between the rapidity of absorption and the activity of elimination, yet their passage through it is proved by the fact, frequently ob- served in regard of all of them, of their being found in the secretions of the eliminating or de- puratory organs. This fact was established by ex- periments performed by myself,—some of them as far back as 1819,—and"published in several periodicals in 1821 and 1S22. 15. 4th. Of absorption from diseased organs and structures.—a. When morbid secretions are generated, or accumulated in any organ or texture, or when any part is changed in such a manner as to secrete a matter different from the healthy con- stituents and fluids of the body, the matter formed is generally, after a while, absorbed into the cir- culation, and contaminates, in a more or less marked manner, according to its nature, the other fluids, and the soft solids, and thereby at last de- stroys life. Illustrations of this procedure are fur- nished us in the pathological history of internal and deep-seated abscesses ; in some morbid states of the uterus; in scirrho-cancer, fungous hasmato- des, and other malignant diseases. The celerity with which the absorption of the morbid matter and the contamination of the frame proceed, is generally according to the principle already recog- nized (§ 9.),—in proportion to the diminution of the vital energy and resistance of the constitution- al powers. 16. b. The commencement of the contamina* tion can scarcely be determined by an apprecia- tion of symptoms : but the experienced observer will readily recognize, in the colour of the surface of the body; in the state of the heart's action, and of all the circulating functions, as well as in the blood itself; in the failure of the energies of life ; in the morbid condition of the nervous functions and of the powers of the stomach, and indeed of the whole digestive canal, sufficient proofs of the early, as well as of the advanced progress of dis- ease, arising from the absorption of morbid mat- ters from the primary seat of morbid action, and the consequent vitiation of the circulating fluids, of the soft solids, and of the secretions and excre- tions of the body. (See Art. Blood.) 17. In many of the more chronic diseases which either commence with or terminate in the malignant state, this contamination is frequently first evinced by the tumefaction and pain of ad- joining lymphatic glands, owing to the irritation produced by the morbid fluid conveyed into them: the inflammation or obstruction thus produced in them becoming an obstacle to the rapid transit of the morbid matters from the original seat of dis- ease into the circulation. But in many cases this 26 ABSTINENCE—Morbid Effects of. is an insufficient barrier ; and in others, these mat- ters seem to pass onwards, either without circu- lating through lymphatic glands, or without occa- sioning irritation, obstruction, or inflammation in them; or are almost directly conveyed into the venous circulation. Whatever may be the chan- nel of conveyance, there can be no doubt of the fact—the practical importance of which is very great—that the rapidity of the absorption of mor- bid matters, and extent of their hurtful effects on the constitution, are in proportion to the depression of the vital energies of the frame,—this depression being frequently the cause of their absorption, par- ticularly in respect of puriform fluids; or at least the circumstance which more especially favours its occurrence, and the rapidity of its progress. Bibliography. — Gasparl, Sur les Maladies Putrides, fcc. in M> Magcn Ii 's Journ. de Physiol., t. ii. — Copland, in London Medical Repository, vol. xvii. for May, 1822 ; and in his Notes and Appendix to M. Ri~herand's Elements of Physiologv, Lond. 1824. — Mtgendie, art. Absorption, in Diet, de Med. et Ohirurg. Prat., t. i., Paris, 1829.— Fodera, Archives Gener. de Med., t. ii. p. 57. —Piollet, Revue Med.. 1826, t. i. p. 165. ABSTINENCE Its Morbid Effects. Syn. Ab- stinentia, Lat. Astinenza, Ital. Die En- thal tung, Ger. Abstinence, Fr. Starvation from Hunger. Classif. I. Class, V. Order (Author, see Classification in the Preface.) 1. It does not come within the scope of this work to enter upon the consideration of the thera- peutical relations of abstinence; but that the prac- titioner should be acquainted with the states of disease which it occasions, and with the best means of treating it, is extremely important; more espe- cially as, when it is too rigidly enforced during the treatment of several diseases, it not unfre- quently gives rise to effects of a serious nature, which not infrequently have been mistaken for the spontaneous course of the malady. 2. Of the Morbid Effects of Absti- nence.—Abstinence has been long employed as a means of cure, and generally as a part of the antiphlogistic regimen, in a very great number of diseases, particularly in fevers and inflammatory affections. Very great difference, however, exists both among writers and practitioners as to the ex- tent to which it should be carried, and the mala- dies in which it ought to be prescribed. As to its applicability to the class of diseases now noticed, there is no doubt : but in disorders of debility, or of irritation merely, particularly those which occa- sionally simulate chronic inflammation, and in va- rious nervous affections, it is extremely injurious; and I believe that it has been carried to a hurtful extent in many of these affections, particularly by Broussais and his followers, as indeed has been recently well shown by MM. Piorry and B arras. A case of this description, which had been long under the care of M. Broussais, very lately came before me, with many of the morbid effects of this practice, which had been carried to a hurtful extent. There can be no doubt, how- ever, that it is extremely beneficial, when care- fully watched and regulated, in many of the dis- eases of the stomach and its associated viscera ; but the fact is equally incontrovertible, that it will often produce effects very nearly resembling those for which it has been prescribed. The importance, therefore, of keeping these effects in recollection, when treating several diseases, particularly those of irritation and debility, must be apparent. 3. In appreciating the usual effects of abstin- ence it is extremely requisite to be aware of two things: 1st, That the effects vary with the state of the patient at the time that abstinence is endured; 2d, that they differ materially according to the sud- denness with which it is entered upon, the extent to which it is carried, and the circumstances with which it is associated. By very corpulent and plethoric persons, abstinence is generally borne well for a long period, and by those labouring un- der febrile or inflammatory excitement; and it is, in them, one of the most necessary means to dimi- nish the one and lower the other. In these, paf- ticularly the latter, total abstinence may be en- dured for many days; whilst, if carried to the same extent in healthy persons, its effects would be fatal, or nearly so. Abstinence, also, is longer endured by persons of the middle or matured epochs of life, than by those of an early age. 4. That the absolute or sudden deprivation of food should be productive of more rapidly serious effects is very obvious; but it is not so well known that there are circumstances, which modify the effects of the less absolute states of abstinence, and which, when thus combined, give rise to very im- portant and dangerous diseases. In order to place the subject more clearly before the reader, I will first notice the effects of abstinence simply, and unassociated with other causes of disease; and next, the morbid conditions, which its association with certain influential agents usually occasion. 5. 1st. The morbid effects of simple abstin- ence. — Keeping in recollection the modifications depending upon the extent to which deprivation of nourishment is carried, and the age and state of the person at the time of its adoption, I may brief- ly describe the morbid effects of abstinence as fol- low:— Paleness and languor of the countenance; muscular debility and emaciation; a weak and small pulse; thirst; at first quickness of intellects, constipation, and flaccidity of the muscles. To these succeed increased frequency of pulse, pal- pitations, alternating with leipothymia, or even full syncope; headach or delirium; flashes of light before the eyes; tinnitus aurium; slight amaurosis; parched state of the throat, and thirst; pains in the'stomach; great wakefulness, followed by de- lirium, sometimes mild, but in other cases furious, or at first mild or muttering, and afterward strong or furious; sinking of the animal heat, or alter- nate coldness and burning in parts of the body; and lastly, morbid sensibility of the organs of sense and surface of the body, and greatly de- pressed temperature, followed by insensibility, stu- por, or coma, terminating in death. 6. It is obvious that the severity and duration of these symptoms will vary in different cases, according to circumstances peculiar to each. But it is not so well known that they will be actually produced by pursuing a too rigid absti- nence in the treatment of various diseases, and particularly when the nature of the disease is mis- taken: as when the irritative symptoms frequently attendant upon diseases of debility, or on nervous affections, are viewed as resulting from inflam- mation. Many cases have occurred to me in the course of practice, where the antiphlogistic regi- men, which had been too rigidly pursued, was itself the cause of the very symptoms which it was employed to remove. Of these symptoms, the affection of the head and delirium are the most ACNE. 27 remarkable, and the most readily mistaken for an actual disease requiring abstinence for its removal. A case of this description lately occurred to me. A professional man was seized with fever, for which a too rigid abstinence was enforced, not only during its continuance, but also during con- valescence. Delirium had been present at the height of the fever, and recurred when convales- cent. A physician of eminence in maniacal cases was called to him, and recommended him to be removed to a private asylum. Before this was carried into effect, I was requested to see him. A different treatment and regimen, with a grad- ual increase of nourishment, were adopted, and he was well in a few days, and within a fortnight returned to his professional avocations. 7. The morbid appearances observed after fatal cases of deprivation of food possess some interest. The most remarkable are the emaciation and absorption of every particle of fatty matter : the paleness, flabbiness, softening, and emaciation of the voluntary muscles, and of the substance of the heart ; an exsanguined and pale state of the viscera ; slight atrophy of the liver and spleen; diminished size of the stomach and colon ; and particularly the increased vascularity of the brain, and sometimes of the membranes also, compared with the other viscera. It would seem that a very large proportion of the blood continues, as in many cases of great vascular de- pletion, to be sent to the brain to the very last. This is obviously owing to the pressure of the air on all parts of the body, from which the encephalon is guarded by its unyielding case. In addition, also, to the vascularity of this part, a limpid serous effusion between the membranes, or in the ventricles, is sometimes met with. 8. 2d. Of the morbid effects of abstinence when it is associated with other hurtful agents.—These effects are occasionally presented to medical men under a variety of circumstances, and from a varied combination of causes ; but in the great majority of instances they result from deficiency of food merely, rather than from a rigid abstin- ence, conjoined with the depressing influence of cold or insufficient clothing, great or continued exertion, or with a moist and unwholesome at- mosphere. Thus we find the association of these causes, particularly insufficient or unwholesome food, laborious exertion, mental depression, a moist, cold, or unwholesome atmosphere or local- ity, not unfrequently give rise to purpura haemorr- hagica, scurvy, scorbutic dysentery or diarrhoea, low or typhoid fevers, affections of the brain and nervous system, emaciation, with chronic ulcera- tions, &c.—effects which have received a partic- ular notice in their respective articles. 9. The best illustration of the effects of this association of other agents with a continued defi- ciency of food is furnished by the diseases which appeared a few years ago in the Milbank Peniten- tiary. The prisoners confined in this prison were suddenly put upon a diet from which animal food was nearly altogether excluded, excepting in as far as it entered into the composition of a weak soup. They were at the same time subjected to a low grade of temperature, to considerable ex- ertion, and confined within the walls of a prison situate in the midst of a marsh which is below the level of the adjoining river. The conse- quences were, first, loss of colour, of flesh and strength ; subsequently, diarrhoea, dysentery, scorbutic dysentery, scurvy ; and, lastly, low ataxic or adynamic fevers, or headach, vertigo, convulsions, delirium or mania, apoplexy, &c. The smallest loss of blood produced syncope or leipothymia, and fatal results. Yet, in the great majority of the fatal cases, independently of the lesions observed in the mucous surface of the digestive tube, or in other situations, increased vascularity of the brain and its meninges, fre- quently with effusion of fluid in the ventricles or between the membranes, was found upon exam- ination after death. , 10. The Treatment of the morbid effects of abstinence is very obvious, yet considerable care is necessary to its successful issue in very urgent cases. Nourishment should be adminis- tered cautiously, in a very small quantity at a time at first, but frequently. It ought to be bland and farinaceous : animal food may be en- tered upon subsequently, and the quantity grad- ually increased. The animal warmth shoved be promoted, at the same time, by the usual exter- nal means—by frictions and warm applications ; and the bowels assisted by the occasional use of bland enemata. Soups may be allowed early in the treatment, but in a small quantity at a time. Milk is often prejudicial, unless diluted and made into gruel with some of the farinaceous articles of food. Internal stimulants are seldom required, unless when symptoms of cerebral or nervous irritation exist, when they may be given ; par- ticularly the preparations of ammonia, the aethers, camphor, vegetable bitters and tonics, at first in very moderate doses, in conjunction with small quantities of an anodyne, as the extract of hop, the extract of hyosciamus or of opium, the pare- goric elixir ; and by warmth, frictions, and stim- ulating applications to the cutaneous surface and lower extremities. These means will generally succeed in removing the effects of simple abstin- ence whilst they admit of removal. The treat- ment of the effects resulting from the conjunction of other causes with the one now discussed, is considered under their respective heads. Birliography.—Carrie, Medical Reports, 4to ed.,vol. i. p. 304.—Willan, Miscellan. Works, by A. Smith, p. 437. —Bai-ras, Traite sur les Gastralgies et les Enteralgies, &.c, 3d ed. 8vo, Paris, 1829.— Piorry, Procede Operatoire dans 1' Exploration des Organes, &c. &c, 8vo, Paris, 1831, p. 368.—P. M. Latham, On the Diseases in the Milbank Penitentiary, 8vo, Lond. 1824.—Andral, Precis d' Ana- torn. Patholog., t. ii. p. 769.—Rostan, Diet, de M£d. t. i. p. 154.—Ch. Londe, Diet, de Med. et Chir. Prat., t. i. p. 103. Collard de Martigny, in Magendie's Journ. de Physiol., &c, t. viii. p. 152. ACNE. 'Axvr. Derived, according to Cassius (JYdt. et Med. Quest, &c, Prob. 33.), from 'axur). Syn. "Ior6oc, Gr. Varus, Lat. Psy- dracia Acne, Sauv. Gutta Rosea, Darwin. lonthus, Good. Boulon, Couperose, Fr. Die Finnen, Ger. Carbuncle, Stone-pock, Whelk. Classif. 3. Class, Diseases of the San- guineous Function ; 2. Order, Inflamma- tion (Good); 7. Order, Tubercles ( Will- an and Bateman). IV. Class, IV. Or- der (Author, see ttte Classification). 1. Def. Hard, inflamed, tubercular tumours, suppurating very slowly, occurring chiefly in the face; sometimes, also, on the neck and shoulders. 2. One or more, sometimes a number, of these tubercles appear, generally in succession, in the face, and sometimes on the neck, shoulders, and 28 ACNE — Simplex — Indurata—Rosacea.. breast, but never lower ; remain permanent for a considerable time ; and suppurate slowly and imperfectly, leaving a dark or livid mark, which gradually disappears. They occur chiefly in per- sons of the sanguine temperament ; commencing at the period of puberty, and generally disappear- ing after thirty or thirty-five. They are common to both sexes, but are most frequent and numer- ous in the male sex. 3. This is one of the most constant and unva- rying in its characters of any of the affections of the skin ; but writers upon this class of diseases differ widely in respect both of its particular cha- racter and seat. Willan, Plenck, Bate- man, and Thomson consider it a tubercular affection ; whilst Alibert, Biett, and Rayer view it as pustular. 1 believe, however, that both opinions are in some respects correct; and that in certain forms or states of acne the tubercular change is predominant, little or no suppuration taking place, but a state of slow inflammation giving rise to a continued exfoliation of the cuticle, or formation of thin scabs on their apices ; and thus they slowly disappear ; whilst in others the pustular character is very distinct, but always preceded by the characteristic tubercular hardness. This affection may be viewed, therefore, as form- ing an intermediate link between the tubercular and pustular eruptions. 4. In respect of the particular tissue in which this disease is seated, some difference of opinion also exists. The greater number of writers on the pathology have considered this disease to be seated in the proper structure of the cutis vera ; many of them admitting, at the same time, an affection of the sebaceous follicles very nearly resembling it. Mr. Plumbe, however, attributes it entirely to obstruction and chronic inflammation of these follicles. I believe that this opinion is too restricted ; and that, whilst one form of acne evidently depends upon this cause, others are essentially disease of the cutis vera. 5. Spec. I. Acne Simplex, Simple Acne. Syn. Gutta Rosea Hereditaria, Darwin. Dartre Pustuleuse Miliare, Alibert. Ion- thus varus simplex, Good. Simple acne affects most frequently young sub- jects, at the period of puberty, and particularly females. They generally appear on the forehead, shoulders, and upper part of the thorax, and are liable to recur at the menstrual periods, especially in cases of dysmenorrhoea. Many of these vari do not proceed to suppuration, but slowly subside. They are very commonly developed in succes- sion ; commencing with small, hard, and inflamed tubercles, of the size of a pin's head. These continue to enlarge for three or four days, and the inflammation becomes more apparent. In seven or eight days they have reached their greatest size. They are then dark red, smooth, prominent, shining, hard, and slightly painful to the touch. After two or three days a small speck of matter appears on the apices of some of them ; and when these break, a thin humour exudes from the tubercular induration, and dries on its surface, forming a thin scab, which adheres firmly ; but, after a few days, is loosened at the edges, and falls off; the tubercular hardness and livid redness gradually subsiding, and disappearing after three or four weeks. 6. In some persons this eruption recurs fre- quently at short intervals, the vari being more or less numerous ; in others it is more extensive, and never altogether disappears, although it winore troublesome at one time than another. When the vari are numerous, many of them undergo no suppuration ; but the sebaceous glands are often excited, giving the skin a greasy appearance. In many of these cases, several of the van assume the characters of the next species. 7. Spec. II. Acne Indurata, Stone-pock. The tubercles are larger, more indurated and permanent than the foregoing ; and are apparently the consequence of a slower and more deep-seated inflammation. They often appear in considerable number, of a conical or oblong-conoidal form ; some of them assuming a roseate hue, and tend- ing to suppuration at their apices ; others remain- ing in a hard, elevated state for a very long time, without any appearance of the suppurative pro- cess, or disposition towards it. In some cases, two or even more of them coalesce, and occas- ionally suppurate at their respective apices ; but one only may undergo this change. As they continue they become more purple or livid, par- ticularly when they have no tendency to suppu- rate. When they experience this process, the same process of scabbing and exfoliation, already described (§ 5.), is gone, through ; but it some- times happens that when they experience any irritation they may suppurate a second time. As they very slowly subside, they leave a purple or livid discoloration, and, occasionally, a slight de- pression, which is long in wearing off, and which sometimes never altogether disappears. 8. This species of acne generally is most fre- quent and numerous along the rami of the lower jaw, on the temples, the nose, and cheeks ; also on the back and neck. They are frequently ac- companied by a greasy state of the skin, from an excited state of the .cutaneous follicles ; are commonly sore and tender to the touch ; and, when numerous, are in every stage of progress, giving the surface a spotted and variegated ap- pearance,—owing to the prominence and redness of some at their commencement, to the yellow points in those that are suppurating, to the scaly crusts covering those which have undergone this process, to the lividity of those that have exfo- liated or are subsiding, and to the discoloured depressions which others have left after them. 9. The general health seldom suffers mate- rially from either the simple or the indurated acne, excepting as far as regards some pre-existing and concomitant disorder of the digestive func- tions. If fever, or acute disease, attack persons affected with these eruptions, the vari generally disappear ; but they frequently also re-appear upon its subsidence., becoming in some respects a critical eruption. 10. Spec. III. Acne Rosacea, Rosy-drop. Syn. Gutta Rosea, Auct. var. Gutta Rosea Hepatica, Darwin. Ionthus Corymbifer, Good. Dartre Pustuleuse Couperose, Ali- bert. Goutte Rose, Couperose Rougeurs, Fr. Kupferbandel, Roth-nase, Ger. Carbuncled Face, Eng. The first and second species, described above, might have been, with propriety, viewed as varie- ties of the same species ; but this is a very dis- tinct species from the preceding. It consists of small, slowly suppurating tubercles, accompanied \CNE — Punctata — Syphilitica. 29 with a shining redness, and an irregular granu- lated appearance of the skin of the part affected. This species commonly appears first at the end of the nose, and afterwards spreads from both its sides to the cheeks, which it never altogether covers. At first it is not uniformly red ; but is pale in the morning, and intensely red whenever the patient is excited or heated, and particularly after dinner, or drinking wine or spirits. After some time the texture of the cuticle is gradually thickened, and its surface granulated and varie- gated by the ramifications of cutaneous veins, and the suppuration of small, prominent vari, which successively arise in different parts of the nose and face. 11. This species of acne seldom appears before the age of forty, excepting in those addicted to the immoderate use of vinous or spirituous liquors, or who possess great hereditary predisposition to it. In advanced life, or in the worst of these cases, it sometimes spreads to the greater part of the face, even to the forehead and chin. The nose usually becomes very tumid, and of a fiery red colour, and sometimes is enlarged to an enormous size. The nostrils, in these cases, are generally distended, and their alae often fissured and divided into lobes. In advanced age, this species of acne becomes more livid ; and if any of the tubercles suppurate, they often ulcerate, and are indisposed to heal. In younger persons, who are attacked chiefly from hereditary disposition, it is often ac- companied with irregular red patches on the face, which are often smooth, devoid of tubercles, and accompanied with occasional slight exfoliations of the cuticle. These patches are extended, or aggravated, by intemperance in food or drink. 12. Spec. IV. Acne Punctata, Maggot Pimple. Syn. Crimones, Auct. var. Punctee Mucosce, Darwin. Ionihus Varus puncta- tus, Good. Der Gries, Ger. Tannes, Fr. Grubs, Eng. This is, in my opinion, the only species of acne which is seated in the follicular glands ; and, al- though often observed as the only form of erup- tion, it also is frequently found intermingled with the species already described, particularly the first and second. It consists of a number of black points, surrounded by a very slightly ele- vated border of cuticle, proceeding from con- creted sebaceous matter accumulated in the glands and their ducts, whence it may be squeezed out in a vermicular form, the external extremity being dark from its exposure. In consequence of the accumulation and distension, these glands some- times become inflamed, and give rise to small tubercles, with minute black points in the centre of then external surface. These tubercles sup- purate partially, as the preceding, whilst others remain stationary for a considerable time, and several are distended without even being in- flamed. They are not infrequently mixed with tubercles without the black punctae, which are evidently owing to a similar obstruction, and to a more complete closure of the outlet of the ducts. In this species of acne the accumulated secretion may be squeezed out. 13. Spec. V. Acne Syphilitica, Venereal Acne. Syn.Gutta Rosea Syphilitica,Plenck. Syphilvle Pustuleuse Miliaire, Alibert. Amongst the very numerous forms of cutane- ous affection in which secondary syphilis may 3* manifest itself, this may be enumerated as one, although not a common one. Plenck has giv- en a very correct description of it. This spe- cies nearly resembles, in the size and form of the pustules, the acne rosea. It chiefly affects the forehead, face, neck, and upper part of the trunk. The vari are round and conical, with an inflamed, copper-coloured, tubercular base and areola. They suppurate slowly at their apices, where a yellowish brown scab is formed; and leave a dirty, dark, and slightly depressed mark. They present a darker colour, and more permanent tu- bercles, on the nose, the adjoining parts of the cheeks, and forehead, than elsewhere ; and are there observed in discoloured patches, in every stage of their growth. They are frequently found complicated with other eruptions, chiefly of a scaly character, on different parts of the body ; are always a secondary venereal affection ; and, al- though sometimes unaccompanied with other sy- philitic symptoms, are most commonly attended with ulcerations in the throat, with nodes, inflam- mation of the periosteum, and nocturnal pains. 14. Diagnosis.—Acne can be confounded only with ecthyma. The tubercular pustules of the former, however, are small, slowly developed, with an indolent and hardened base ; whilst the pustules of ecthyma are large, superficial, unac- companied with chronic induration, and forming thick scabs, more or less prominent, much less adherent, and such as never are formed in acne. The characters of syphilitic acne, the antecedent and accompanying symptoms (§ 13.), the colour and predominance of the eruption about the-nose and commissures of the lips, the tendency of the vari to ulcerate, and the associated affection of the throat, and sometimes of the periosteum, suf- ficiently mark the nature of this species of the disease. 15. The Prognosis of acne regards merely the persistence of the eruption, and the inconve- nience attendant on it. Acne simplex and punc- tata are often of comparatively short duration. The acne indurata is much more tedious ; and in some constitutions will resist, even for many years, every mode of treatment, particularly if the causes in which it not infrequently originates be over- looked. Acne rosacea is seldom or ever cured, excepting by a strict attention to regimen. 16. The Causes of acne are extremely various. The species simplex, indurata, and punctata usually occur during youth, in the sanguine and bilious temperaments, and disappear about middle age. They are very generally connected with chronic affections of the stomach, bowels, and liver; with haemorrhoids; in some, with a tenden- cy to phthisis ; and in females, with painful and scanty menstruation. These species, as well as the acne rosacea, evidently arise, in many cases, from hereditary predisposition ; and are most common in cold and moist climates,—probably owing to the use of ardent spirits. Excesses at table, cold indigestible articles of food, sedentary habits, fits of passion, anxieties of mind, and the depressing passions, cold drinks—particularly if taken when the body is overheated—the use of irritating cosmetics, and disorder of the digestive functions, are very common causes of these eruptions. I believe, however, that the simple, indurated, and punctated species of acne are most frequently occasioned by uterine irritation, 30 ACNE—Treatment of. and excitement, or an imperfect performance of the uterine functions ; by constipation ; by torpid conditions of the liver ; and by the injurious ad- diction to onanism. 17. Treatment.—In the treatment of these affections, our chief attention ought to be directed to their pathological relations and causes. These latter must be removed as far as may be done ; and the former should both guide our indications, and direct our means of cure. The apprehensions entertained by the older writers, of producing in- ternal disease by the sudden repulsion of the eruption, were founded on the results of observa- tion, although explained by partially inaccurate or unsound pathological views. Affections of the stomach, bowels, chest, and head, have been thus induced, and been relieved upon a re-appear- ance of the eruption : but such consecutive dis- eases are more common after the repulsion of other eruptions. We should, however, as being both the safest and the most permanent method of cure, direct our remedies to the constitutional or internal relations, as well as to the external manifestations of disorder. In the treatment of this, as well as many other diseases, the causes, the state of the habit and con- stitution of the patient, its morbid relations, and its duration, are severally to be kept in recollection. 18. 1st. Treatment of acne simplex.—Indeli- cate constitutions, the chief attention should be directed to the state of the digestive functions. These should be promoted by gentle aperients, combined with tonics, and the functions of the skin promoted, by preserving a free transpiration on its surface. With this view, sulphur may be combined with magnesia, or with cream of tartar, and confection of senna, and taken in a sufficient dose, at bedtime, to procure a full evacuation in the morning, or any one of the formulae ( Ap. Nos. 82. 89. 98.) may be had recourse to. These may be occasionally changed for a powder with rhu- barb, sulphur, and magnesia, or for the extract or decoction of taraxacum, with subcarbonate of soda or sulphate of potash. If the functions of the liver are torpid, the following may be taken for a few nights :— No. 6. R l'.lul. Hydrarg. Submur. Corop. 9j.; Fellis Tauri Inspiss. gr. xv.; Saponis Castil. er. x.; Exlr. Ta- raxaci gj. M. Fiant Pilule xviii., quaruui capiat binas vel ties hor& somni. After the bowels have been evacuated, and the secretions brought to a healthier state, the dilute mineral acids, either alone or with bitter infus- ions, may be taken through the day. 19. When the eruption occurs in young ple- thoric persons, and when it is in females attended with scanty and difficult menstruation, small blood- lettings may be practised ; in the latter, by the application of leeches to the superior and internal parts of the thighs. In more delicate females the functions of the lower bowels are to be promoted by the pilula aloes cum myrrha, combined either with pilula ferri composita, or with the extractum gentianae. When the eruption is obviously con- nected with imperfect and painful menstruation, the use of the warm saltwater hip-bath, or of the hip vapour bath, or warm salt water pedilu-via, after the application of a few leeches to the insidesof the thighs, will be extremely serviceable. In such cases, the internal exhibition of the sub- borate of soda, either in the form of pill or draught, combined with camphor, the extractum taraxacij or the extr. rutae, or, as directed in Form. Nos. 93. 184. 209. 254. will be found of great advantage. 20. In addition to these internal remedies, which require to be varied according to diflerent pathological relations of the eruption, external applications will be necessary ; and when con- joined with the above treatment, or employed subsequently to it, no dread may be entertained of any injurious consequences from them. The ancients, particularly Celsus, Pi.iny, Aetius, Paulus,Actuarius,&c. recommended lotions and liniments with vinegar and honey ; and these sometimes combined with turpentine, emulsion of bitter almonds, myrrh, alum, soap, Cimolian earth, the bruised roots of the lily, the cyclamen, narcissus, and the fruit of the wild vine ; the most of them calculated to be advantageous in many states of the common forms of acne. 21. If the tubercles are much inflamed, and inclined to be pustular, mildly stimulating appli- cations are most serviceable, as dilute spirit, or the pyroligneous acetous acid, or liquor ammonia acetatis, with rose or elder-flower water. In the more indolent cases, or when the skin can bear an augmented stimulus, Willan and Bateman recommend from half a grain to a grain, or more, of the muriate of mercury, in each ounce of the vehicle ; or a drachm or more of the liquor potas- ses, or of the muriatic acid, in six ounces : and Thomson advises that the emulsion of bitter almonds, containing ten minims of hydrocyanic acid to each fluid ounce of the emulsion, should be the vehicle adopted. The solution of the sulphuret of potass, in the proportion of a drachm to twelve or sixteen ounces of water, may also be employed ; and, in the more obstinate cases, the baths directed in Form. No. 14—17. may be had recourse to. The solution of the muriate of am- monia, either alone or with the chloride of mer- cury, is often serviceable. 22. The lotion from which I have derived the greatest advantage in practice, and which I have found the most generally applicable, is a solution of the sub-borate of soda in rose or elder-flower water, or in water which had been poured in the boiling state over sulphur, and allowed to infuse for ten or twelve hours. The borax may also be dissolved in equal quantities of elder-flower water and honey, and used as a lotion in the more chronic cases. 23.2d. Treatment of 'acne indurata.—In young and plethoric subjects, or in females, when the eruption is accompanied with a scanty and pain- ful menstruation, the treatment already pointed out(§,19.),shouldbe put in pra ctice. When we suspect that sexual irritation or masturbation iii connected with the causation of the eruption, early rising, mental occupation, the use of gentle cooling aperients, of soda combined with small doses of camphor, soda water, sulphur with soda or antimony, are the most serviceable internal remedies. After these, the mineral acids, the sulphureous mineral waters, and gentle vegetable tonics, will be useful. Where the eruption is de- pendent upon torpid function of the stomach, or liver, or bowels, mild alteratives, exhibited at bed- time, as the pills already prescribed (§ IS.), and gentle tonics through the day, will be required. In a most obstinate case, which some time ago came before me in a lady, whom all the prac- titioners who had acquired a reputation in the ACNE — Treatment of. 31 treatment of cutaneous affections had attended, strict attention to the state of the digestive and uterine functions removed the eruption. The fol- lowing electuary has sometimes been used by me in this and other obstinate cases. No. 7. R Potassae Supertart. in pulv. §j. ; Suh-boratis Sodae 3 'jss-i Sulphuris Praecip. §ss. ; confeclionis Senna; et Svrup. Zingiheris aa § jss. M. Fiat Electuarium, cujus capi'it Coch. unuin minimum omni nocte. At the same time a solution of two grains of the chloride of mercury in four ounces of the compound tincture of cinchona was prescribed, and a tea- spoonful of it directed to be taken twice daily, in half a glass of infusion of camomile flowers. The lotion already recommended (§ 22.) was also employed. In cases similar to this, and, indeed, in all those accompanied with disorder of the digestive functions, cold or drastic purgatives ought to be avoided; and the bowels should be regulated with the pilula aloes cum myrrha, com- bined with a little blue pill, or with the pill pre- scribed above (§ 18.); or the ext. aloes purif. conjoined with the extr. gentianae; or the electuary now directed. Advantage will also be obtained from a draught of infusion of cascarilla, or of calumba, with subcarbonate of soda or potass, or the liquor potassae, taken twice a day. 24. As to external applications in this form of acne, little need be added to what has been already stated. The lotions with the chloride of mercury, or with the borax, are most to be de- pended upon, particularly when dissolved in an emulsion of bitter almonds, or in camphor mix- ture, with the addition about twelve minims of the hydrocyanic acid to each ounce of the vehicle. In cases where the tubercles have at all suppurated, it will be advisable to open them with the point of a lancet before the lotion is used. 25. At the commencement of the eruption, mild emollient poultices and fomentations are useful; and afterwards, particularly in the more obstinate cases, M. Biett, and after him MM. Cazenave and Schedel, recommend the following oint- ments to be used, in order to promote the resolu- tion of the tubercles :— No. 8. R Protochlor. Hydrarg. et Ammonia?* (Sub- mt;r. Hydrarg. et Amnion.)V)j.— 3j- i Axungiae Jj. Misce. Of this ointment I have had no experience; but the following I have employed with advan- tage in several chronic eruptions, and in two cases of this species of acne :— No. 9. R Sulphureti Iodinae gr. xii.—xxiv.; Axungia Sj- m. Ambrose Pare and Darwin considered that blistering successively small portions of the face was the most successful means of ridding it altogether of this very obstinate eruption. This practice has been employed at the hospital St. Louis, by M. Biett, with great benefit. When the disease has disappeared, this scientific physi- cian has derived great advantage from a douche of cold sulphureous water in preventing a return of the eruption. 26. 3d. In treating the punctated species of acne, it will be frequently necessary to press out the accumulated and hardened matter from the follicles. The vapour bath, the warm sulphur bath, followed by frictions either with a coarse towel or a flesh-brush; and lotions such as have * Prepared ">y subliming equal quantities of the cor- rosive sublimate and inurias ammonia:. been already recommended, or a weak solution of pure potash, or of ox-gall, or of sulphuret of potash, also followed by frictions, are particularly indicated in this species of acne. 27. Internally, the solution of the carbonate of potash, or the oxymuriatic acid, advised by Un- derwood and Willan, may likewise be em- ployed. Sulphur, magnesia, soda, rhubarb, and the subborate of soda, are also of much benefit. Dr. Thomson states, that he has seen the skin com- pletely cleared by the use of the following alka- line tonic for six weeks; at the same time regu- lating the bowels:— No. 10. R Zinci Sulphatis gr. xxiv.; Liquoris Potassa> f. 3X'B- Solve. Suinautur guttse xxx. ex cyatho aquae bis quotidie. It ought always to be observed, as a general principle, in this as well as in the other forms of acne, that attention to the secretions of the abdo- minal viscera, and to the general health, by pro- moting the digestive functions, will of itself, in- dependently of external means, go far in promoting a cure; and that, without such attention, no cure will be permanent. 28. 4th. The treatment of acne rosacea is gener- ally unpromising. It should always have a strict reference to the particular nature of the affection of the liver, or digestive canal, or both, with which this eruption is associated, and in many respects symptomatic. A. rosacea often precedes serious disease of the liver, more frequently co-exists with it, and most commonly indicates a congested and obstructed state of the viscus. To this organ, therefore, ought our remedies to be particularly directed. A moderate blood-letting; the applica- tion of leeches on the region of the liver; and, if the eruption occurs in females, and is attended with obstructed or scanty menstruation, leeches also to the upper part of the insides of the thighs, or bleeding from the feet, and stimulating pe- diluvia, or the hip-bath; the use of mild mer- curials, or alterative and deobstruent medicines, such as the pills previously prescribed (§ 18.); the blue pill, or the hydrargyrum cum creta with soda and taraxacum; Harrogate, Barege, and other sulphureous mineral waters; the de- coction of dulcamara, liquor potassae, and chlo- rine or sulphureous fumigating baths; are severally of advantage in some cases. But from none of these will any permanent benefit be derived, un- less the regimen presently to be noticed is rigidly observed, and the pathological relations of the eruption appropriately treated. 29. Blood-letting in tliis, as well as the fore- going species of the eruption, was strongly insisted on by Ambrose Pare ; and certainly in the cases pointed out as requiring this practice should never be omitted; more particularly when accustomed discharges have disappeared, as the haemorrhoidal flux and the menstrual evacuation. In this form of the disease, much advantage will sometimes be procured from the nitro-muriatic acid foot-bath; and from a lotion with these acids applied to the affected parts twice or thrice a day (see F. 4. 5.). This practice has received the sanction of MM. Biett, Cazenave, and Schedel. The ad- vantages to be derived from the use of these acids as a lotion will be more certainly secured by apply- ing a few leeches to the vicinity of the eruption, and afterwards a fomentation, which may be followed either by a spirit and alum or zinc lotion, or by the lotion with the sub-borate of soda (F. 334.) 32 ADHESIONS. If these fail, the nitro-muriatic acid lotion maybe employed. Stimulating and irritating applications ought to be avoided; and whilst the tone of the digestive organs and the secretions of the liver should receive the closest attention, drastic and cold purgatives are to be avoided. 30. 5th. The treatment of the syphilitic or specific form of acne must be directed as in other states of secondary venereal disease. At the same time, however, that the mercurial preparations are being exhibited, the external means which have been recommended may be employed, ac- cording to the particular form the acne may as- sume. The mercurial preparations should be com- bined with sarsaparilla or taraxacum, or both, and with small doses of antimony. The decoction of Feltz, which chiefly consists of a combination of these remedies (see F. 588.), is much employed in these eruptions on the Continent, and may be taken to the extent of a pint and a half daily. When the tubercles remain long, the ointments formed with the iodurets of mercury or sulphur (F. 774, 775.) maybe employed twice daily, and assisted by douches of vapour. 31. The diet and regimen of persons affected with acne, particularly the A. rosacea, ought to be carefully restricted. In the A. simplex, in- durata, and punctata, the diet should be light, nutritious, and easy of digestion. Cold, raw, and indigestible vegetables, particularly cucumbers and n?elons, and very cold fluids, should be avoided. Moderate and regular exercise in the open air, and early rising, as tending both to promote di- gestion and invigorate the frame, are always of service. In the acne rosacea, more will often de- pend upon regimen, than upon the medical treat- ment of the patient. The careful avoidance of all its exciting and concurrent causes, and of excesses of every description, both in eating and drinking; the adoption of a mild farinaceous diet, with a small portion only of light and nutritious animal food, and of toast-water or barley-water for drink; shunning mental excitement and de- pression, as well as heating and fatiguing exertions; gentle and regular exercise, and attention to the promotion of the secretions and functions of the abdominal viscera; are essentially requisite to the removal of tins very obstinate and often uncon- querable eruption. Bibliography.—Ambrose Pare, De la Goutte Rose, liv. xxvi. ch. xlv.—Plenck, Doctrina de Morbis Cutaneis, &c, 2d edit. Vien. 1783.—Darwin, Zoonomia, class ii. 1. 4. 6, et cl. iv. 1, 2. 13. and 14.—Bateman, Synopsis of Cutaneous Diseases, by Thompson, and Atlas, p. 387. —Alibert, art. Couperose, in Diction, des Sciences Med., t. vii.—Biett, art. Couperose, in Diction, de Medecine, U iv.—Rayer, Des Maladies de la Peau, &c, t. i. p. 446. Paris, 1826.—Plumbe, On the Diseases of the Skin, 8vo, 2ded. Lond. 1829.—Cazenave et Schedel, Abrege Pra- tique des Maladies de la Peau, 8vo, Paris, 1829, p. 208. ADHESIONS. Syn. Adhesions, Adhirences, Fr. Di/eAnhdnglichkeit,Gei. Congiunzioni, unioni, aderenzee, Ital. Classif. Morbid Structure.—Thera- peutics. Chiefly a result of some one of the Inflammatory States.—See Inflamma- tion. 1. Adhesions of opposite surfaces of tissues are amongst the most common organic lesions present- ed to our view in post mortem examinations. They may be congenital, arising either from an original disposition of parts, or from intra-uterine disease. As they are commonly brought before us in prac- tice, they are generally one of the consequences of inflammatory action, affecting the adhering surfaces, or which had affected them previously; and occur in those parts which are in contact, or so nearly in contact, that the effusion of a com- mon product of the inflammatory act becomes the medium of union. 2. It is requisite to all adhesions, that a fluid be thrown out from the inflamed surface, previously to the adhesion being commenced. This fluid varies somewhat in its characters with the state of inflammatory action; but it soon passes into a much more consistent condition, and thus becomes the medium of adhesion. In some places it is scarcely perceptible between those parts of opposite surfaces which are naturally very nearly or altogether in contact with each other, the agglutinating medium being there so remarkably thin; whilst those parts that are fur- ther separated in their natural state, have the interstices filled up by a copious exudation. The fluid exuded in thus variable quantities, has been denominated, in its first stages, or iiiorganised states, coagulable and coagulated lymph, albu- minous exudation, coagulated albumen, &c. When first poured out from the inflamed surface, particularly of serous membranes, it consists of a lymph-like fluid, which soon becomes somewhat o«paque, more solid, and assumes the appearance of a softly coagulated albumen,—its chemical properties very nearly approaching to those of pure albumen, containing a small proportion of the usual saline ingredients of the blood. 3. The longer this matter has been effused, and the longer adhesions, which it has occa- sioned, have endured, the more firm and more- closely resembling cellular or cellulo^fibrous tis- sue do they become. This change in the state of the adhesions, according to their duration, is fully stated in the article on the morbid states of serous membranes. It may, however, be here premised, that the medium of adhesion, which is first fluid, and afterwards albuminous and nearly solid, soon becomes partially organized; blood-vessels. shoot into it, and thus opposing surfaces become more or less firmly united, according to the de- gree of motion occurring between them, that may either prevent their firm adhesion, or disturb it after it has been already formed, and to the state of the fluid which becomes the medium of union. In some cases this fluid is secreted so copiously, and is so deficient in the albuminous constituent, the watery part being so predomi- nant, that adhesions are formed only in differ- ent, or in numerous and irregular points, be- tween which serum in various states is effused, separating the opposite and partially united sur- faces, stretching the adhesions, breaking down some, and reducing others te cellular bands run- ning between these surfaces through the effused fluid, which is in such cases usually very tur- bid, and abounds in flakes of albuminous matter. This appearance is not unusually observed in cases of adhesion of the pleura, pericardium, and occasionally of the peritoneum. 4. The concrescible fluid, as will appear in the sequel, which is formed between the surfaces of divided structures, originates in two distinct modes, generally assumes a firmer and more fibrous cha- racter in its advanced stages, and undergoes a more marked diminution of volume than is ob- ADHESIONS — Reparative. 33 served in those adhesions which form on serous surfaces. From this it will be apparent that ad- hesions are formed by the medium, 1st, of a con- crete inorganic albuminous matter; and 2d, of this matter, at a later period, in a more or less organized state, and presenting various appear- ances, according to the length of their duration, and the nature of the inflammatory disease which produced them. It will be also apparent, from the foregoing, that the adhesion of opposite sur- faces is not in itself a specific disease, but the result of disease,—generally of inflammation in some one of its grades. 5. Adhesions, in respect of their ultimate tenden- cies, are either reparative or morbid. M. Cru- veilhier, who has divided them in two classes, according to this view, comprises under the former the adhesions between divided tissues and sur- faces brought about by surgical aid; to whjchl may add those that take place around puru- lent formations, and prevent the extension or effusion of the collected matter into adjoining parts. Whilst the reparative class of adhesions are stated to form generally between divided structures and diseased surfaces, it should be kept in recollection that all the tissues do not admit of adhesion taking place immediately be- tween their divided surfaces. Blood-vessels, nerves, muscular fibres, and tendons do not unite after division. It is the minute vessels of the cellular tissue which surrounds them, and their individual fibres, that chiefly furnish the means of their adhesion. From these vessels, if protected from the atmospheric air, a coagulable lymph is thrown out; which gradually becomes vascular, organ- ized, and in a few days cellulo-fibrous, and as firm as the parts which formed it. This newly produced substance is the medium by which the muscular fibres, or other structures which had been divided, are united; and this gradually be- comes thinner and less apparent, and admits of the nearer approximation of the separated parts, until they at last seem continuous, although the existence of the medium of union may still be detected. This constitutes primary adhesion, the union by the "first intention" of surgeons. 6. When the division takes place between bones, this exudation forms the callus, into which ossific matter is deposited. Some pathologists believe that the concrescible lymph, thus fur- nished by the capillary vessels of the divided surfaces, particularly those of the cellular tissue, is the matrix, in which the peculiar structure, of which nerves or muscular fibres consist, is after- wards formed or deposited. But, if this were the case, the firm, and even fibrous, matter into which the medium of union is ultimately changed would at last disappear, and these structures be actually continuous. This, however, never unequivocally occurs; for, although the uniting medium is re- duced to a very thin, and scarcely perceptible, substance, yet it may be made apparent by ma- ceration and careful dissection. 7. When air is admitted between the divided structures, or when primary adhesion fails of taking place, a different process obtains; minute granulae or carunculae form upon then surfaces, whence proceeds at first a fluid pus, subsequently a more concrescible fluid, which forms a sort of false membrane, and which, when the opposite surfaces are kept in a state of near approximation, be- comes the medium of adhesion, unless the state of the system is such as not to admit of the form- ation of this concrescible fluid, and of the other steps of this restorative process. When di- vided parts come in contact with the air, the adhesion is always formed in this manner, — by the suppurative process, whatever may be the nature of the structure which is thus circum- stanced; and the false membrane, which is the medium of union, becomes more thin, firm, and fibrous, and, at the same time, less apparent with the lapse of time. This may be called consecu- tive adhesion. When the divided surfaces are protected from the air, and primary adhesion takes place, the process is more rapid; but its quickness will depend upon the quantity of blood effused between the divided surfaces. If tliis be considerable, one of two things will result,— either the effused blood will be absorbed, and a cyst, or cellulo-fibrous medium of union, be slowly formed, which will be gradually diminished in thickness; or the coagulum may act as a foreign substance, keep up irritation of the vessels in the divided surfaces, cause suppuration, and consecutive adhesion, with the cicatrix formed by the medium of union. (See art. Abscess.) 8. There is one important point connected with adhesions in their various states and seats, —whe- ther reparative or morbid, whether primarily reparative or consecutively reparative, and whe- ther taking place between cellular, serous, or other structures, — which has not received the at- tention from modern pathologists that its prac- tical importance requires for it, and to which John Hunter first directed notice. I allude to the important truth, that adhesions of either of the above descriptions, but particularly the pri- mary reparative, whether taking place between divided surfaces or around purulent formations, either will not form, or, if in the process of form- ation, will be dissolved, in certain states of the vital energies of the frame, and of the circulating fluid. Great depression of the vital influence will have this effect, whether it be produced by the exhaustion proceeding from profuse discharges, by contagious and other noxious miasms, by the close air of hospitals, and other places loaded with animal effluvia, by the inoculation of cer- tain animal poisons, by the absorption of puriform or sanious secretions, or other morbid matters, into the current of the circulation, by the mercu- rial affection of the frame, or by the gouty dia- thesis. When the vital energies of the frame are greatly depressed, and the tonic action of the capillaries much relaxed, by causes acting either extrinsically or intrinsically as respects the blood- vessels, the ability of throwing out a concrescible or coagulable lymph from the divided or inflamed vessels is destroyed, and in its place is produced an ichorous serum, or sanious fluid, which may either pass out, or, if no ready outlet is afforded, will infiltrate itself through the tissues adjoin- ing, or be partially absorbed and vitiate the per- haps already morbid blood. (See art. Blood.) 9. In order to prevent this very dangerous state from supervening in all cases where the reparative process of adhesion is required, the ut- most attention ought to be devoted to the state of the vital energies, particularly as indicated by the tone and frequency of the pulse, and the states of the digestive organs. When the former becomes 34 ADHESIONS — Morbid. very quick, and the powers of the latter fail, that much dreaded state of the frame, which is insuf- ficient for the formation of coagulable lymph, may be considered as approaching, if it be not actually present. In all cases where blood-ves- sels are liable to be inflamed, this state of the constitutional powers, owing to the risk of the blood being vitiated, is particularly to be guarded against. Having advanced as much as belongs to my province respecting the reparative states of adhesion, I proceed to state briefly the doctrine of Morbid adhesions. The particular morbid adhesions are noticed under the articles on the pathology of the parts in which they form. 10. Adhesions in some one of the states de- scribed above (§ 1—4.) are liable to occur, as a consequence of certain grades of inflammation, in the following situations:—1st, In the cellular tissue; 2d, between serous surfaces; 3d, between mucous surfaces; 4th, between synovial surfaces; 5th, in the internal surface of blood-vessels; and 6th, between the surfaces of morbid or accidental formations. 11. A. Adhesions of cellular tissue.—The first step of the process is the exhalation of a quantity of yellowish serum and of coagulable lymph into the cellules of this tissue, which ulti- mately agglutinates them together, upon the absorption of the former, and the concrescence of the latter. The consequence of this is, that the product of inflammation formed in the centre of the inflamed cellular tissue, consisting chiefly of the more fluid and least concrescible portion of the exhalation, is prevented from permeating the agglutinated cellules, and a barrier is set up against it. If resolution takes place and the pu- rulent matter is absorbed, the surfaces of the cavity become united, and the medium of union is changed, as in cases of recent wounds, and in the manner described above (§ 5.). If the parts go on to the evacuation of the matter, adhesion is also effected, as in the cases of consecutive re- storative adhesion (§ 7.); leaving, however, a cicatrix, which is gradually diminished, formed of the cellulo-fibrous medium of union. In all cas- es of inflammation of cellular tissues, adhesion of the cellules, from the exudation of a concres- cible lymph, takes place; and it is this adhesion which forms the fibrous cysts to abscesses, iso- lates their contents from the surrounding struc- tures, and in some respects excludes them from the economy. Adhesions of the cellules of this structure also strengthen the cysts of aneurisms, and form sero-fibrous cysts around foreign bodies that are accidentally lodged in it. 12. B. Adhesions between serous surfaces are the next most common; being formed through the medium, either of a more or less thick and firm inorganic albumen, in the form of a false membrane, or of this substance advanced to a more or less organized state, and assuming either the appearance of cellular tissue, with a surface partaking of the serous character, or one of the states about to be noticed. The organized nature of those adhesions has been denied by some; but the observations of Stoll, Hunter, Dupuytren, Baillie, Mecke, Home, Lobstein, Cru- veilhier, Gendrin, Baron, and others, who have traced blood-vessels in them, have put the question at rest. Adhesions occur most frequently between the pleurae, next in the peritoneum, and next to these in the pericardium. They are comparatively rare in the tunica vaguialis; and in the arachnoid they are still more rare. 13. It is not necessary to the formation of ad- hesions between opposite serous surfaces, that the pre-existing inflammation shall extend continu- ously to both. When the coagulable lymph is thrown out upon one of the two inflamed surfaces, __as, for instance, of the peritoneal surface of the small intestines,—it seems to act as an irritant to the opposite part of the omentum, with which it is brought in contact, inducing inflammation of that part only, and leaving the intervening surface both above and below it unaffected. The part thus irritated by the contact of the coagu- lable lymph, poured out by the part primarily affected opposite to it, becomes also inflamed, and exudes this concrescible fluid; and the inflammation thus secondarily induced in a part of the omentum may advance to the external surface of the omental duplicature, and, by means of the exudation of this product of inflammation in that situation, excite a similar state of action in the directly opposite part of the peritoneum reflected over the abdominal parietes. Thus the inflammation and its consecutive adhesions may proceed, without the disease having affected any of the continuous surfaces intervening between them. A similar circumstance is sometimes ob- served in respect of the convex surface of the liver and peritoneal surface of the diaphragm. Inflammation, commencing in a part only of the former, will excite it in the part of the latter exactly opposite, and be followed by adhesion; and the inflammatory action, not infrequently ex- tending upwards through the diaphragm to the dia- phragmatic pleura, will be further followed by the exudation of coagulable lymph on its free surface, winch, irritating that portion only of the pulmonic pleura opposite to, or in contact with it, will inflame that part, and form adhesions with it, without affecting the continuous surface intervening be- tween, and surrounding the adherent parts. The unadhering cavity, however, not infrequently contains a turbid or flaky serum, with patches of false membrane, arising from a less acute state of inflammatory action in those parts of the serous surface immediately adjoining the adhesions. Thus it is not unusual to find, in cases of acute inflam- mation affecting either the peritoneum, pleura, or arachnoid, and limited to a particular part, a similar state of disease, and the same product, formed only in the parts opposite, and most nearly in contact; whilst the continuous surfaces sur- rounding them are either altogether sound, or much less affected;— most commonly only so far as to give rise to a serous exudation, or slight albuminous coating in their immediate vicinity. 14. From this it will appear, that the near approach, and more especially the immediate contact of opposite surfaces, and the want of motion between the one surface and the other, will favour the formation of adhesions : thus they are most frequent at the superior parts of the pleura, between the convex surface of the liver and the diaphragm, and the serous surfaces of parts included in Herniae. The different species of media, by which adhesions of serous surfaces are affected, are the following, according to M. Cru- veilhier: — an inorganized false membrane; a filamentous adhesion, and a cellular adhesion, ADHESIONS. — Morbid. 35 in neither of which blood-vesseis are evident ; a permanent organized membrane ; and a tuber- culated membrane. All these originate in a con- crescible lymph, as in adhesions of cellular tis- sues. (See art. on Serous Membranes.) 15. C. Adhesions between mucous surfaces are not frequent. Bichat denied the possibil- ity of their occurrence, unless destruction of the mucous membrane had taken place. He was led to this conclusion more by the functions of this membrane in health and disease, than by observ- ation of facts. There can be no doubt, however, that the opposite surfaces of canals, covered as they are by mucous membranes, occasionally adhere, in consequence of very acute attacks of inflammation ; but this occuis very rarely, owing to the access of atmospheric air, to the pre- sence of gases, to the various matters constantly passing through them, and to the nature of the fluid which usually proceeds from inflammation of these surfaces. 1'he most common exception which takes place to the general inference adopted by Bichat is met with in the vagina. I have observed several cases, at the Infirmary for Chil- dren, where adhesions of the opposite surfaces of this canal had taken place in consequence of inflammation,—some of them at so early a stage, that they were removed by merely forci- bly separating the adherent surfaces, when the mucous membrane was found perfectly entire, but highly inflamed, and covered by an exuda- tion similar to that which is thrown out upon inflamed serous membranes. Similar facts are recorded by MM. Dupuytren, Villerme, Breschet, and Cruveilhier. Adhesion also of the os uteri, as a consequence of inflamma- tion, is sometimes observed. Occlusion of the Fallopian tubes, and even the adhesion of the op- posite internal surfaces of the uterus, have been occasionally met with. Walther, Renaul- din, and Meckel observed these changes so often in prostitutes, that they attributed them to the frequent irritation of the parts, and imputed the barrenness of these females partly to this cause. But, in the cases of occlusion of the Fallopian tubes, more is to be imputed to the ac- cumulation of an inspissated or albuminous mucus, the product of inflammation, which, from its ten- acity and consistence, cannot flow along these tubes, than to actual organized adhesion of their opposite surfaces. The occeisional occurrence of obliteration of the canals of the common bile-duct, and of the ureters from the impaction of a calcu- lus, seems to proceed from the irritation and abrasion occasioned by calculi, and the conse- quent exudation of a concrescible fluid, which agglutinates their surfaces, and ultimately tends to reduce them to a cellulo-fibrous cord. 16. Adhesions are either never met with in the air passages, or so rarely, as to render their actual occurrence doubtful. I believe that, although albuminous concretions are occasionally formed in the bronchi, and frequently in the trachea and larynx, &c, they cannot be so produced as to give rise to adhesions of the opposite surfaces. They never, or at least very rarely, become or- ganized ; and, although they may completely ob- literate the canals of several of the bronchi, they cannot have this effect on the trachea without causing immediate death. The organization and form of the larger air-tubes completely prevent their adhesion ; although they are often nearly filled up with concrete albuminous formations, as a consequence of certain states of inflammation. Adhesions of the internal surface of the oesopha- gus, or of any other part of the digestive tube, are never met with ; although constriction, with thickening, &c. to the almost entire obliteration of this canal, is not infrequent. As in the air pas- sages, nature has made in the functions, during health and disease, of the membranes which line them, sufficient provision to prevent this lesion from occurring. And we uniformly observe, when inflammation attacks any portion of those tubes, the preservation of the canal of which is essential to life, that, although a copious albuminous exu- dation will sometimes occur, its organization will generally be prevented, and its detachment from the surface on which it is formed will be secured, sooner or later, by the secretion of a more fluid, or mucous, or muco-purulent matter underneath, which loosens the concrete albuminous coating or false membrane from its attachment to the surface on which it is formed. The circumstances which chiefly seem to favour the formation of adhesions between mucous surfaces, are : 1st, The abrasion of the epidermis which covers them ; owing to which their secretions are changed, and they partake more of the characters of cellular tissue. 2d, Entire destruction of the mucous membrane in a great part, or the whole, of the circumference of a canal, favouring its gradual constriction, suppuration, and ultimate obliter- ation. The bile-ducts, ureters, urethra, rectum, and oesophagus occasionally furnish proofs of this change in some one of its stages. (See art. on Mucous Membranes.) 17. D. Adhesions of the synovial surfaces of joints are rarely observed, excepting in cases of anchyloses, of which they cannot be considered even as the commencement, although they may accompany the earlier stages of this change, par- ticularly in anchyloses consequent upon rheu- matism. Many, however, of the alterations which take place in the synovial apparatus of tendons are consequent upon their adhesion and oblitera- tion. Inflammation occurring in them primarily, or extending to them from contiguous parts, is generally followed by their adhesion, and reduc- tion to a state of dense cellular tissue. Hygroma almost always terminates by adhesion. 18. E. The adhesion of the internal surface of blood-vessels takes place through the medium of the coagulated lymph secreted by the inflamed vasa-vasorum. The vessel becomes impervious in consequence of this exudation, which is poured out in the form of a false membrane from its in- ternal surface. The lymph which is exuded, particularly when its coagulable or concrescible property is well marked, frequently produces coagulation of the blood in contact with it ; so that, generally, the obliteration is occasioned both by tliis lymph, and the coagulum of blood which it occasions. In a short time the coagulum thus formed within the inflamed blood-vessel becomes more and more pale and dense, sometimes par- tially organized ; and, as its density is increased, so is its bulk diminished : the coats of the vessel, at the same time, lose their specific characters; they seem constricted around the substance form- ed within them, the middle coat becomes less distinctly fibrous, and at last they are reduced to 36 ADIPOSE TISSUE —Morbid States of. the state of a cellular, or fibro-cellular, chord. This may be viewed as the primary form of their adhesions, and its usual results. When, how- ever, suppuration takes place in their internal surface, the adhesion is formed consecutively in the manner described above (§7.) ; or the pri- mary may pass into the consecutive form of ad- hesion, particularly when the false membrane is insufficient to fill up the entire canal of the vessel. 19. Adhesions take place more readily in veins than arteries ; are produced in both, and in lym- phatics also, in the manner now stated, generally in consequence of inflammatory action, attended with sufficient power of the constitution to form concrescible lymph (see the articles on Arte- ries and on Veins) ; and sometimes, even after a very slow and slight grade of this action, when the opposite surfaces of the vessels are pressed together by any tumour existing exteriorly to them. When artificially excited in arteries, as by the application of ligatures, the inflammatory state which produces the adhesion is not so prone to extend along the axis of the vessel, or to occa- sion dangerous effects, as when it is excited in the same way in veins. When thus produced in these latter vessels, fault of constitution, an un- healthy habit of body, unwholesome state of the atmosphere, &c, or the other causes above as- signed (§8.), will generally interfere with the process, and occasion that state of morbid action, and of its products, which will vitiate the current of the circulation, and even destroy life. (See Veins — Inflammation of.) 20. F. Adhesions of the internal surfaces of cysts, and other morbid formations, sometimes take place from a consecutive state of inflamma- tion extending to them. Large cysts, which in consequence of their situation cannot be removed, may be obliterated by their puncture, and the production "of inflammation of their internal sur- faces, so as to procure their adhesion. 21. G. Adhesions may also form between parts of the cutaneous surface, when deprived of the cuticle, and kept in close contact. This is not infrequent after scalds and burns, and is produced in a similar manner, as I have explained, in re- spect of adhesions taking place primarily, and without suppuration, or subsequently to the occur- rence of this process in the cellular and mucous tissues. Adhesions also occur in other situations, as between the iris and capsule of the crystalline lens, &c. ; but I have noticed those which more especially belong to my province. Bibliography.—Bichat, Analomie Generale, t. ii. passim.— Copland, Lond. Med. Pepos., t. xv. p. 372.— Scoutetten, Archives Gen£r. de Med., t. iii. p. 497., t. iv. p. 386., t. v. p. 537.—Renauldin, art. Adhcrences, in Diet. des Scien. M£d., t. i.—Breschet, art. Adhcrences, in Diet. de Med., t. i. p. 340. — Baron, On Tuberculated Accre- tions of Serous Membranes, 8vo, 1819; and Illustrations of Tuberculous Diseases, 1822. — Cruveilhier, Essai sur l'Anat. Pathol., t. i. p. 144.; et art. Adhesions in Diet, de Med. et Chirurg. Tratiques, t. i. p. 317. — Meckel, Analo- mie Gener. et Palholog., t. iii. passim. — Gendrin, His- toire Anatom. des Inflammations, 2 ts. 8vo. Paris, 1827. — And>-al, Archives Gen. de Med., t. iii. p. 246. ; et Cli- nique Medicale, &.c, t. iii. et iv. passim; et Anatomie Pathologique,passim. — Craigie, on General and Pathol. Anat., passim. ADIPOSE TISSUE. Tela adiposa, Lat. Tissu graisseux, Fr. Das Fett, Ger.—Its Morbid States. Classif. TV. Class, IV. Order (Au- thor, see the Preface.) 1. The adipose substance is frequently either diminished or increased far beyond the healthy standard.----i- Excessive diminution of this sub- stance, atrophy, occurs naturally in very aged persons ; and there seems to be, even m early life, a tendency to it hereditarily in certain consti- tutions, particularly in those of a peevish, anxious, and irritable temper. It is often met with as a consequence of, or conjointly with, pulmonary and other organic diseases, particularly those which interrupt assimilation and the supply of nutrition. But it is also a symptom of all dis- eases which impair the vital energies by morbid- ly increasing the secretions and evacuations: as in diabetes, diarrhoea, and dysentery. It also necessarily proceeds from long abstinence, &c. 2. Atrophy of this substance may be temporary or permanent. It is usually the former in early or middle life, and continues merely as long as the causes which occasioned it. It is usually permanent in advanced life, and in those of an active, peevish, restless disposition. In every case the removal of the fatty matter is produced by absorption ; and, according to the experiments of Magendie, Tiedemann, Gmelin, May- er, &c, this process maybe ascribed, at least in part, to the minute veins. The circumstance of fatty and oily matter being constantly found in the blood, but hi variable quantity, as shown by Trail, Babington, Le Canu, &c, seems to support this view ; for, if taken up by the absorbents, it may have been changed or assimi- lated in its passage through the absorbent glands before it could have reached the blood. 3. B. Excessive deposition or hypertrophy of this substance (adiposis) is very common, affect- ing the body generally, but sometimes locally only. Persons have weighed as much as 500 or 600 lbs. owing entirely to this state of hypertro- phy. This tissue is naturally abundant in females and eunuchs. Its hypertrophy is frequently occa- sioned by excessive venereal indulgences, particu- larly in early life, and when conjoined with high living and indolence. It generally is attended by a weak languid circulation, weak digestion, with craving appetite, defective secretions and excretions, and disinclination to active mental or physical exertion. It also evinces a marked here- ditary character. Full living, particularly on food which abounds with the elements of the fatty sub- stance, as sugar, spirituous and malt liquors, &c. tend greatly to promote it. The connection of this morbid state with deficient assimilation ap- pears fully proved. It would seem that in persons whose vital energies are diminished, whilst the appetite remains unimpaired, or is excited by sti- mulating liquors, &c, the sanguifaction of chyle does not take place so rapidly nor so perfectly as in health ; that a large portion of this fluid assumes an oily or fatty character, and is deposited in the adipose tissue, which thus becomes one of the emunctories of the frame, in which a substance that cannot readily be carried out of the circula- tion by any other organ is set apart for the purpose of future absorption, assimilation, and nutrition, as the wants of the system may require, and to prevent its hurtful accumulation in the circulating fluid. Thus, in persons otherwise ap- parently healthy, the excessive accumulation of fat is often one of the earliest and most remark- AFTER-PAINS — Symptoms and Diagnosis. 37 able signs of diminution of the vital energies of the frame. (See Art. Obesity.) 4. C. In many instances, when the powers of the constitution are either greatly reduced or other- wise perverted from the healthy state, the adipose matter is also changed in colour, composition, and consistence, becoming remarkably pale, or dark, reddish, or gelatinous. It may likewise be, par- ticularly in cachectic persons, uncommonly watery, soft, smeary, or jelly-like; and, on the contrary, but more rarely, hard, waxy, or even horny. 5. D. It may be a question whether or not this tissure is liable to inflammation. Considering it merely as a modification of the cellular structure, chiefly in as far as it contains the fatty substance of the body deposited in its areolae, the containing tissue only must be looked upon as that which is liable to inflammation or any other disease; the fat or contained matter being entirely passive, and modified only by the morbid states of the tissue which secretes and contains it. There seems little doubt that the adipose tissue participates in the various states of diffuse inflammation; whether that attending upon certain forms of erysipelas, or following accidents, or the inoculation of morbid matter. When thus inflamed, it rapidly passes into a state of sloughy and fetid suppuration; large portions of it being not unfrequently con- verted into an ash-coloured, semifluid pulp, mixed with shreds of cellular tissue and albuminous matter, or becoming entirely sphacelated. 6. E. Effusion of blood into the adipose tissue occurs under similar circumstances to those con- nected with haemorrhage into the cellular sub- stance, but much less frequently. This change has been occasionally noticed by Huxham, Cleghorn,Craigie, and by myself and others, in scorbutus, purpura haemorrhagica, and in the liquescent or malignant forms of remittent fever in warm or unhealthy climates. 7. F. Of the tumours most frequently developed in this tissue, the most remarkable are,—a. adipose sarcoma, which is surrounded by a thin capsule of cellular tissue condensed around it, and consists of an unusual accumulation of fatty matter in cells, the component fibres of which are so firm as to give consistence to the tumour: it closely re- sembles a local hypertrophy of the adipose tissue, excepting that it is surrounded by a capsule; and it may have either a broad or narrow base: b. stea- tomatous tumours are chiefly a peculiar modifi- cation of the fatty secretion, which is accumulated in masses, surrounded by a spheroidal cyst: they are not formed of cells, in which the fatty matter is deposited, but consist of a simple semifluid sub- stance secreted by the inner surface of the cyst: they occur more frequently in the cellular, than in the adipose tissue: c. atheromatous and melicerous tumours are either modifications of the steatom- atous, or proceed from the change induced in small chronic abscess; but they are most com- monly the former when seated in this tissue. 8. G. Melanoid deposition is sometimes found in both the internal and external adipose substance. It may be either disseminated in the form of small inky spots, or accumulated in spheroidal masses; or found in a semifluid state and brownish-black colour, surrounded by a cyst formed by the con- densation of the contiguous cellular tissue. As to the state in which this peculiar matter is formed, great diversity of opinion exists. Laennec sup- posed that it is first secreted in a solid form, and, like tubercular deposits, afterwards becomes soft I am, however, inclined to adopt the opposite opinion; viz. that it is secreted in a fluid or semi- fluid state, and that it afterwards becomes firm by the absorption of its more fluid parts. The obser- vations of Drs. Cullen and Carsewell, and of M. Chomel, seem to confirm this opinion. Bibliography.—Art. Graisse, Corpulence, and Obente, in Diet, des Sciences Medicales.—Graefe, in Journ. fur Chirurg; und Augenheilk. b. ix. p. iii. p. 367.—Grune, De Sanl et Morbosa. Pinguedinis in Corpore Secretione, 8 vo. Ber. 1826.—Otto, in Selt. Beobacht, p. ii. p. 166.—Cho- mel, Nouv. Journ. de. Med., t. iii. p. 41___Craigie, Gen- eral and Pathological Anatomy, p. 62. AFTER-PALNS. Syn. Parodynia Secundaria Dolorosa, Good. Classif. 5. Class, 3. Order (Good). II. Class, III. Order (Author). 1. Defin. Pains, more or less severe, either continuing or supervening shortly after the ex- pulsion of the placenta in child-birth. 2. Symptoms and Diagnosis. Attacks of pain in the abdomen are usually experienced in the early part of the puerperal state. They pro- ceed, when very severe, from the contraction of the uterus, irregularly excited by the presence of coagula. They usually soon follow delivery, are least severe after a first labour, are increased upon the application of the child to the breast, and last for a day or two. They are generally aggravated by flatulence and costiveness. 3. It is extremely requisite for the young prac- titioner to be on his guard respecting the nature and seat of pain after delivery, as the commence- ment of the most fatal diseases to which the sex are liable may be mistaken, if not carefully ob- served, for after-pains. These latter are the result of the natural contractions of the womb, and of its return to its former state; and are dis- tinguished from disease, particularly inflamma- tions of the uterus, ovaria, or pelvic peritoneum, by their remissions, and by the absence of ten- derness or tension of the abdomen, especially on pressure. The uterine discharge also is not ob- structed; the milk is secreted; there is no shiver- ing nor vomiting; and the pulse is seldom in- creased in frequency. 4. When the patient's bowels have been neg- leoted previously to confinement, and when much flatulence exists, the after-pains are often complicated with colic, or they assume a colicky character. In cases of this kind the abdomen is often somewhat more tense and distended than usual; the fits of pain are severe, with complete remission's; the patient complains of flatulence; the bowels are constipated: but the pulse is not much affected ; the skin, particularly of the trunk, is not hot; the tongue is moist; and the feet are often cold; in a few cases there is retch- ing. It is important to attend carefully to the character of pain consequent upon delivery, and to consider it in relation to the attendant symp- toms, particularly the states of the pulse, and of the abdomen. We ought, therefore, to enquire into its exact seat, examine the pained part care- fully with the hand; and, having ascertained in what manner it is affected by the examination, we readily arrive at just conclusions as to its nature. When it is felt in the regions of the uterus and ovaria, and accompanied by great fre- 38 AGE—its different Periods. quency of pulse, disorder of the lochia! discharge, tenderness, and fulness of the hypogastric region, &c. the existence of the inflammatory diseases of the uterus, and of its appendages, are to be in- ferred. If it be complained of about the groin, it may be the forerunner of phlegmasia dolens; and if it be felt about the hip, or in the muscles of the pelvis, abdomen, or thighs, it may be rheumatic, owing to the application of cold in some form or other. The pains of rheumatism are readily recognised from their seat, their ach- ing or gnawing character, the manner of their affecting the motions of the part, and the attend- ant symptoms. The diagnosis, however, of these diseases is fully pointed out under their respect- ive heads. 5. Treatment. The exhibition of an ano- dyne, with attention to the state of the bowels subsequently, has generally been considered suf- ficient for the relief of after-pains. In the more severe cases, an anodyne liniment has been re- commended to be applied to the abdomen, hi addition to the exhibition of a dose of laudanum internally; and in protracted cases, Dr. Burns advises a purgative—certainly the best part of the treatment usually resorted to. I am, how- ever, of opinion, from remarking the results of this practice, that the common or less urgent cases would have been better left to nature; and that friction of the abdomen merely with any of the liniments in the Appendix (F. 297, 298.), or friction followed by a purgative, or an enema, is all that is necessary. We ought to recollect that these pains are merely the result of the healthy tonic contractions of the uterus upon the congested veins, and the coagula remaining in it, occasion- ing their expulsion, and the discharge of the blood accumulated in its sinuses; and that the more effectually these ends are accomplished, particularly in unhealthy situations, and lying-in hospitals, the less risk will there be of the occur- rence of dangerous forms of puerperal disease. 6. Whilst, however, anodynes allay the morbid sensibility of the uterus, they tend to diminish its tonic contraction, to induce a congested and re- laxed state of its parietes and mouth, and to favour the admission of air into its cavity. Air, when admitted, particularly under certain circum- stances, is productive of the most dangerous re- sults, from its effects upon that portion of the surface of the womb to which the placenta was attached. Impressed with the justness of this view, 1 have usually recommended frictions with liniments over the region of the uterus, and a purgative, or purgative injection, which will tend essentially to favour the contraction of tlie uterus, and the expulsion of the cause of irritation. 7. In cases complicated with flatulency and colic (§ 4.), the above means are still more re- quisite ; but much will depend upon the choice of purgatives. My own experience, derived en- tirely from consultation, is decidedly in favour of a draught, consisting of half an ounce of the oleum terebinthinae, combined with the same quantity of oleum ricini; or an enema, contain- ing the same medicines. The combination, also, of a purgative with assafcetida, or any other antispasmodic, and an injection, consisting of in- fusion of valerian, or containing assafoetkla, with a due proportion of any aperient medicine (see F. 130.135.138.), will seldom fail of giving relief, by removing flatus, and promoting the restoration of the uterus to its natural state. In the more urgent cases, anodynes may be conjoined to the foregoing means; for, when thus associated, they willnot act in preventing the contractions of the uterus. (For Hysteralgia, and the various diseases of the uterus in the puerperal and unim- pregnated states, see Uterus.) BiDHOGRArHY.—Dcnman, Introduction to the Prac- tice of Midwifery, &c. Lond. 1816, 5th edit.—Gardien, Traile complet d'Accouchmens et des Maladies des Femmes, &c, t. iii. Paris, 1826.—Burns, Principles of Midwifery, tc. Lond. 1824, p. 526.~-Good, Study of Med- icine, vol. v.—Ryan, Manual of Midwifery, 3d. edit. Lond. 1831. AGE. Syn. JEtas, Lat. Das Alter, Ger. Age, Fr. Eta, Ital. Classif.—Pathology and Therapeutics. 1. In the succinct view I purpose to take of the pathological and therapeutical indications which this subject will naturally suggest to the mind of the practical physician, I purpose, first, to sketch the successive epochs of life, and thus consider the word in its generic acceptation. When I ar- rive at those periods of existence to which the wo. \ age is specifically applicable, the changes which take place in the human frame, in respect both of organization and function, with the ad- vanced progress of years,—with age in its specific acceptation, will be fully stated, as furnishing important data for practical indications in the treatment of diseases of this epoch. 2. Of Age in its generic Acceptation, —or different Epochs of Life. Before I proceed to consider the subject in its enlarged point of view, I may briefly advert to the periods into which the usual natural duration of human exist- ence may be divided. Without occupying my limits with the divisions adopted by ancient and modern writers, I shall adopt that arrangement of the different epochs of life which has been suggested to my own mind, from observing the varying manifestations of life and function, and the modifications of diseased action with advanc- ing age. The division which I have thus adopted may require more to be said in support and illus- tration of it, particularly in respect of its physio- logical relations, than I am willing to advance on a subject which may be considered as nearly verging on the speculative. Leaving, therefore, out of sight many of the physiological and psy- chological views, which would arise out of an extended investigation of the subject, I shall merely briefly advert to topics of practical im- portance ;—those which concern the medical jurist fall not within the scope of this work. (For epoch of fatal life, see Fcbtus.) 3. Before proceeding to consider the different periods of age individually, it may be useful to exhibit a view of the arrangement I intend to follow :— L Period, or that of Infancy. 1st Epoch, to the commencement of the first dentition. 2d Epoch, from the commencement, to the completion of the first dentition. II. Period, or that of Childhood. Extending from the completion of the first to the completion of the second dentition. III. Period, or Boyhood—Girlhood. From the seventh or eighth year to the com- mencement of puberty. AGE—Infancy. 39 IV. Period, or Adolescence. Commencing with the first appearance of puberty, and extending to adult age. V. Period, Adult Age. 1st Epoch; or early adult age, or confirmed virility. 2d Epoch, or mature age. VI. Period, Declining and Old Age. 1st Epoch, declining age. 2d Epoch, green old age. 3d Epoch, advanced old age, ripe old age. 4th Epoch, decrepitude, second infancy. 4. I. Period, or that of Infanc y, (Infantia, from the privation of speech,) commences with birth, and extends to about the end of the second year, when the first dentition is completed. It may be divided into two epochs; the first begin- ning at birth, and extending to the sixth or seventh month, when dentition is fully com- menced; the second proceeding from this age to the end of the period, the completion of the first dentition, when the relations of the young being with the external world are fully established by the developement of the sensorial and locomotive organs. 5. A. During the first epoch, or that preceding the commencement of dentition, all the structures are merely in the course of developement; par- ticularly the osseous system, the cerebro-spinal nervous system, and the organs of locomotion. The functions are only acquiring activity, and several of them have not yet appeared. The vital phenomena gain strength, whilst certain of those functions, by which the young being is to hold converse with the objects around him, either begin to dawn, or have not yet merged into existence. The manifestations of life are chiefly vegetative, and the movements automatic. The attitudes are generally without variety, and the changes of the countenance express merely plea- sure and pain to the spectator; but, to the medi- cal observer, they convey important information, and often all that he can obtain respecting the maladies incidental to this period of life. At this epoch, the position of the limbs, the character of their motions, the cry, and its numerous va- rieties; and especially the changes of the coun- tenance; the state of the eyes and eye-lids; the openness, contraction, &c, of the eye-brows; the appearance of the lips and nostrils; of the mouth, gums, and tongue; — all furnish means of ascertaining the nature and progress of dis- ease. 6. a. At this age the organs of digestion are un- suited to any other food than that derived from the breast of the mother; and so little capable are they to assimilate any other, even of the blandest and most digestible kind, or the milk of other animals, that very few, not more than one in six or seven, ever arrive at the more advanced periods of life who are deprived of the kind of nourishment nature intended for this epoch. At this age the system is extremely susceptible of external impressions acting upon the lungs, sur- face of the body, and digestive organs; and par- ticularly to the influence of cold. Recently re- moved from a constant and unvaried warmth, and having heretofore existed with all the mucous surfaces shut from the action of foreign agents, the young infant imperatively requires to be pre- served, particularly during the first months of this epoch, from the influence of a low range of temperature, and from its sudden changes. The disposition to increased action in all the mucous membranes, and the great susceptibility of the respiratory nerves, require the surface of the body, and particularly the organs of respiration, to be guarded from atmospheric vicissitudes; the chief source of the diseases which are so preva- lent and fatal at this age. A similar suscepti- bility of the digestive mucous surface also exists, and is but too frequently evinced by the slightest change in the milk of the mother, or addition of articles of food unsuited to the state of the digestive organs. Much of the mischief, however, which improper ingesta are calculated to produce is guarded against by the copious secretion of mucus, with which the internal surface of the stomach and bowels is covered, particularly in very early life. 7. The susceptibility of the mucous tissues to stimuli and irritants, and their proneness to in- flammatory action at this age, extend also to the cutaneous surface, as shown by the frequency of acute exanthematous diseases, and of chronic eruptions. The intimate sympathy existing be- tween both these structures is very strikingly evinced, by the frequent association of inflam- matory excitement of the mucous surfaces, par- ticularly of the digestive canal, with a similar affection of the skin. The co-existence and close connection of inflammatory irritation of the di- gestive mucous surface, and an analogous state of disease of the brain and its membranes, or the supervention of the latter on the former, are also often observed. During the first months of ex- istence, vascular action in the brain is promi- nently developed, and engaged in perfecting the organization of this organ : and partly owing to this circumstance, as well as to the quantity of blood sent to it, compared with the rest of the body, and to the various causes tending at this age to derange its circulation, is readily kindled into an inflammatory state of its substance or membranes, giving rise to active congestions, effusions of fluid in the cavities and between the membranes, and to various other organic changes particularized in their appropriate ar- ticles. 8. b. With the susceptibility to be impressed by the causes of disease, evinced chiefly in the ner- vous centres and mucous surfaces, and producing their effects, not only on them but also on the serous cavities, there is intimately connected a marked disposition to be affected by medicines, which exert their influence in an especial manner upon the nervous system. Of these the most re- markable are narcotics and irritating stimulants. The susceptibility to the influence of the former, particularly the preparations of opium, and their effects, primarily in increasing vascular action in the brain, and secondarily in favouiing con- gestion in the same organ, according to the dose, have appeared to me so important, that, during an extensive public practice amongst this class of subjects, I have scarcely ever ventured, during this epoch, on the exhibition of these medicines, excepting under peculiar circumstances, which will receive a more particular notice in other places. A similar caution is also necessary in the use of stimulating and irritating substances. The aperient medicines which are so often re- 40 AGE — Infancy. quired at this age should be chiefly of a mild and unirritating quality; and, whilst cold and moist- ure must be avoided, too warm clothing, particu- larly of the head, ought to be equally shunned. Exposure to a mild, healthy air, frequent ablu- tions of the surface, with cold water during the latter part of this epoch,— commencing first with warm water, and passing on to the use of tepid, and afterwards of cold water, as the infant increases in strength, — followed by frictions, and careful attention to the state of its evacu- ations, are means which should not be omitted in the management of this period of life. Although cold bathing is generally beneficial after the first months of infancy have elapsed, care should be taken not to subject the infant to the influence of cold beyond a minute or two, or longer than may be requisite to the perfect ablution of the surface; for, at this epoch especially, the impression of cold continued for any considerable time de- presses the vital energies, and prevents the devel- opement of that state of healthy secretion on the surface, which usually follows the momentary or brief action of cold, particularly when followed by dry frictions. 9. B. The second epoch of this period, extend- ing from the commencement of the first dentition to its completion, embraces also the important period of weaning. The natural changes pro- ceeding in the different structures and functions during the first epoch also continue through this. As this period advances, the functions of external relation, particularly speech and voluntary loco- motion, commence, the phenomena of perception are more perfect, and the manifestations of mind begin to appear. The instinctive desires and emo- tions become more and more evident and active, and furnish, with the other functions, important indications of disease, and of the means of re- moving it. The susceptibility of the nervous system, and of the mucous surfaces, to be im- pressed by the usual exciting causes of disease, — particularly by cold, moisture, atmospherical constitutions, and vicissitudes, contagious or infec- tious miasms, and errors of diet and regimen,— is unimpaired. 10. a. Teething, which terminates the preced- ing epoch, and ushers in this, is commonly con- nected with more or less disorder of the system. In infants of a healthy constitution, and in whom the powers of life are energetic, disorder is scarcely perceptible unless from the operation of very efficient causes; but in those who are de- bilitated, whose conformation has been originally feeble, or imbued with any hereditary taint or morbid diathesis, or who have been weakened by unwholesome food and impure air, this process is often attended with great disturbance in the frame, and, owing to the morbid sensibility and irritability it excites, frequently kindles up most dangerous disease. During the process of teeth- ing, particularly at its early stages, the itching and irritation of the gums are a constant source of excitement, or focus, whence irritation extends to the salivary apparatus, as proved by the in- creased flow of viscid saliva. The continued de- sire evinced by the little patient to allay the itching of the gums, by pressing between them whatever it can lay hold of, and the evident dis- tress expressed by it if this sensation, which is known to be more insupportable than pain, can- not be allayed, are indications which ought not to be overlooked. If this distressing sensation be not allayed by judicious means, the nervous sys- tem becomes inordinately excited, febrile com- motion is induced, the functions of digestion are disordered; and we are, consequently, not infre- quently called upon to remove inflammation of the membranes or substance of the brain, various convulsive affections, and inflammatory disorder of the digestive mucous surface, owing to the extension of irritation along the alimentary canal, as well as to the acidities formed in the stomach and bowels, from the imperfect digestion of the food. During dentition also, a marked disposi- tion seems to exist in the pancreas to become ex- cited, owing to its close sympathy with the salivary apparatus; and I am persuaded that several states of diarrhoea observed at this epoch originate in, or are perpetuated by, an increased secretion of pancreatic fluid. 11. Owing, moreover, to the excitement and irritation existing in the gums, affections of the respiratory and digestive mucous surfaces are more frequently associated with one another, and with increased vascular action in the nervous centres and their envelopes. It would seem that the irritation existing in the mouth disposes, from its influence on the nervous system, the mucous membranes not only to be invaded by the exciting causes of disease, but also to undergo the morbid action throughout. How frequently has the ex- perienced practitioner observed inflammatory irri- tation of the digestive and of the respiratory mucous surfaces associated in the same case; and how often has he had cause to suspect the rapid supervention of irritation of the membranes of the brain, or of the brain itself, either with or with- out effusion, upon inflammation of the digestive mucous surface! 12. b. Weaning.—During this epoch wean- ing must take place. This should not be earlier than the eighth or ninth month, or later than the fifteenth; and the infant ought to have, at least, four teeth quite through the gums before it be commenced. The milk of the mother is the in- fant's only food during the greater part of the preceding epoch, or, at least, until the fourth or fifth month, unless the mother and child be in a weakly state. From this age upwards it requires food in addition to the nourishment afforded by the mother; but this must be given at first in small quantities, and not oftener than twice daily. As the period of weaning approaches, food in larger proportion, and increased frequency, is necessary; and as soon as it shall have got teeth to masticate animal food, this may be given it in small quantity, and at first only twice in the week. Animal diet is seldom required before the completion of the first year, or previous to wean- ing; afterwards it may be given in gradually in- creased frequency, as the termination of the epoch approaches. 13. Whilst the infant is liable to most of the maladies which affect it during the first months, it is now also exposed to the invasion of many more; owing to the excitement occasioned by teething, the state of the milk, particularly during the last months of lactation, and the errors in respect of both the quantity and quality of the food. At the same time, however, its vital ener- gies are more developed, and its functions more AGE — Boyhood. 41 perfect; and thus increased resistance is opposed to the extension of disease, and to its disorganiz- ing effects. All infectious and exanthematous disorders are very prevalent at this age ; and, in addition to the maladies of the mucous surfaces already alluded to, the lymphatic glands, particu- larly those of the abdomen and thorax, are fre- quently the seat of disease ; and worms often begin to form, particularly after the period of lactation. At this age also, owing to the changes in the infant's food, as well as to the irritation occasioned by dentition, the disorders which originate in depraved or imperfect digestion and assimilation are especially prevalent, particularly aphthae, rickets, tubercules, marasmus, and tabes mesenteriea, remittent fever, scrofula, and nu- merous cutaneous eruptions. 14. c. The therapeutical indications at this epoch chiefly relate to the care which is required to preserve the head cool, and ward off the vascu- lar excitement to which it is liable. Anodynes are less injurious at this period than in that preceding it, and are often required, particularly in sooth- ing the irritability of the nervous system arising either from difficult dentition, from the exhaustion occasioned by previous treatment, or by disease, and particularly in the advanced stages of whoop- ing-cough and croup. The state of the gums requires particular attention ; and where there is evidence of itching, this sensation requires to be allayed, first, in the way that nature points out, by pressing hard and smooth substances between the gums, as a coral, ivory ring, and what is best, a gold ring, when this may be directed. If the least appearance of local affection, as tumefac- tion, redness, &c, or even merely constitutional disturbance, manifest themselves, the gums should be freely and deeply scarified. Aperients, of a mild and cooling nature, are often required during this epoch ; and in it, as well as in the preceding, blisters, even for a few hours only, particularly when the respiratory mucous surface is obstructed and its functions interrupted, or when the energies are exhausted and the vital resistance consequently reduced, must be em- ployed with extreme caution, and give place to the use of those liniments which I shall have occasion to recommend as substitutes for them under such circumstances. 15. II. Period, or that of Childhood (Pue- ritia), extends from about the second to the seventh or eighth year, when the second dentition is completed. During this period the develope- ment of the different textures and organs pro- ceeds rapidly, and their functions are more and more perfect. The mental manifestations, par- ticularly those which are intellectual, are de- veloped, and the various moral emotions gain strength. The distinctions which exist between sexes throughout the whole physical and mental constitution at more advanced ages have not yet appeared. All the soft solids of the, body evince increasing firmness, vital cohesion, and elasticity, and are protected by a firm covering of adipose matter below the integuments, and in the interstices between the muscles. 16. a. If the constitution be not vitiated by hereditary or acquired taint, defective nourish- ment, or previous ailment, or if the causes be not of a depressing nature, disease at this period assumes the sthenic character. Febrile diseases | 4* are generally acute ; and, unless proceeding from sources of infection, usually the result of local inflammatory action, which evinces a marked disposition to terminate in the formative process, or effusion of coagulable lymph, particularly when the serous surfaces are implicated. The susceptibility to infectious diseases, particu- larly those with exanthematous symptoms, is very great ; as well as to inflammations of the different textures and organs — to pneumonia, bronchitis, cerebritis, meningitis, gastritis, ente- ritis, &c. : besides these, glandular obstructions, chorea, verminous diseases, epilepsy, and the various forms of angina, are very prevalent at this age, particularly in those whose digestive organs have been neglected, and when morbid matters have been allowed to accumulate in the prima via. 17. b. The therapeutical indications applicable to this age present few peculiarities, besides the necessity of resorting to active depletions, with a cooling regimen and alvine evacuations in the majority of its diseases ; and the keeping in recol- lection the tendency of mucous sordes and se- cretions to form and accumulate on the digestive mucous surface. Such accumulations furnish a nidus for the generation of worms, and sources of irritation to this surface itself, and to the nerves proceeding from it; and originate many of the affections which appear at this, and a subsequent period of existence. The necessity of enjoying, and the injurious consequences of the privation, of wholesome nourishment and active exercise in a pure atmosphere, and the advantages of sleeping alone in a large well-ventilated apart- ment, should not be overlooked, in then relation both to the production and to the removal of disorder. The employment of the faculties of the mind during this early stage of their de- velopement should be left, until the last year or two of this period, more as a matter of amuse- ment than of exertion ; and, even then, greater attention should be paid to the developement of the physical powers,—the organization upon which sound mental manifestations very intimately depend,—than to the precocious and even hurt- ful excitement of faculties which are merely bud- ding into existence. The emotions of mind, however, particularly those which are connected with temper and disposition, ought first to receive attention ; strict control cannot be prematurely applied in this direction. In this and the preced- ing epochs of life, it is indispensably requisite no? to allow the child to sleep with persons in bad health, or who are far advanced in life. 18. III. Period, or Boyhood—Girlhood. From the seventh or eighth year to the epoch of commencing puberty, is chiefly characterized by the continued growth of all the structures, and the developement of the manifestations of mind. Towards the middle and end of this period the physical and mental distinctions of sex become more and more apparent, a. The frame, when free from disease or hereditary taint, evinces a sthenic diathesis, a predominance of the sanguine, or sanguineo-nervous temperament, and a liability to nearly the same diseases, particularly those proceeding from infection and inflammation, that prevail during childhood. There is a greater liability to be affected with idiopathic continued fever, with scrofulous enlargements and inflam- 42 AGE — Adolescence. mations, particularly of the lymphatic glands ; with various nervous affections, as epilepsy, con- vulsions, chorea, &c. ; with cutaneous eruptions ; with inflammations of the throat and air-passa- ges ; with tubercles, especially in the lungs and alimentary canal; with flexures of the spinal column, and with verminous diseases. The nervous system possesses great susceptibility of impressions, moral and physical; and inflamma- tory action has a marked disposition to give rise to new formations, unless when appearing in the advanced stages, or as a sequela, of eruptive or infectious fevers, when it generally occasions serous or sero-albuminous effusions. 19. b. The diseases of this period generally require antiphlogistic remedies and evacuations, especially purgatives, either alone or in suitable combination, unless proceeding from depressing causes, particularly those of a specific kind ; and even there the necessity of resorting to alvine evacuations, by means of laxatives, or purgatives combined with tonics, is imperative. The vital resistance is usually well marked, excepting in those who have been deprived of wholesome nourishment and pure air, or whose constitutions are radically in fault ; and in these, whilst tonics and other means of restoration are required, the due evacuation of morbid secretions and accu- mulations is equally necessary. Care also should be taken during this, as well as in the preceding period, not to allow the young to sleep in the same bed with the old, nor even with those advanced in age or debilitated, nor with too many—not more than three—in the same sleeping apartment, which ought to be large and well aired. Want of attention to this, is one of the chief causes of disease in early life in Lon- don, and other large towns. Academies and boarding schools for both sexes are continually furnishing numerous proofs of this too generally overlooked cause of disease, not only at this, but also at a later stage of life. Attention is also necessary to the exercises of both the mind and the body. Active amusements in the open air are now particularly required. As this period advances, the mental powers acquire such a de- gree of developement as to admit of their further improvement and active exertion,—not only with- out risk to the organization with which they are related, but with the certain prospect of advanc- ing them nearer to the perfection to which our natures may attain. 20. During this and the earlier terms of life frequent changes of locality and of air, particu- larly from one healthy and open situation to another, and especially to one which is more salubrious, where this can be attained, are ex- tremely beneficial, both in promoting the de- velopement of the frame and in removing diseas- es, particularly those of a chronic kind, or which affect the digestive and assimilating organs. In many of these diseases I have often derived more advantage from change of air than from the use of medicine. But, during advanced convales- cence from these and febrile diseases, the benefit derived from change of locality is most remark- able. 21. IV. Period, or Adolescence, commen- ces with the first appearance of puberty, and ex- tends to the twentieth year of females, and the twenty-fourth of males. Puberty appears at va- rious ages, according to the climate, the circum- stances connected with education, and the consti- tution of the individual. The usual period m this country, is from the twelfth to the fourteenth year for females ; and from the fourteenth to the sixteenth for males. In the northern parts of the island, it is often a year or two later in both sexes. It is often observed earlier in boarding- schools, both in respect of males and females. In the latter (in London or its vicinity), I have not infrequently met with instances of menstru- ation at ten and eleven years ; especially in sanguine and plethoric constitutions ; and where the apartments, particularly those for sleeping, have been crowded and close. 22. a. This is one of the most important epochs of human existence : for during it the natural developement of the sexual organs imparts a healthy and tonic excitement throughout the economy ; bringing to their state of full perfection all the organs of the body and all the mani- festations of mind, excepting those that are de- rived from experience. The organs of respiration and voice have acquired their full growth and tone, the muscles their due proportion, and the cerebro-spinal nervous system its beautiful or- ganization ; placing man, by the exercise of its admirable functions, at the head of all animated creation,—the dread of all other animals, the wonder of himself. It is chiefly during this period of life that the mind becomes stored with ideas, derived both from the learning of the ancients, the science of the moderns, and the arts and accomplishments of highly civilized life ; and is more particularly and more ardently en- gaged in decomposing the information thus ac- quired, and recombining it in new and useful and attractive forms. 23. As the functions and destinies of this period are important, so they require the super- vision of the experienced and the good. For, with this developement and activity of both the physical and mental powers, the instinctive feel- ings and emotions of our nature have also reached the utmost limits of their activity ; and many of them, particularly those which are related to the perfect condition of the reproductive organs, ac- quire an ascendency, that both the dictates of reason and moral restraint are required to con- trol. Hence the propriety, both at this and the preceding period of life, of improving the moral affections of the mind ; of inculcating sound prin- ciples of action and conduct, founded on moral and religious obligations ; and of placing them in such relations to the feelings, the intellectual manifestations, and, moreover, to the accomplish- ments, the elegances, and the endearments of life, as to render them attractive to a state of mind and constitution which is more easily allured by example than taught by precept. 24. The practices which both sexes are liable to acquire at this period of life, and to which they are more commonly addicted when they associate in numbers at seminaries and academies, demand the strictest supervision. They have been too generally overlooked, both morally and medically, from the circumstance of their consequences having been imperfectly appreciated. There is no practitioner of observation and experience,— certainly none of even limited knowledge,—who has travelled into foreign countries, and is yet AGE — Mature Age. 43 unacquainted with the physical exhaustion, the mental torpor, and all but annihilation of ex- istence, which is the ultimate result of indulging them. From this source frequently spring, impo- tency hereafter ; the extinction of families and hereditary honours — honours which such per- sons -are incapable of achieving ; the infliction, during after-life, of many of the diseases which proceed from debility, and the exhaustion of the nourishment and vital energy of the various structures and organs ; of numerous nervous and convulsive maladies, as hysteria, epilepsy, neu- ralgia, chorea, melancholia, mania, idiotcy, &c. ; the dangerous or fatal visitation of fevers ; dis- eases of the heart, disorders of the digestive organs, premature baldness and old age, the formation of tubercles, and the production of pul- monary consumption ; and, lastly, the transmis- sion of weak and decrepit bodies and minds to the offspring ; of scrofula, rickets, verminous complaints, marasmus, hydrocephalus, convul- sions, tubercles, chorea, &c. : the curse is visited on the children to the third and fourth genera- tion, until the perpetuated punishment extin- guishes the very name of the aggressor. 25. b. The pathological conditions of this age are especially characterized by exalted action. At the approach and commencement of puberty, the glandular system is extremely prone to congestive inflammations, particularly the lymphatic glands of the neck and arm-pits. Tubercles are rapidly developed in the lungs ; and this organ is much disposed to acute and chronic inflammations of both their substance and mucous surfaces. Pulmonary haemorrhages usurp the place of the epistaxis of earlier epochs ; and, in females, dysmenorrhaea, protracted or retained menstruation, chlorosis, hysteria, and occasion- ally menorrhagia or leucorrhcea, occur. The sanguine diathesis and plethoric habit, in those of a sound constitution, and the sanguine, irri- table, and nervous temperaments, or the one associated with the other, most commonly pre- vail at this period of life. 26. The progress of disease is generally rapid, and its character acute. Inflammations are more prone to give rise to the formative processes ; and febrile affections, when they terminate by crises, evince a preference to haemorrhages and sweats. Idiopathic fevers, inflammations of the respira- tory organs, and of the brain or its membranes, are the most common diseases of this age. 27. c. The therapeutical indications require but little remark ; for the system has now nearly, or altogether, reached its full growth ; and the general inferences which guide the practitioner in the employment of remedial means have now reference, especially, to states of habit, consti- tutional powers, temperament, and diathesis,— physical manifestations, which are now, in a great measure, developed, but which acquire their most predominant characters in adult age. As the maladies of this period are generally in- flammatory, and evince a strong tendency to the formative process, and as the powers of life are now most energetic, vascular depletions, with the antiplilogistic regimen, are generally required, and are well borne ; excepting in those whose constitutions have been originally in fault, or who have greatly injured it by the injurious practice of masturbation, from which so many j suffer, both at this and subsequent epochs of life. 28. V. Period. Adult Age may be divided into the epochs, 1st, of early adult age; and 2d, of mature age, or confirmed virility. Of each of these I shall take a brief notice. A. Early adult age may be dated from twenty to thirty in the female, and from twenty-four to thirty-five in the male. During this epoch, if the constitutional powers have not been injured previously, the whole frame and its individual organs continue to acquire strength ; and, al- though the body has ceased to grow in height, it increases in bulk, particularly the muscles of voluntary motion and the parietes of the large cavities. It is also more capable of enduring continued exertion and privations ; its vital en- durance and resistance being greater than during the period of adolescence. The features and ex- pression of the face ; the character, disposition, temperament, and diathesis, are more unfolded, and towards the termination of this period fully display their manifestations. 29. B. Mature age, or confirmed virility, may be considered as being from thirty to forty, or forty-two, in the female, and from thirty-four to forty-eight in the male. During this time of life, the features of the countenance fully assume those modifications of character arising from the influence of the passions and emotions of the mind ; and the appetites, habits, and occupations of life imprint upon the frame generally certain appearances, arising from their continued influence on the constitution. The muscular organs, par- ticularly the muscles of the extremities, are prom- inently marked ; the chest fully developed ; the body spare and active ; the adipose structure ex- tremely scanty, and the abdomen small, in those habitually devoted to laborious employments, not of a sedentary nature, and to active exercise, either on foot or horseback. The sedentary, those ad- dicted to the indulgence of the appetites, and particularly those given to the gratifications of the table, have large abdomens, small extremities, and large depositions of adipose matter beneath the integuments, between the muscles in the omentum and surrounding the viscera, with a weak and defective developement of the muscular parts. The studious present the chief marks of their occupations on the features of the counte- nance and character of the head ; the appearance of the rest of the frame varying with the habits and indulgences with which study or the pro- secution of science may be conjoined. At this period of life also the feelings, the anxieties, the disappointments, the losses, and the various mo- ral emotions of life, begin to manifest those effects upon the frame, which become still more fully marked during the following epoch. 30. This and the preceding period of adult age are, upon the whole, the most exempt of all others from disease ; but about the age of forty, and still more so as the age of fifty is approached, the sanguineous circulation becomes more and more languid, particularly in the veins : hence the frequency of venous congestions and visceral obstructions, with the various diseases depending thereupon, particularly haemorrhoids ; bilious de- rangements ; bilious and gastric fevers; inflamma- tions ; affections of the heart ; apoplexy and para- lysis ; derangements of the stomach and liver; 44 AGE — in its spec ific Acceptation. hsematemesis ; affections of the joints, as gout and rheumatism ; diseases of the urinary organs ; hys- teria and uterine disorders ; hypochondriasis, and affections of the mind. At this period therapeu- tical means require to be strictly regulated ac- cording to the sex, constitution, temperament, habits, and occupations of the affected. 31. VI. Period. Age, in its specific ac- ceptation, may be divided into four epochs : viz. 1st, Declining age ; 2d, Green old age ; 3d, Advanced old age ; 4th, Decrepitude, or second infancy. Before I proceed to consider these in- dividually, I will take a view of the changes which supervene with age in the structures and functions of the body. Age, in the specific acceptation of the word, may be considered as commencing when the vital energies of the different organs begin to de- cline,—when the maturity of life glides into de- cay. The period at which this change supervenes varies very much in different persons, according to their constitutions, employments, and habits during the earlier epochs of existence. In many it is so gradual as to be imperceptible ; in others it is more obvious ; and in some it is induced rapidly and remarkably, by mental anxieties and bodily disease. The usual period of its advent, in both sexes, and the different epochs in which age may be divided, will be stated in the sequel. 32. As age steals on, all the functions are per- formed more languidly than in earlier life. The energies of the ganglial system decline, as evinced by the digestive, circulating, and secret- ing functions, which it actuates. The sensibility of the cerebro-spinal system, and of its dependent organs ; the acuteness of our intellectual powers, our moral emotions and affections, and the ac- tivity and strength of the locomotive organs,—all experience diminution, great in proportion to the advances of age. In noticing the pathological and therapeutical relations of age, those changes of structure and of function which supervene with it will first re- ceive attention ; next, the different terms into which it may be divided, with those modifications which diseased actions generally assume in each term respectively, and those indications which should guide our practice in the diseases to which each is most obnoxious, will be briefly considered. 33. A. The modifications of structure produc- ed by age are occasionally slight ; but most com- monly they are very remarkable, particularly in certain organs. In some parts they are scarcely perceptible, in others more obvious, consisting chiefly of increase of density ; and in many they amount to actual change of texture. The integuments, particularly those of the face, and the hair, are amongst the earliest parts to exhibit the advance of age ; and they most ob- viously indicate the different stages of its pro- gress. The integuments of the face seem more developed than in early or mature age. They are denser and thicker, especially the cutis vera and rete mucosum ; which latter assumes also a somewhat darker tint. The skin appears more loosely attached to the parts underneath it, chiefly owing to the diminution of the subjacent fat, and shrinking of the other soft solids. Hence it ap- pears, particularly in the face, neck, and hands, flaccid and wrinkled. 34. The hairs of the head are, perhaps, the first to evince the commencement of age ; and they present the most common indications of the pro- cess of decay, either by a more or less complete change of colour, or a partial and general loss of them. The change of colour at first consists of a few white or gray hairs, scattered amongst those of a natural hue; but these gradually be- come more numerous, particularly on the tem- ples, until the whole hair is altogether gray, and ultimately white and transparent. As this change proceeds, the hair also falls out, especially on the crown and forehead. There are, however, many circumstances which accelerate these phenomena, independently of age. Thus fevers, severe cour- ses of mercury, masturbation, &c. will occasion the loss of the hair. But when it falls out from disease, the bulbous roots not being obliterated, its reproduction generally follows; whereas, when it is lost from old age or from masturba- tion, it is never reproduced. There are also various causes which occasion a change of its colour, particularly the depressing passions, in- tense application to study, anxieties of mind, venereal indulgences, &c, and which at the same time accelerate the loss of it. The change of colour, and subsequent loss of hair, seem to arise from deficient nutrition, and consequent atrophy, or destruction of the bulb, together with some change in the skin itself. In some cases it seems to arise from chronic disease of the rete mucosum and cuticle, as stated in the pathology of certain cutaneous affections. 35. The adipose and cellular tissues experi- ence considerable change. The fatty deposit diminishes with the progress of age, and it some- times becomes more fluid and watery, as well as of a deeper tint. The cellular tissue is somewhat denser, more fragile, and less elastic than in early life. La some situations it assumes a fibrous character, particularly that portion of it which invests the muscular fibres. The serous mem- branes are also more dense, more subject to ossific deposits, and their free surface drier than in early life. The mucous surfaces exhibit but little change, excepting as respects their greater pale- ness, and tendency to certain states of disease. The fibrous structures become more rigid, and in various parts the seat of ossific deposits. They aiso assume a deeper colour, and firmer and tougher consistence, whilst their physical cohe- sion is much increased as age advances. 36. The muscles of voluntary motion expe- rience a very marked change, particularly at the advanced epochs of age. They are much diminished in bulk. Their fibres are more rigid, less readily influenced by stimuli, and less con- tractile than in early life. They are also less under the control of volition, much less energetic in their actions, more flaccid, and endowed with less vital tenacity. Their structure is also some- what modified. They are paler, sometimes of a light yellow colour, and their fibres less distinct than in youth. The tendons and aponeurotic expansions of muscles, as well as the cellular tissue intervening, are often partially ossified. Portions of muscles, near their tendons, are some- times converted into a tendinous structure ; and the secretions poured into the sheaths of the ten- dons are remarkably diminished. From all these changes result the vacillating, embarrassed, and weak movements of the aged AGE. 45 37. The bones acquire a dense structure, and even a somewhat increased size, particularly the bones of the head, the sutures of which become firmly united, first in the internal, and afterwards in the external surface. The cartilages are ossi- fied, particularly those of the ribs. The inter- vertebral cartilages become hard, inelastic, and shrunk: hence the impaired flexibility of the spinal column, the bending forwards of the trunk, and diminished stature of aged persons. 38. The blood-vessels undergo very remarkable changes. The arteries are gradually diminished, in proportion to the bulk of the body, as age proceeds; and the predominance of the venous over the arterial system is more and more appa- rent. Whilst the arterial vessels become, on the one hand, more dense and rigid in their coats, their calibre diminished, their smaller ramifica- tions altogether obliterated, and their vasa va- sorum indistinct, the veins seem, on the other hand, somewhat thinner in their coats, more dilatable, and their calibre increased; they are also more tortuous, and hence their capacity is augmented : so that, although the quantity of blood contained in the body is diminished, par- ticularly at the most advanced stages of life, about two thirds of it are contained in the veins. Besides those changes of capacity, the coats of the vessels present changes of structure. The arteries are liable to ossific and other deposits, rupture of their coats, &c.; the veins to varix, inflammation, &c. 39. The brain and nerves are also somewhat modified by age. The membranes of the former are generally slightly thickened and opaque. The bulk of the brain is diminished, and its sub- stance firmer and tougher than natural, and less readily acted upon by chemical re-agents. The nerves seem to possess a diminished quantity of medullary substance, and their blood-vessels are indistinct. The ganglia become firmer, of a deeper colour, and smaller than in early life. 40. The organs of sense undergo important al- terations. The eyes are changed chiefly by the diminished secretion of aqueous fluid into the anterior chamber, occasioning less prominence of the cornea, and a change of its refractive power. The crystalline lens acquires a yellowish tint, and is less transparent. The nerves of the eye, par- ticularly the optic nerves and ophthalmic branch of the fifth pair, and the iris, are less sensible than before ; and hence the dilatation of the pupil, the distant sight, and the confused appear- ance of near objects to aged persons. The ear experiences a change similar to that which takes place in the eye. The fluid occupying its inter- nal cavities is diminished or altogether absorbed; and the auditory nerve rendered insensible to im- pressions, from this and other changes in the con- ditions necessary to its functions. The other or- gans of sense, particularly taste and smell, have also their sensibility similarly blunted. 41. But changes are not limited to the more elementary structures of the body; and organs of sense, the viscera of digestion, secretion, assimila- tion, sanguifaction, and generation undergo analo- gous alterations. The teeth loosen or decay; the gums are partially absorbed; and the jaws, de- prived of teeth and of their alveolae, approximate more closely. Hence the projection of the chin, its approach to the nose, and diminished capacity of the mouth. To these causes are partly to be imputed the change which takes place in the speech of the aged. The stomach and bowels are generally flaccid, owing to deficient contractility of their muscular coats; but the liver, pancreas, and spleen present but little change, excepting they are, or have been, the seat of disease, unless slight atrophy, or enlargement and increased dens- ity. The urinary organs are more frequently altered: calculi are not infrequently met with in the tubuli uriniferi and pelvis of the kidneys; and the urinary bladder is generally thicker and firm- er in its coats than in early life; the prostate gland is commonly somewhat enlarged. 42. The lungs are not necessarily changed by age, further than that they become less elastic, their air-cells enlarged, some of the bronchial ramifications more dilated, and portions of them emphysematous. They frequently, however, pre- sent the remains of antecedent disease. The heart partakes, although in a less remarkable manner, of the changes experienced by muscular parts. The tone and energy of its fibres are low- ered ; its structure is softer, more flaccid, and oc- casionally also paler. It is sometimes diminished in size; or some of its cavities are dilated, and their parietes thinned; and cartilaginous or ossific formations, or both, occur in parts of its internal surface, particularly in the valves. 43. The organs of generation experience a marked alteration. The ovaria shrink, become dense, and their vesicular structure changed. The uterus is diminished in bulk, unless it is the seat of organic disease, to which it is very liable, particularly at its mouth and neck. The mamma also waste, are soft, pendulous, and lastly are en- tirely absorbed. The areolae become dark, and the nipples shrink. At the commencement of age they are subject to congestions, indurations, and scirrhous disease. The testes shrink, or be- come soft and small, or even nearly disappear. The penis is shrunk, seldom experiences the vital turgescence, and lastly not at all; the faculty of generation having previously disappeared. 44. In this rapid sketch of the chief changes which the structures and organs of the body un- dergo from age, there are several phenomena which must strike the reader. The chief of these are, the gradually increased density of the different textures, and the consequent diminution of their watery or fluid constituents, as well as of the blood itself. In childhood and early life the tex- tures are succulent, and the circulating fluid abundant. But as age advances, they acquire an increase of their physical cohesion, whilst their vital attraction is diminished. This increase of density and diminution of the fluid elements of the structures, with the progress of age, are constantly observed in the vegetable kingdom of nature: and, as we advance upwards, through the various grades and classes of animals, we find this prin- ciple strictly adhered to. In addition to this, another phenomenon is remarkable; namely, the redundance of osseous matter, as evinced not only by the increased quantity of earthy matter in the bones and cartilages, but also by the deposition of this substance in the coats of the arteries and in other textures. Somewhat analogous to these formations, and sometimes even vicarious of them, is the abundance of sabulous deposits from the urine, frequently observed to occur either during 46 AGE. the secretion and retention of this fluid, or after its discharge. 45. Not only are the mechanical conditions of the different parts of the body modified by age, as now stated, but their chemical properties are also similarly affected. The gelatin disappears, or be- comes changed to albumen; the fibrin is increas- ed, and assumes a deeper hue, and is less easily affected by maceration or exposure to the air. The phosphate of lime is augmented, and often accumulates to a very hurtful extent, together with the other earthy salts and urea. 46. B. Of the conditions of function charac- terizing the advance of age. a. Although the changes, which have been now described as supervening in the different structures with age, may have originated in those imperceptible and slow modifications which the various organic functions experience from peculiarities of consti- tution, of food and employment, or from ac- quired habits and indulgences ; yet there can be no doubt that, when once induced, they modify still further these functions, and thus draw on other lesions, and ultimately still greater alter- ations of both function and structure, or even speedily fatal disease. But we are not altogether justified in considering these contingencies as the primary causes of the changes now described. We are rather to view them as more or less re- mote effects of the failure of the vital endowment of the frame, manifesting itself first in a less per- fect performance of the different functions, and subsequently in modifications of structure, and ultimately in very obvious lesions of both func- tion and structure. 47. b. It is supposed by some, that the embryo at its earliest formation is endowed with a certain sum or allotment of vitality, which, in the earlier epochs of life, is engaged in the formation of, and in bringing to perfection, the different structures and organs of the frame; that it is gradually ex- hausting itself ever after, until it at last expires; and that the greater the excitement of its diflerent manifestations and functions during the subsequent stages of existence, the more rapidly will its termination be reached; that the oil with which the lamp of human, and indeed all animal, exist- ence burns is filled at its commencement, and is never afterwards supplied; and that the more brilliant the flame, the shorter will be its du- ration. This captivating hypothesis, however, appears, on an intimate view, irreconcilable with many of the phenomena of health and disease. It cannot readily be conceded that the allotment of vitality bestowed upon the germ or germs can exceed that possessed by the parents,—for the hypothesis is, that the sum of vitality is greater the younger the animal; and that it diminishes with the advance of days and years, from the period of its endowing the embryo. But it is ob- vious, that the greater vital endowment cannot issue from the smaller; that the parents cannot possibly impart to the embryo more than they possess, they still retaining a portion afterwards : more particularly when we consider that the greater endowment is imparted not to one embryo only, but to several, as is the case in the lower animals, and often in the human species also. 48. The phenomena, moreover, of disease fur- nish us with proofs that this sum of vital endowment is neither thus early and at once bestowed, nor thus uniformly diminished, according to the waste it experiences, without occasional reinforcement. We frequently perceive all the manifestations of life reduced, at different epochs of existence, nearly to total extinction, particularly in several kinds of fever, when, having received the requi- site aid from external stimuli, they have been gradually restored to their former activity. In- deed, the various circumstances in which the body is placed, and the different states it presents at different periods of life, and from numerous causes which affect it, seem rather to favour the idea that the sum of vitality, and its manifestations in the different organs, fluctuate more or less during the allotted period of existence; that a certain eman- ation of vitality proceeds from the parents, great in proportion to their constitutional powers; but that this endowment is constantly experiencing an accession, first from the mother, and subsequently from the common sources of air and aliment; that this reinforcement is thus constantly supply- ing the waste arising from the exercise of the various functions, and adding to the bulk of the structures, until manhood is reached; and that at this period the sum of vitality has reached its greatest amount, from which it gradually declines, owing rather to the waste, particularly that occa- sioned by the exercise of the generative functions, exceeding the supply, than from the continued expenditure of what is at first bestowed and never afterwards reinforced. 49. Having been induced by the foregoing, and other considerations, to relinquish the former for the latter hypothesis, I infer that the gradual di munition of the vital energies that accompanies the progress of age is more or less manifested throughout all the functions; that the functions first evince this decline, and that the organs them selves are at last modified in organization, from the slightest and almost inappreciable shades to the most marked alterations. The changes of structure, once induced, tend most essentially to heighten and to perpetuate the previously slight disorders of function, until both the one and the other undergo, by reciprocity of influence, most important alterations, terminating at last in death, and the dissolution of the frame. I now pro- ceed briefly to notice those changes of function, which, frequently related to the alterations of structure described above, mark the existence of Age. 50. c. I have, in another place, stated that, of all the different tissues of the frame, the ganglia] system is the most intimately related, in every way, to the vital influence which endows the body. And it is precisely those organs which are most immediately connected with this system that first furnish proofs of incipient decline in the languor or imperfections of their functions. Amongst those functions are comprised those-of digestion, secre- tion, circulation, assimilation, the preservation of the animal temperature, and generation. The functions of animal relation are not so soon af- fected; and at first the change in them is rather secondary, and owing to the pre-existing change of the functions of organic life,—of those func- tions which are excited or actuated through the medium of the ganglial system. 51. As very intimately dependent upon the state of the ganglial system, the secretions manifest, with the advance of age, the most remarkable AGE. 47 lesion. These are generally modified in quantity, in fluidity, and in quality. 1st, The quantity of the secretions, both recrementitial and excremen- titial, is sensibly lessened. The salivary, gastric, biliary, cutaneous, and spermatic secretions evince this change. 2d, Their fluidity is diminished, as shown by the salivary, the lachrymal, cutaneous, and watery exhalations and secretions. And, 3d, their properties are modified, as proved by their marked tendency to assume, immediately as they are secreted, irritating and acrimonious qualities, as shown by their effects upon the tissues, with which they remain for any time in contact, and to pass rapidly into decomposition. The urine, and occasionally the lachrymal, the mucous, the biliary, cutaneous, and sebaceous secretions evince this change. It very generally happens that the secreted fluids experience more than one of the above alterations ; they being diminished both in quantity and in fluidity, and at the same time deteriorated in quality. This is remarkably the case in respect of the cutaneous, mucous, and urinary secretions ; the chief exception being fur- nished by the mucous fluid, which is sometimes increased, although it is of diminished fluidity and altered quality : but tins is rather an effect of dis- ease, than merely of advanced age. 52. Next to the function of secretion, and owing to the same cause, —the diminution of vital influence, — that of circulation is most sensibly affected. The action of the heart is slower than in early life, much less energetic, and occasionally irregular. The capillary circulation is more lan- guid, and a much smaller quantity of blood pene- trates the extreme ramifications and nutritious vessels, in consequence, most probably, of the diminished calibre of those vessels, and the in- creased density of the tissues in which they ter- minate. The venous circulation is more congest- ed, and more prone to experience the conse-' quences of engorgements, particularly varicose dilatations, giving rise to effusions of blood and other serious diseases. The blood itself is not only diminished in quantity, but is also of a darker colour, and is probably also slightly changed in quality, particularly in respect of certain of its saline constituents. The absorbent system is less frequently disturbed in its functions by age than almost any other part of the frame, although it occasionally evinces diminished power, but chiefly in connection with disease. To the predominance of the absorbent function over that of arterial circulation has been partly ascribed, and with apparent justice, the wasting and condensation of the structures characterising the most advanced epochs of life. 53. As intimately connected with the weaken- ed energy of the ganglionic and vascular systems, the functions of digestion and assimilation are languidly performed. The gastric, pancreatic, and biliary juices are less abundantly secreted in the aged than in those of early or mature years ; and the tonic contractility of the coats of the sto- mach and bowels is diminished. Hence result various dyspeptic ailments, flatulence, and a slug- gish state of the bowels. The receptacles which nature has provided for the temporary retention of the secretions and excretions, particularly the biliary and urinary bladders, react imperfectly on their contents, owing to the lowered power of the nerves which actuate them : hence arise distension from the inordinate accumulation of the secre- tions poured into them, and changes of the pro- perties of these secretions during their retention, either occasioning their expulsion, or producing actual disease. 54. As closely related, also, to the lowered energy of the nerves of organic life, and conse- quent languor of the circulation, the generation of animal heat in the aged is evidently diminished, although the causes which usually moderate it in the young, — namely, abundant exhalation and evaporation from the surfaces of the lungs and skin, —exist in a much less degree in the former. The functions of generation are, however, those most remarkably affected. In the female the faculty of conception is altogether abolished, and important changes occur in the state of her ap- propriate organs ; yet the sexual desire still lingers for awhile : and in the male, although the ability of procreation may remain, under favourable cir- cumstances, for some time, it is at last entirely abolished. 55. Thus we perceive, that as the different vis- cera of organic life increase in density, and expe- rience a diminution of vital expansibility and con- tractility, so their functions become more languid or imperfect, until some of them cease to be per- formed, and others are remarkably altered. But the change is not limited to this class of structures. Those organs which are devoted to the extension of our intercourse with surrounding nature, and are subservient to the manifestations of mind, as well as those manifestations themselves, in both their intellectual and moral relations, undergo, although at a more advanced period, in respect of some of them, very marked modifications. 56. The changes that take place in the mus- cular and their associated structures evidently would render them incapable of performing those actions, to which volition may impel them, with energy, rapidity, and steadiness, even although the nervous system of voluntary motion were altogether unaffected. But this system, owing probably to those slight, and nearly unappre- ciable, alterations noticed above (§ 36.), pos- sesses much less energy and susceptibility of action than in the prime of life, and therefore actuates the muscles in a less vigorous manner. 57. The same condition of the brain and cere- bro-spinal nerves, which contributes to render the actions of volition less precise and energetic, seems also to be connected with the less vigorous exer- cise of the intellectual powers, and the imperfect conditions of the functions of sense. These func- tions generally indicate incipient decay before the powers of mind are affected ; and some of them are nearly abolished, particularly hearing and seeing, before the latter evince any marked change. But more commonly the decay of the senses is soon followed, occasionally as a neces- sary result, by a slight failure of some of the men- tal faculties. The memory, and the power of association as intimately related to memory, are the first to evince this declension, generally by a want of recollection of the names of persons, subsequently of the names of things and of recent events, or recently detailed information ; the judgment continuing either altogether or but slight- ly impaired. With this declining state of the faculties, the emotions of the mind are often re- markably blunted ; the desires and affections are 48 AGE —Old Age. impaired, excepting in as far as respect early- formed associations and affections, which are often recalled with acute and even overwhelming emotion. 58. As age advances sleep is much lessened ; and not only is the duration of repose abridged, but also its soundness ; the rest of the aged being imperfect, and disturbed by dreams. It is diffi- cult to explain this — indeed no satisfactory explanation of it has yet been offered ; but it is generally observed, particularly in very advanced age. 59. Such are the changes induced by age in the various structures and functions of the body, as evidently caused by the gradual decline of the vital energy, from the period of full manhood to its ultimate extinction. ' I have described them as much divested as possible of the effects of dis- ease. As now noticed, those changes gradually lapse into death, —the lamp of life having burnt out, its oil having been exhausted, after a gradual diminution of the supply, without any single organ evincing that state of disease to which the ces- sation of life can be ascribed. This is, however, not a common occurrence ; for, during the grad- ual decay that marks the progress of age, some organ or other, owing to the deleterious influence of surrounding agents, or of mental emotions, and the weak resistance of the vital influence, experiences a more or less marked derangement, which increases to actual disease, and either abridges the remaining short period of existence, or renders it less supportable. I now proceed to notice the different epochs of advanced age, with reference chiefly to the dis- eases incidental to each, and to the therapeutical considerations which should influence the treat- ment of them. (See Climacteric Disease.) 60. 1st Epoch, or declining age extends from forty or forty-two to fifty-two in the female, and from forty-eight to sixty in the male. a. During this period the appetites, occupations, and habits express themselves still more strongly upon the outward appearance of the frame than in that immediately preceding it; and the feelings, emo- tions, disappointments, and anxieties of life mani- fest more fully their effects upon the internal or- gans, as well as upon the external aspect. Venous congestions, visceral obstructions and engorge- ments, with all the specific forms of disease al- ready enumerated, (§30.) are more frequent than during earlier epochs, particularly apoplexy and paralysis, haemorrhoids, hepatic disorder, dropsies, structural change in the kidneys and bladder, hy- pochondriasis, haematemesis, gout, and chronic affections of the respiratory organs. 61. b. In this period, the second great change to which the constitution of the female is liable generally occurs, terminating that epoch in which her sexual constitution is especially marked ; and with this change frequently commence, or are matured, several diseases o'f the female organs. Morbid changes of the uterus and its appendagesj as well as of the breast, are now very frequent; and sometimes they assume a malignant character! Various maladies, to wliich the female was less exposed than the male, are now oftener met with • and her constitution, with its disposition to disease] approaches more nearly to that of the male than during the time of marked uterine activity. 62. 2d Epoch, or green old age, may be reck- oned to commence about 53, and to extend to 60 or 65 for the female ; and to begin about 60, and extend to 65 or 70, in the male. During this epoch the nervous, circulating, and muscular energies begin to languish, with the vital actions of the different internal organs. The functions of the sexual organs gradually disappear. The female no longer conceives ; and sexual plethora ceases to supervene and to relieve itself by a periodical discharge. The ovaria begin now to be gradually diminished in bulk, and to assume a firmer structure ; the appetite for procreation slowly disappearing (§ 43. 54.). The male organs also either become less disposed to their proper functions, or nearly altogether lose the faculty of performing them, particularly when the ener- gies of the constitution have been exhausted by previous indulgences carried to an excessive length, or by mental exertions. The teeth decay, and the digestive functions suffer from the imper- fect mastication of the food (§ 41.). 63. 3d Epoch, or ripe old, age, dates from the preceding, and extends to 70 or 75 in the female, and to 75 or 80 in the male. During this term the sensiferous and sanguiferous systems languish more and more, and all the vital organs expe- rience a rapid decline of activity. The teeth fall out, the gums are partially absorbed, and the di- gestive functions are gready impaired. The sex- ual organs are nearly or altogether deprived of their functions ; the digestive and assimilating viscera experience a marked diminution of pow- er ; and senile marasmus, or the leanness of old age, advances (§ 53.). 64. a. The diseases of this and the preceding epochs are chiefly weak or imperfect digestion and assimilation ; chronic inflammations ; general asthenia and cachexia ; apoplexies ; paralysis ; loss of the senses of sight and hearing ; senile gangrene ; comatose affections ; dyspnoea ; dis- eases of the heart and liver ; dropsies ; organic changes in the urinary and sexual organs of both sexes ; passive haemorrhages, from the stomach, bowels, and urinary organs ; mental disorder; and gradual extinction of the vital functions and energies. Febrile and inflammatory diseases have a much more marked disposition to terminate in organic change, owing to the diminution of vital re- sistance, than during the preceding epochs of life. 65. b. The therapeutical indications of this period are in some respects important, but chief- ly with reference to the necessity of supporting the powers of life during the diseases to which it is liable. When inflammatory or febrile disor- der is present, ar.d depletions or evacuations are necessary, we should, particularly if we employ them actively, watch their effects, and resort to the use of means calculated to support the frame as soon as indications of exhaustion are mani- fested. Purgatives at this period should, if fre- quently repeated, always be combined with warm, tonic, or supporting medicines, or with a restor- ative regimen ; and a strict reference ought to be made to the habits, constitutional powers, and feelings of the patient, in all the remedies we prescribe. Old habits must not be suddenly relinquished or opposed, and the powers of life should be carefully watched ; for, if unheedingly reduced, they will, particularly in large cities, often sink most rapidly, without the power of rallying. When we consider that, in persons AGE—Decrepitude. 49 advanced to this age, a considerable portion of the arterial system is often in a state of slow or- ganic disease; that the venous system is prone to congestion, is sometimes relaxed and almost varicose, always deficient in vital contractility, and scarcely able to perform its functions; and that both the one and the other cannot thereby so readily accommodate themselves to sudden or copious losses of blood as in early life and when they are perfectly free from disease, we cannot be surprised at the sudden depression occasioned by Vascular depletion, or other means which produce a rapid discharge by the emunctories of the watery parts of the blood, or a sudden depression of the nervous energy, even although symptoms seemed unequivocally to demand their employment. b6.' The last epoch, or that of Decrepitude, or second infancy, commences at 70 or 75 in the female, and at 75 or 80 in the male, and termi- nates the life of those whose span of existence is thus far prolonged. During this period, all the physical and mental powers rapidly decline. The body emaciates, the muscles waste, and the adi- pose structure is absorbed; the integuments be- coming lax, wrinkled, dry, and disposed to retain accumulations of sordes. The knees totter and bend under the weight of the body; the trunk stoops, and is incapable of any considerable mo- tion, excepting forwards; and the features are wan, devoid of colour, wrinkled, and emaciated, and apparently consisting chiefly of integumental covering (§ 33.). 67. a. Congestions, enlargements, obstructions, and even atrophy of the internal viscera; effu- sions of fluid into the shut cavities; irregularity of the heart's action from loss of its vital activity, or structural change of its valves, its arteries, or muscular texture, or from disproportion between the capacities of its compartments; lesions of the vascular system generally, in which either those of the arteries or of the veins predominate. Pas- sive haemorrhages from the mucous surfaces, particularly those of the alimentary canal and urinary apparatus; general asthenia, or cachexia ; and slow extinction of the vital and natural functions of the frame,—the ganglial, the cerebro-spinal, and the circulating systems; and the digestive, the respiratory, the secreting, and excreting organs, evincing individually, or either of them conjointly with others, more or less disease,—are the princi- pal causes of death: and thus man, whose mental and physical constitution and organization were objects of profound study and admiration to him- self, passes away ; the vital essence, that actuated the wisely devised frame with which it was so surprisingly associated, returning to the Divine source whence it emanated; and the gross mate- rials, which it combined and preserved in won- derful states of association, assuming novel modes of existence, and serving to form new beings much lower in the scale of organized creation. 68. b. The rapidity with which acute disease generally runs its course at this period, and the celerity with which organic change will frequently supervene and extinguish the dimly burning taper of life, require great decision and circumspection on the part of the physician. The resistance which the energies of life usually oppose, both to the extension of disease to other viscera from that first attacked, and to its disorganizing effects in its primary seat, is now so excessively weakened, that remedies, directed with a due regard to the previous habits of the patient, in support of those energies are particularly necessary. On the choice of cordial remedies, and on their appropriate ap- plication to the circumstances of individual cases, will depend their success, and the reputation of the physician. At this period, depletions and all evacuations, excepting such as are requisite to carry off accumulations of morbid matters from the prime vice, and which impart, along with their evacuating operation, a restorative and cor- dial influence, must be abstained from; and care should be taken that fainting, or even nervous de- pression, may not supervene from their action. Warmth, at this and the preceding terms of advanced age, is indispensably required, both in the clothing and apartments; but it should be equable, and not too high. The lungs of very aged persons should be guarded from the ingress of very cold air, as the impression of cold in this organ paralyses its functions, arrests those changes which the blood undergoes during respiration, and induces apoplectic or comatose seizures, and idiopathic syncope or inaction of the heart. For these reasons, also, atmospherical vicissitudes should be assiduously avoided, as far as the means of doing so are placed within our reach. There is scarcely any measure more influential in sup- porting the sinking vital energies of age as the communication of animal warmth, particularly from the young of our own species. This was well known to the ancients, and is one of the oldest-restorative means of treatment practised, having been adopted by David. The aged ought also to avoid the use of very cold fluids, as being apt to depress the energy of the stomach below the power of healthy re-action. Medicines, also, particularly purgatives of a cold nature, as the neutral salts, if exhibited at all, require to be combined with warm aromatics or stimulants, in or- der to counteract their depressing influence upon the alimentary canal, and on the nerves of organic life. Bibliocbaphy. G. E. Stahl, De Morborum .ffitatum Fundamentis Pathologico Therapeuticis. Halae, 1693, 4lo. —F. Hoffmann De ./Etatis Mulatione Morborum Caus& et Remedio. Hall. 1720, 4to. — Linnaus, Disser. Meta- morphosis Humana in Amaen. Acad., vol. vii. p. 143. — Wehud, De JEiate Vergente, 8vo. Lond. 1724. — Plaz, De Brevioris et Infirmioris Vita? Causis. Lips. 1782. — C.A. Philites, De Decremento Homin., .flitatis Periodo, et Ma- rasmo Senili in Specie. IIala», 1808.—J.H. F. Autenrietk, De Ortu quorund. Morbor. Provectior. jEtatis, &c. Tub. 1805. — J. Schneider, Handb. Uber die Krankh.,des Mann- baren Alters. 2 abth., 1808-12.—Pinel, in Archives Gen. Medecine, t. xi. p. 7. — Foucart, in ibid., t. v. p. 398.; t. vi. p. 87---P. J. B. Esparron, Essai sur les Ages de l'Homme. Paris, Ann. vi. 8vo. — F. E. Jolly, Apercu Physiol, et Medical sur les Premiers Ages de la Vie Hu- maine. 4to. Paris, 1816.—J. A. Gessner, De Mutationibus quas subit Infans statim post Partum. Erlang. 1795. — H. X. Boer, Versuch einer Darstellung des Kindlichen Or- ganismus in Phvsiogolisch-patholog. und Therapeut. Hin- sicht. Wien. 1813. — B. G. Seiler, Progr. de Morbia Se- num. Viteb. 1807. — A. Cwlisle, Essay on the Disorders of Old Age. Lond. 1817. — L. H. Friedlaender, Funda- menta Doctrinse Pathologies, &c. Lips. 1828. 8vo. — Rullier, art. Age, Dictionnaire de Medecine, en 18 vol., t. prim. Paris, 1821. — L. J. Begin, art. Age, Dictionnaire de Medecine et de Ohirurgie Pratiques, t. i. Paris, 1829. — B. C. Faust, Die Perioden des Lebens. Berlin, 1794. Byo. —C. W. Hufeland, und R. A. Rudolphi, Encyclopa- disches Worterbuch der Medicinischen Wissenscha/ten. Zwieter Band. Berlin, 1828. AGEUSTIA. See Taste, Defect or Loss of. AGRYPNLA. See Sleeplessness. AGUE. See Fever-—Intermittent Fe- vers. 50 AMAUROSIS —Pathology of. AIR. See Disease, its Causation, Removal, &c. ALOPECIA. See Hair, the Loss of. ALUS I A. See Illusion. AMAUROSIS, from(Vi/cn>oucobscure. Syn. Gut- ta Serena, Suffusio ^tgra, Celsus, Lucretius, Pliny. Obscuritas, Hebetuio, Paulus Mgm. Paropsis Amaurosis, Good. Cataracta .Ni- gra, Auct. Germ, quibusd. L'Amaurose, Fr. Die Schwarze Staar, Germ. Gotta Sere- na, Ital. Stekelindheit, Hoi. Suffusion, Drop Sere/ie, Milton. Dimness of Sight, Blindness. Classif. 4. Class, Local Diseases; 1. Order, Impaired Sensations (Cullen). 4. Class, Diseases of the Nervous Function ; 2. Order, Affecting the Sensations (Good). Functional Amaurosis, I. Class, IV. Order. Organic Amaurosis,\V. Class, UJ. Order (Author, see the Preface). 1. Defin. Partial or total blindness,from affection of the retina, or of the nerves, or of that part of the brain related to the organ of sight, whether arising primarily from func- tional disorder, congestion, inflammation, or any other change of these parts; or occurring from sympathy with other organs. Or, in other words, Partial or total loss of sight, from other causes than those which obstruct the passage of the rays of light to the bottom of the eye. 2. Amaurosis is met with at all ages; but most frequently in the more advanced terms of life. It is sometimes congenital; and in these cases it is often difficult to ascertain the nature and seat of the affection. When it occurs at advanced periods of life, an attentive enquiry into the history of the disease, of the previous habits and ailments of the patient, and of the various resulting and related morbid phenomena, will generally throw light upon its pathology. 3. I. Seat of Amaurosis.—1st, In the re- tine. Viewing the delicate structure of the retina ; its relation to the optic nerve, of which it is an expansion of great tenuity; its connection with the choroid and hyaloid membrane, and its nervous and vascular communications; and considering the various morbid states it is liable to undergo, in consequence of its relations with these and other parts; a partial, and even total, abolition of its functions is to be looked for on some occasions. It is, like all other parts of the frame, liable to congestion and inflammation, with their usual re- sults; and, like other nervous parts, its functions are subject to a partial or complete extinction without itself evincing any change of structure, its sensibility alone being impaired or abolished ; owing either to some unappreciable change, or to some one or more of those alterations in its adjoin- ing or related parts about to be noticed. 4. 2d, In the optic nerves. These nerves may be more or less changed in some part of their course, from the anterior pair of the corpora quadrigemina, along the thalami, the tubera cinerea, and their partial decussation, until they terminate in the formation of the retinae. In appreciating, however lesions in the course of the optic nerves, the results of experiments on them should be taken into con- sideration:— if an optic nerve be divided previous to this decussation, sight is altogether lost on the opposite side ; but if the division be made between the decussation and the eye, vision is lost on the same side. 5. 3d, In the ganglial nerves. There is every reason to suppose that the retina is in intimate com- munication with other nerves, and that it mutually influences and is influenced by them. Branches of the great sympathetic may be traced upwards, from the first cervical ganglion, to the ganglion lodged in the cavernous sinti9 ; whence branches proceed and communicate with the third, the first division of the fifth, and sixth pairs of nerves. Branches also pass from the cavernous ganglion directly to the lenticular ganglion. As the internal carotid artery passes into the cranium, it is sur- rounded by the sympathetic nerves, which accom- pany all its ramifications. The ophthalmic artery is invested with these nerves; its branches to the choroid, iris, and retina being similarly provided. Branches of nerves, moreover, proceed from the lenticular ganglion, asM. RiBEs*and others have demonstrated, to the iris, giving more minute branches in their course to the retina. This con- nection being established, morbid states of these nerves and ganglia, or changes of structure in their vicinity affecting their functions, must neces- sarily impair the sense of sight. 6. 4th, Other nerves, as the fifth and third pair, are, in some cases, also the seat of amaurosis. It has been shown by Magendie and Desmou- lins that the integrity of the fifth pair is neces- ary to the perfect function of the retina; and Mr. Mayo has furnished evidence that the third pair is requisite to the motions of the pupil. If the great sympathetic be divided in the upper part of the neck, the pupil becomes contracted and immove- able, and the eye wastes. 7. 5th, Parts of the encephalon connected with the optic nerves in their course are occasionally the seat of amaurosis, as pathological research and experiment have shown. MM. Magendie and Serres have proved that, when these parts are wounded, the sight of the opposite eye becomes either weak or extinct. 8. 6th, The pineal and pituitary glands are frequently the only parts in which any alteration can be detected in the examination of amaurotic subjects. The connection of these glands with the ganglial system is stated at another place. Be- sides these, other parts of the brain, when the seat of organic disease, are not infrequently the princi- pal source of amaurosis, as shown hereafter. 9. II. Causes.—1st, The predisposing causes of amaurosis are very diversified. Amongst these, the influence of hereditary disposition is well esta- blished. Beer traced it in several families; in one of them through three successive generations, and particularly in the females of that family who had not borne children, it having appeared in them at the cessation of the menses. Beer also states, that dark eyes are much more liable to it than the light; the proportion being upwards of twenty to one. 10. Whatever tends to favour sanguineous con- gestion of, or serous effusion in, the encephalon, particularly insolation ; forced exertions of the mind or body; excesses of passion ; the pregnant and puerperal states; occupations requiring fre- quent stooping; errors of diet, and neglected ail- ments affecting the stomach and liver ; the abuse of wine or spirituous liquors; suppressed dis- charges, particularly those from the nose and ears; interruption, or entire cessation, of the 'Mem. de la Soc.Med. d'Emulation, t. vii. p. 99. AMAUROSIS- menses ; the gouty, rheumatic, and strumous diathesis; the retrocession or suppression of eruptive diseases ; and habitual constipation ; — whatever exhausts the vital energy of the brain, and nerves supplying the organ, as chronic diar- rhcea, typhoid fevers, the excessive use of snuff, long continued grief, prolonged suckling, neg- lected fluor albus, excessive venery, and manus- trupation ; —and lastly, whatever exhausts slow- ly the sensibility of the organs of sight them- selves; as the incautious use of the eyes in a glaring light or on minute objects, and the exist- ence of strumous ophthalmia in childhood, gen- erally predispose to amaurosis. 11. 2d, The exciting causes are very numer- ous ; indeed, any of the causes enumerated as merely predisposing to the affection may excite it, when acting long or intensely, although the suc- cessive or combined action of various causes are generally required. Amongst the most common exciting causes, are over-exertion of the sight; exposure to very bright light; its occupation on minute objects, or employment in candle or lamp light, and during the hours usually devoted to sleep. The sensibility of the retina may be de- stroyed, even by a single exposure to these causes. Lightning is another cause, which seems to act by extinguishing the sensibility of this very deli- cate part. In general, however, it is the long- continued over-excitement of the organs of sight that occasions the gradual abolition of their func- tions. Injuries on the eye, and in iis vicinity, are also frequent causes of the disease. 12. Poisonous substances occasionally pro- duce an attack of amaurosis; sometimes sudden- ly, at other times slowly. Belladonna, stramo- nium, solanum dulcamara, &c, fish-poison, vari- ous fungi, and animal poisons, occasionally have the former effect ; but it is most frequently only of temporary duration ; whilst other narcotics taken habitually, as opium and tobacco, produce the latter effect, and in a more permanent man- ner. The poison of lead, blows on the head, child-labour, and puerperal convulsion, frequent attacks of epileptic or other convulsions, cerebral apoplexies and paralysis, injuries of the branches of the fifth pair of nerves (three cases of which have come before me), and even irritation of these nerves, will produce this affection ; it has also been observed to supervene to gastric and intestinal irritation, particularly when occasioned by worms ; to hypochondriasis, and accumu- lations of bile in the liver, &c. ; to frights, and to the irritation proceeding from carious teeth. The sudden suppression of epistaxis, of haemorrhoids of the lochia, of the milk in nurses, of the menses, or of the perspiration ; the repulsion of eruptions on the head and behind the ears, and the drying up of old ulcers, have, severally, occasioned the disease. But most frequently it is the result of two or more of these causes, acting under cir- cumstances of predisposition. Females with dark eyes are extremely liable to the disease, upon the cessation of the menses ; and, like deafness, it is apt to appear after severe attacks of typhoid and scarlet fevers. Amongst the more rare exciting causes of this affection, are the gouty and rheu- matic diathesis, or misplaced and retrocedent gout and rheumatism ; the constitutional effects of syphilis, and hurtful influence of mercurial cour- ses ; — all which have been assigned as causes of -Pathology of. *jj the disease by some authors, and denied by oth- ers ; but, undoubtedly, producing it on some occasions, although not so frequently as the for- mer believe. 13. 3d, The proximate or efficient causes of this affection are various. It has been disputed whe- ther or not it can arise from altered function only, and without change of structure. Mr. Travers believes that it does, but Mr. Mackenzie denies it can depend upon morbid function merely ; and other writers take opposite sides of the question. There can, however, be no doubt, if we atten- tively consider the disease in relation to the ex- citing causes and the effects which are observed to result from them, that, although most com- monly the consequence of some appreciable change in some one or more of those parts in- stanced as its seat (§ 3 — 6.), it is occasionally unattended with such change, — at least to such an extent as our observation of the effects proceed- ing from similar alterations would lead us to expect. It should not be overlooked that the operation of many of the causes which have been adduced above is entirely vital — upon the func- tions of life, as manifested in the organ, or in remote parts of the frame ; — that their effects are sometimes almost instant, and before organic change could have been produced ; and that the disappearance of their effects has been sometimes as sudden, and often before the restoration of morbid structure, providing that it existed, could have been brought about. I believe, after a care- ful perusal of the works which have been fur- nished by surgeons on this disease, that a too marked disposition has been evinced to consider it as a result of organic change in the organ and the nerves, and vessels connected with it, and without relation to constitutional and vital causes. 14. When describing the seat of amaurosis, the influence of organic changes has been briefly noticed ; and a fuller reference to them will be made in the sequel. Amongst the numerous lesions of structure that occur in the brain and its membranes, there are many that affect the nerves of sight, more particularly the optic nerves, or which implicate them organically in some part of their course in a very remarkable manner. Alterations in the bones of the cranium, as well in the membranes, obstructing the functions either of these nerves or of the other nerves subservient to the perfect exercise of this important sense, are also not uncommon. 15. The efficient causes of this affection, therefore, are, 1st, vital or functional, depending upon imperfect or abolished sensibility of the retina, or the optic and other nerves subservient to vision, owing either to causes which, from their direct and local action, depress or exhaust this property, or to those which, form their primary influence upon the frame, have an indirect de- pressing effect, which is not limited to tins organ, although manifested in it in a more marked de- gree, owing to various concurrent circumstances. This constitutes the functionalform of amaurosis admitted by Beer, Wardrop, Travers, Sanson, and others, and which Beer divides into two subordinate kinds : first, that which pro- ceeds from direct depression of the vital sensi- bility of the eye ; and, second, that which is owing to inordinate excitement, and consequent exhaustion of this property. 52 AMAUROSIS — Symptoms. 16. 2d, A congestive or inflammatory state of the vessels of the retina, or parts immediately adjoining, or the usual effects of these states. Portal, Ploucquet, Prochaska, Rous- seau, Sanson, Magendie, and other path- ologists, have observed varicose states of these vessels ; unusual injection of the minute arteries of the adjoining coats, and of the retina itself; a complete retinitis ; exudations of lymph under the choroid, near the ciliary circle ; inflammation of the external surface of the sclerotic ; vascular injection, and firm adhesion of the retina to the choroid ; partial detachment of the retina from this coat ; and thickening, morbid density, and change of colour of the retina. Ossification ; fibrous degeneration, with partial thickening ; wasting, and malignant disease of the retina, and even the developement of transparent vesicles in it, have all been noticed by Haller, Morga- gni, Heister, Sanson, and other authors. 17. 3d, Lesions affecting the optic nerves. These consist chiefly of tumours of various kinds —osseous, fibrous, encysted, steatomatous, puri- form, aneurismal, &c.— formed in their vicinity, either in the brain, the membranes, or in the bones of the cranium, and involving, or com- pressing them, in any part of their course. They are likewise, occasionally, the seat of some one, or even more, of those organic changes of their proper structure and sheaths, to which nervous parts are liable. Their vessels may be varicose ; their fibres may be infiltrated with serum ; they may be injured by external violence, and they may be wasted ; which last is very frequently obser- ved. Adventitious deposits, as osseous and earthy matter, malignant formations, cysts and hydatids, may even form in their sheaths, although more rarely than the foregoing lesions. The writings of pathologists abound with instances of these changes. When only one eye has been amau- rotic, the optic nerve of that side has been found wasted anterior to its partial decussation ; and on the opposite side, posterior to this union. But this is by no means an uniform circumstance, and, when observed, the atrophy is not distinctly con- tinuous. Indeed, the wasting has been detected on the same side, after the union of these nerves, as well as before. But if the opinion of Tre vi- ranus and Wollaston be correct, — that decussation of these nerves at their union is only partial, and that it takes place chiefly between the parts which are nearest each other,— wasting of one of them may be in one case more remark- able on the same side, and in another case more observable on the opposite side. When the am- aurosis is accompanied with wasting of the optic nerve, from causes not primarily consisting of inflammation or its consequences in the retina or adjoining coats, this nervous expansion is also generally wasted, transparent, or changed in colour. When the cause exists in the pineal or pituitary glands, the wasting is often chiefly ob- servable at the union of the optic nerves. In these cases, both eyes are affected. Facts illus- trative of this have been recorded by Vieussens, De Haen, Rullier, Rayer, Ward, and Sanson. 18. 4th, Lesions seated in the encephalon. The scope of this article will not admit of further reference to the numerous changes which occa- sionally produce amaurosis, from their affecting the optic nerves in their different connections with various parts of the encephalon. All the alter- ations which are described in the articles on mor- bid structures of the brain and its mem- branes, will produce the disease, when they impede the functions of the optic nerves, although the structure of these nerves may be uninjured. The most frequent and remarkable of these are, organic lesions of the pineal and pituitary glands (§ 8.), sanguineous and serous effusions, various kinds of tumours, abscesses, softening of the brain, &c. 19. 5th, Lesions of nerves subsidiary to the integrity of the organ and of its functions. In- juries, compression, and even irritation of the fifth pair of nerves, particularly its ophthalmic branch, of the third and sixth pairs, and of the ganglia or their ramifications, by organic change in the brain, its membranes, bones of the cranium, or parts in the course of their branches, have been shown, in numerous instances, to have been the chief effi- cient causes of amaurosis. 20. III. Symptoms. — The symptoms of am- aurosis are, 1st, those which the patient himself experiences ; and 2d, those which the physician detects in the eyes, or in the various organic and animal functions. Each of these classes of symp- toms are to be enquired into separately, commen- cing with either of them. Each eye should be carefully and separately examined ; and it will be better that the other is excluded from the light, whilst the examination is being made. 21. 1st, The patient complains of impaired vision, which may be of gradual accession, or re- markably sudden, and amounting to almost total deprivation of sight. Hence the disease has been distinguished by the epithets slow and sudden, in- complete and complete, or imperfect and perfect. 22. At the commencement, the failure of vision is sometimes only occasional, for a short time, and after longer or shorter intervals (amaurosis vaga). In some cases, it assumes the form of day-blind- ness, in others of night-blindness: and it not in- frequently recurs for a time after great exertion of the eyes, either with minute or bright objects. Transient and sudden attacks of the disease are often the consequence of disorder of the digestive organs, or rather the result of a state of the vital manifestations which occasions equally loss of sight as well as loss of the digestive functions. The failure of sight is often at fust only partial — ex- tending only to a part of the field of vision. In some cases intervening portions of the field are ob- scured (visus interruptus). In other cases, one half of it is hid from view (hemiopia). Occa- sionally objects are only seen in a particular direc- tion (visus obliquus) ; and some patients discern objects in a distorted form — crooked, mutilated, shortened, lengthened, or inverted (visus defig- uratus). Beer states that the flame of a candle will often appear elongated, and as if separated into several portions, to such patients, — a symp- tom indicating disease within the head. 23. In some instances the failure of sight as- sumes a myopic or a presbyopic form : but this is not so frequent as the occurrence of false impres- sions, in the form either of flashes of light, shining stars, globes of light, and various other lucid spec- tra (photopsia), or of muscae volitantes. False impressions of colour (chrupsia) are also frequent attendants on the early stages of amaurosis. lumi- nous spectra are commonly met with in plethoric AMAUROSIS — Symptoms. 53 persons, and when the amaurosis depends upon increased vascularity, or inflammation of the re- tina; motes, black specks, muscae volitantes, and thick mists or clouds, when the affection is de- pendent upon exhaustion of the sensibility and vital energy of the organ, and when it occurs in dyspeptic subjects from exhausting causes. Double vision is also a common symptom, particularly when the cause exists within the head. 24. As the disease advances, the field of vision appears as if obscured by a cloud, or net-work; the latter appearing gray or black in a good light, but occasionally becoming white, silvery, yellow- ish red, and luminous in the dark. In addition to these, the patient sometimes complains, particu- larly early in the disease, of some intolerance of light, or of pain in the eyes on being exposed to it. But, in other cases, from the very beginning, diminished sensibility of the retina, and a constant desire for a stronger light—a thirst of light—are present. 25. Pain in the eyes, and commonly also in the head, is one of the most important symptoms of amaurosis. It should, therefore, be carefully in- vestigated. We ought to ascertain its precise seat and extent; its character—whether it be acute, gravative, throbbing, occasional, or permanent. The circumstances which relieve or exasperate it should also be noted; as the horizontal posture, temperature, exercise, diet, the use of stimuli, &c. We should also notice whether it be accompanied with vertigo, tinnitus aurium, watchfulness, or stupor, coma, forgetfulness, inability of exertion, or failure of other mental manifestations; as, from the nature and grouping of these symptoms, we infer the nature of the efficient cause of the disease, particularly as they suggest its existence within the cranium. 26. Unusual dryness of the eyes and nostrils sometimes is observed in amaurosis; and in these cases benefit is often derived from a restoration of the secretions of the lachrymal gland, conjunctiva, and Schneiderian membrane. (Mackenzie.) 27. The general health, and previous ailments of the patient, require a particular investigation. The constitution and diathesis—whether he be strumous or gouty; whether he has had syphilis, or undergone long courses of mercury; whether he has had typhoid fevers, or inflammations of the brain, or apoplexy, paralysis, epilepsy, or injuries on the head; whether he has been sub- ject to complaints of the digestive organs, or has been, or is, affected with worms: if a female, whether she has been frequently attacked with paroxysms of Jiysteria, or any of its anomalous forms, or with convulsions in the puerperal state, and particularly whether or no there exist any sign of disorder in the uterine organs — are all particulars most requisite to be known. 28. 2d, The form, colour, vascularity, and mobi- lity of the different parts of the eye, and habit and appearance of the patient, next require investiga- tion. The amaurotic patient walks with a gait of uncertainty, and a staring and unmeaning look. In some cases this want of convergency of the eyes towards an object may amount to slight squint- ing, occasionally with oscillation, and sometimes with unusual fixity of the eyes. In some instances, the motions of the eyelids, and of the eyes them- selves, are more or less impeded, or even palsied, •—the evator palpebrse superioris, and the orbicu- 5* laris palpebrarum being often affected. These phenomena are chiefly remarked in cases where the motor oculi, or the facial nerve, is injured. 29. One or both eyes are often unusually pro-' minent. The colour of the sclerotica is frequently somewhat changed—being either yellow ,'ish, blu- ish, or ash-coloured. This coat is often covered with small varicose veins. The consistence, also, of amaurotic eyes is occasionally altered; in some cases the eyeball is firmer to the touch, in others softer, than natural. In rarer instances, it is flattened on one or more of its sides. 30. The pupil is generally sluggish and limited in its motions, or altogether deprived of motion, and dilated. More rarely it is contracted. In many ca- ses it is neither dilated nor contracted. A widely di- lated pupil, although generally attendant on pres- sure on the brain, also occasionally depends on other causes. Early or incomplete amaurosis is rarely- attended with dilated pupil; but after all vision is extinct, the pupil is generally more or less expand- ed and motionless. It should not be overlooked, that where only one eye is amaurotic, the motions of the pupil of the affected organ will often follow those of the sound one, when protected from, or exposed to light; and even, as observed by Janin, both eyes may be completely amaurotic, and yet both pupils will vary in diameter with the inten- sity of light to which they are exposed. This phenomenon can only be explained by referring to the nerves supplying the different parts of the organ. The iris, being chiefly supplied with ganglial nerves, will often retain its faculty of mo- tion, when the efficient cause of the disease affects the optic nerves at any place between their origin and their communication with the third pair; or when the affection of the optic nerves within the cranium does not leave the retina altogether deprived of sensibility, although the impression cannot be conveyed to the brain, the subsidiary nerves, particularly the third and fifth pairs, and the branches from the cavernous and lenticular ganglions, still bestowing sufficient sensibility and mobility on the iris to admit of motion on being stimulated. 31. Besides the size of the pupil, it is necessary to attend to the characters of the motions of the iris. This part may contract on one side, or in one part, drawing the pupil to one side, or giving it an irregular appearance. It may also seem as protruded towards the cornea, or it may appear sunk inwards, and have a funnel-like shape. (Mackenzie.) 32. The appearance of the humours of the eye is also important. In hydrocephalus, or when occurring in young subjects, the pupil has the natural black hue. But in elderly subjects some degree of glaucoma accompanies amaurosis. Thia appearance is in general unfavourable. 33. The presence of the marks of injuries about the face and head is important, as marking pro- bable injury of parts within the cranium, or of some nerves subservient to the perfect condition of the organ. The character of the countenance, the shape of the head, the state of the vessels of the head and eyes, and the general habit of body, require to be noticed. The inference which ought to be drawn as to the exact nature of the disease will be very different when it is met with in the plethoric, the highly fed, and the indolent, from that which will be deduced from its occurrence in 54 AMAUROSIS —Species or. the emaciated, or exhausted subjects. The pro- bable predisposing and exciting causes should also be investigated, as they have an obvious relation to their effects. Attention should be directed to the previous habits, indulgences, ailments, occu- pations, and modes of life of the patient, &c, with the view of throwing light upon the causes and pathological relations of the malady. 34. The duration of the disease is extremely various. It may, in slighter cases, be only of a few hours' or days' continuance; may altogether disappear, either spontaneously or from treatment, and never afterwards recur; or it may return after an indefinite period, from errors in diet, disorders of the digestive organs, or from the operation of the causes usually producing the disease. It very frequently continues all the life of the patient. 35. IV. Stages, Grades, and Forms.— The stages of amaurosis are incipient and confirm- ed. In the former the sight is generally not altogether lost, although more or less impaired. Treatment will often retard or check the progress of the disease, and sometimes even bring about a perfect cure. But the blindness may be complete from the first: in this case, medicines are generally without effect. In the confirmed stage, the disease is usually stationary; but the sight is not always altogether lost: the patient often retaining a perception of light and shadow, or even of objects, when illuminated or strongly contrasted. When this power of distin- guishing any object or colour is still retained, even in the slightest degree, the amaurosis is said to be incomplete. When the patient is insensible even to the presence of light, the disease is complete. It may be limited to one eye, in the incipient or incomplete states; or it may affect both equally, either in an incomplete or complete form. It may also be incipient in one eye, and confirmed in the other; and it may be more or less complete in either. It may likewise, in one or other of these states or forms, assume a recurrent or remittent type; but such cases are comparatively rare. 36. But, besides these stages and grades of the disease, other forms occasionally present them- selves, which will be more fully noticed in the sequel. It may be Idiopathic, depending upon changes, either functional or organic, taking place primarily in the nervous apparatus of the eye, and existing simply, and without any other associated lesion : or it may be complicated with lesions of adjoining parts, or with other diseases of the eye, particularly of its humours, more especially with glaucoma and cataract. It may also be consecu- tive of other diseases; most frequently of organic changes within the head, or in the vicinity of the orbit, as in apoplexy, paralysis, &c. And, lastly, it may be symptomatic of', or supervening to, pre- existent disease of distant parts, particularly of the abdominal viscera; or it may be occasioned by pregnancy, and more rarely by diseases of the puerperal state. It is not infrequently thus symp- tomatic of colic from lead, accumulations of faecal matters in the large bowels, hypochondriasis, &c. 37. According to these states of the disease, its different species will next be considered, and the treatment which is appropriate to each of them will subsequently be pointed out: for it is obvious, that the success of remedies will, in this very diffi- cult and variously complicated disease, mainly depend upon the strict appropriation of remedies to its different varieties and states. 38. Spec. 1st, Functional Amaurosis. This form of the disease generally arises,—1st, from suspension or exhaustion of nervous and sensorial power; from various local and constitutional causes (§ 13. ); from inordinate excitement or exertion of the visual organs; from mental exertion, watchful- ness, and sedentary habits; from the deleterious action of mineral, vegetable, and animal poisons, as lead, mercury, narcotics, &c. : 2d, from venereal indulgences; excessive secretions and evacuations; depression of the vital energies from diseases of debility and exliaustion : and 3d, from temporary diminution of the local circulation; from simple congestion, or occasional determination of blood in the veins or arteries; and from the irritation or disturbance of the digestive organs, or of some other of the abdominal viscera. 39. The symptoms of this species are, chiefly, more or less obscuration of vision, occurring slowly or suddenly, the visus nebulosus, and muscae vo- litantes; a somewhat contracted pupil, and clear state of the humours; equal imperfection of sight in both eyes; pale, languid countenance, and de- pression of the eyes in the orbits; a languid, small, or weak pulse; increased dimness, or sudden abo- lition of sight upon quickly assuming the erect, from the horizontal posture. An improved state of the sight after a light meal, or grateful stimulus; nervous headachs; weak digestion, sluggish state of the bowels, flatulency, foul or loaded tongue, and indisposition for, as well as incapability of, physical or mental exertion or occupation; weak- ness in the joints; occasionally nocturnal emissions, &c. in the male, and leucorrhoea in the female. 40. This species of amaurosis may be, 1st, primary and uncomplicated. In this case it usually proceeds from causes which depress or exhaust the sensibility of the retina and its re- lated nerves. 2d, It may likewise be consecutive; particularly of excessive secretions and discharges from the uterus, mammae, kidneys, testes, and prostate; or from exhausting and debilitating diseases, as adynamic diseases, haemorrhages, &c. 3d, Symptomatic of, or complicated with, hy- steria, hypochondriasis, colica pictorium, diminish- ed vital energy of the digestive organs, and all the various forms of indigestion; the presence of worms in the bowels; pregnancy; obstruction and accumulation of bile in the bile-ducts or bladder, &c: and 4th, Metastatic, or supervening upon impeded or checked secretions and discharges; in which cases it is generally accompanied with con- gestion, or determination of blood to the head, in which the eyes may partake, but not to an extent constituting inflammatory action or organic change; and it assumes a state nearly approaching to that characterizing the next species. 41. Spec. 2d, Amaurosis from active conges- tion. The existence of this species of the disease is more a matter of inference, than almost any other of those in which I have divided the disease. Yet it seems undoubtedly to exist; especially when amaurosis is consequent upon obstructed secretions and discharges, or the drying up of eruptions; upon frequent stooping, or wearing a tight neckcloth; upon fits of passion, when it occurs in plethoric persons; and after narcotic poisons. 42. The symptoms indicating it, are throbbing in the eyes, tinnitus aurium, turgescence of the vessels of the sclerotica and conjunctiva, a some- AMAUROSIS —Species of. 55 what contracted pupil, and clear state of the thick or muddy; and there are more or less humours; turgescence of the features, or lividity acceleration of pulse and constitutional dis- or bloatedness of the face; fulness of the jugular turbance. veins, prominence of the eyes, and impeded circu- j 48. This species of amaurosis is often primary lation through the lungs or cavities of the heart, j or, idiopathic; it may also be simple or compli- es. This form of the disease is seldom primary \ catel. When it occurs in a complicated form, it and uncomplicatel. It is commonly consecutive, is, most frequently, associated with iritis, with or symptomatic, generally of obstructed discharges, meningitis, with eruptive or continued fevers, &c. (§ 12.), of disease within the head, purticu- and with rheumatism, gout, or syphilis. It may larly of sanguineous congestions, or effusions, and also occur consecutively and from metastatis, diseases of the lungs and heart. It not infre- particularly after the disappearance of exanthe- quently occurs transitorily from pregnancy, epi- matous eruptions, as in the measles, small-pox, lepsy, and hysteria; and more rarely from gout erysipelas; of chronic eruptions; and after the and rheumatism 44. Spec. 3d, Amaurosis from inflammation of the retina, and internal parts of the eye. In stating amaurosis to be often a symptom merely of reti suppression of habitual or periodical discharges, secretions, and evacuations (§ 12.). 49. Spec. 4th, Amaurosis from advanced dis- organization of the retina and adjoining parts. nitis, I am supported by the opinions of many of Disorganization of these parts is usually a result the best British and Continental writers on the of inflammation. But it is difficult to determine disease. But I believe it very seldom occurs, j at what stage of the inflammation organic change that the inflammation is limited to this membrane, j commences. I am to consider it here as far but that the choroid and iris generally participate \ advanced; yet, the inflammation that occasioned with it in the morbid action; and that, when j it may be still present. The causes of this species they, on the other hand, are thus affected, the are the same as those of the foregoing; but the retina is also inflamed. Amaurosis is therefore a consequence of inflammation of the internal struc- tures of the eye : but does inflammation of these symptoms are somewhat different. The vision is more obscured. A film seen is interposed between the eye and field of vision. The pupil is sluggish, parts uniformly produce amaurosis? It is not and it is often scarcely dilated; it is frequently always consecutive of iritis; and I believe that irregular. The margin of the iris sometimes the retina may be inflamed, and yet but very! partly adheres to the capsule of the lens. The slight amaurotic symptoms may be occasioned sclerotic is often very vascular, and even livid, thereby, particularly during the early stages of , from the enlarged and loaded state of its veins, the retinitis. It is chiefly when the inflammatory which are very numerous and tortuous. The action has produced some degree of organic lesion of the affected parts, that amaurosis is manifested. 45. This form of amaurosis generally proceeds shape of the eye is sometimes changed, particu- larly in the most advanced cases; it is prominent in some parts, and depressed in others. The eyeball is occasionally, also, softer or firmer than from nearly the same causes as the foregoing ! natural (§ 10—12.). It may be produced by syphilis, mer- 50. This form of amaurosis is always consecu- cury, eruptive and continued fevers, cold in any five of the second and third species, more particu- form acting upon the eyes or face; suppressed larly of the latter; and hence, participates in discharges, or eruptions on the head or behind the many of their characters (§ 41—48.), and occurs ears; injuries of the eye and adjoining parts; concussions, and the usual causes of inflamma- tion in other parts. 46. The symptoms vary with the extent and intensity of the inflammation. In its slighter states, the progress of the disease, and of the symptoms, is insidious and slow. In these cases, little or no pain is complained of, either in the eye or in the head. The pupil is more commonly contracted than dilated, and the spectra are usually luminous, but sometimes not very sensi- bly so. With tin's slight and often chronic state of inflammatory action, the amaurosis may be increasing fast, and the observation of vision very great, and yet the symptoms may not be dis- tinctive; if we except the appearances furnished by the sclerotic, which, in retinitis, as well as in iritis, abounds in red vessels, converging in distinct lines, and forming, by their delicate reticulations, a red zone round the cornea, and which thus furnishes the only symptom, that can be de- pended upon, of slight or incipient retinitis. 47. In the more intense states of inflammation of the internal parts of the eye, the amaurosis is attended with painful vision; intolerance of light; sparks of fire, or drops of a red colour falling from the eyes; flashes of light; pain darting through the head, either from, or to the bottom of the eye- balls; the pupils are dilated, and the humours under many of the same circumstances as they. It is occasionally complicated with cataract, with opacities of the cornea, or with disorganization of parts within the head. 51. Spec. 5th, Amaurosis from external inju- ries of the eyes. A blow on the eye-ball will not infrequently occasion blindness, without produc- ing any apparent injury of its visible parts. It is difficult, or altogether impossible, to ascertain the nature of the mischief that has been inflicted. The concussion of the organ, and the lesion of the sensibility of the retina and optic nerve, may, in some of the cases, particularly when the con- sequent amaurosis is merely temporary, constitute the principal or only change. In more perma- nent and severe instances, it is very probable that the delicate connections of the retina with the adjoining parts are injured. Ecchymosis may also be occasioned, or inflammation may super- vene. In these cases the pupil is either dilated, or of an irregular form; and according to the ex- tent of injury will the phenomena partake of the characters which have been assigned to the third and fourth species of the disease. 52. Spec. 6th, Amaurosis from disease within the head affecting the functions of the optic nerve, or other nerves subservient to the sense of sight. It is obvious that disease within the cranium, either of the substance of the brain, or of its membranes, 56 AMAUROSIS — Species of. producing pressure of, or interrupted circulation in, the parts with which the optic nerve is con- nected at its origin, or during its course, or acting in a similar manner on the nerve itself, will pro- duce amaurosis. In these cases it is a consecutive affection — a symptom merely of disease, often existing for a long time previously. I have al- ready alluded to the nature of these lesions, and to their extreme diversity (§ 17, 18.). Perhaps the most common and the most interesting of them are organic changes of the pituitary and pineal glands, haemorrhage, sanguineous congestion, aneurismal and other tumours, &c. In these cases it is very common to find cerebral symptoms complained of long before the sight is affected; and to observe the gradual accession of the dis- ease either in one or both eyes; or first in one and afterwards in another, with complete loss of vision, followed at last by changes of the structure of the eye. 53. When organic lesion of the pituitary and pineal glands has occasioned the disease, judging from the cases recorded by De Haen, Wenzel, Vieussens, Leveque, Ward, Rullier, and Rayer, both eyes are generally gradually and equally affected, after the existence of cerebral symptoms, chiefly consisting of pain and weight referred to the more anterior parts of the head; of a repugnance to exertion, apathy, loss of memory, and weakness of the mental energies. In cases of sanguineous congestion, or haemorrhages in the situations referred to, the attack is sudden, and the blindness is often not the most remarkable symptom. 54. In some cases resulting from organic dis- ease within the head, cerebral symptoms, particu- larly those of an acute kind, are not complained of until the amaurosis is far advanced. In its progress, objects frequently seem to the patient disfigured or perverted. In many cases of amau- rosis from organic change of the skull, mem- branes, or brain, the affection commences with intolerance of light, strabismus, giddiness, lumin- ous spectra, convulsive motions of the eyes and eyelids, contracted pupil, and turgescence of the blood-vessels of the eyes, loss of hearing, smell or taste, or both, violent headach, rapidly followed by complete amaurosis, protrusion of the eyeball, and abolition of the external senses and of the powers of mind. 55. This species of amaurosis is often compli- cated with, or preceded by, epilepsy, paralysis, apoplexy, ottorrhaea, or disease of the ears, hyste- ria, and various nervous affections. It is chiefly by attending to these antecedent disorders, or other slighter cerebral symptoms, that we can form any idea of the nature of the amaurosis. The appear- ance of the eye, and particularly of the pupil, is not to be depended upon; for, although the pupil is usually dilated and immoveable, the exceptions are too numerous to admit of considering it as an uniform occurrence. 56. Spec. 7th, Amaurosis from disease of the optic nerves, or of their slveaths. This species of amaurosis always advances slowly, generally commencing in one eye, with a black cloud, which grows more and more dense, great disfigurement and perversion of objects, without pain of the head or eye. There is, however, a sensation of pres- sure at the bottom of the eye, as if forcing the eyeball from its socket. The pupil is generally, from the commencement, much dilated, and an- gular from irregular action of the iris. By de- grees, according to Beer, glaucomatous change of the vitreous humour supervenes, and after- wards of the lens itself, but without any varicose affection of the vessels of the eye. At last the eyeball becomes somewhat smaller than natural, but complete atrophy does not ensue. 57. Spec. 8th, Amaurosis from lesions of branches of the fifth nerve, &c. The experiments of Bell and Magendie first threw light upon this cause or form of amaurosis. I believe that it is by no means infrequent. Four cases of it have come before me in private practice; in three of which the principal trunk or branches of the ophthalmic nerve were implicated. In one of these the amaurosis was very slight; in the other two it was very considerable, although not com- plete, and was a consecutive phenomenon of very extensive disease. I saw two of them, in consultation with respectable practitioners in my vicinity. The fourth case very recently occurred in a member of my own family. In it the frontal branch on the right side was pressed upon by a common boil; the sight of the eye was nearly altogether lost, but was soon restored when the boil broke. 58. Numerous cases are on record, in which partial amaurosis is said to have occurred after injuries and wounds of the eyebrows, cheeks, and forehead; or from the irritation and extraction of diseased teeth. The appearance of the disease from these causes was noticed by Morgagni, Pinel, Beer, Wardrop, Travers, Pena- da, Ribes, &c, before the functions of this nerve were so well known as they are now. Its occur- rence from wounds of the eyebrows is mentioned even in the writings of Hippocrates. 59. Amaurosis from these causes is, in some rare instances, complicated with facial neuralgia, toothach, rheumatism of the face, and tumours or abscesses developed in the vicinity of the eye, and within the cranium in the course of the fifth nerve. I met with it in a case of ottorrhaea, ter- minating in caries of the bones, and extensive disease of the internal parts in the vicinity. It is also, in some cases, accompanied with paralysis of the upper lid, and in others with paralysis of different muscles of the eye. In these cases, the third or sixth nerves have, most probably, been chiefly affected. When the ophthalmic nerve is affected within the cranium, it is difficult, if not impossible, to determine the particular seat of lesion from the amaurotic symptoms. Facts have not been observed in sufficient number, and with requisite precision, to admit of any state- ment being made respecting the pupil and motions of the iris in this species of the disease. I believe, however, that serious organic, as well as func- tional, lesions of the organ may supervene to it 60. There are other varieties of amaurosis par- ticularized by Beer, Weller, Sanson, and other German and French writers, some of them of rare or doubtful existence, or at least referrible to the species into which I have here divided the disease. From amongst these I may enume- rate the following: — Gouty amaurosis; rheu- matic amaurosis; amaurosis from the sudden re- pulsion, or cure of cutaneous eruptions, or old ulcers; amaurosis from suppressed secretions and | evacuations; puerperal amaurosis, &c. It is AMAUROSIS — Diagnosis — Prognosis. 57 evident that these are only occasional, and by no means frequent, causes of the disease, which ought to be kept in recollection by the practi- tioner, but which can act only by inducing some one or other of the forms into which it has been divided ; more particularly the second, third, fourth, and sixth. In as far as they may require a modified plan of treatment, they will receive attention in the sequel. 61. In addition to these, I may notice the caVs- eye amaurosis of Beer, which is only met with in the old, debilitated, thin, and emaciated ; parti- cularly those who are gray, or white-headed. At the commencement of this amaurosis, the aris retains its mobility ; but it afterwards is slow and the pupil dilated. Deep in the bottom of the eye, a concave pale gray, oryellowish green, or reddish, variegated opacity is observed. The further the disease advances, the paler the bottom of the eye becomes, the paleness extending to the iris, until at last a slender vascular plexus — the ordinary ramification of the central artery and vein — may be discerned. With this state of the eye, decline or total abolition of vision is the consequence. This rare form of amaurosis seems to consist of a deficiency of the piginentum nigrum, and of the tapetum of the uvea. It appears closely allied to far advanced glaucoma. This form of the disease is seldom or ever benefited by medical treatment. 62. V. Diagnosis.—Amaurosis is liable to be mistaken for incipient cataract, and for glau- coma. When cataract is fully developed, the two diseases can scarcely be confounded. That a clear diagnosis should be made between incipi- ent cataract and amaurosis is of the greatest im- portance in practice. (A) As to the impaired vision in both diseases at their commencement, it may be remarked that in cataract, the difficulty of sight increases very slowly, and is compared to a diffused mist, thin cloud, or gauze intervening between the eye and the object: whereas in amaurosis, the dimness or loss of sight is either sudden or partial, resembling a fly, spots, or motes covering parts of an object. However, a mist, or thin cloud, often is complained of in incipient amaurosis, and, increasing in density, at last de- prives the patient of sight ; but a complete depri- vation of sight never occurs in cataract. As inci- pient cataract depends upon commencing opacity, generally at the centre of the lens, the appearance of a mist, &c, is generally most perceived when the patient looks straight forward ; vision being more distinct when he looks sideways. This com- monly does not obtain in amaurosis, although it sometimes does. 63. (B) The degree of light which the pa- tient desires is also important. When amaurosis depends upon insensibility of the retina, there is a great desire of strong light, and he sees the best at noonday, or when objects are brilliantly illu- minated. The opposite of this obtains in cataract; for a strong light, causing the pupil to contract, the rays of light reflected from the object must pass chiefly through the central and more opaque part of the lens. In addition to this we should attend to the antecedent and attendant symptoms of amaurosis ; especially vertigo, headach, dis- order of the digestive organs, without wliich cata- ract usually commences. 64. (C) Upon examining the pupil, incipient amaurosis presents either the jet-black colour of | health, — excepting in the cat's-eye amaurosis of Beer, which is of rare occurrence, and presented to us under circumstances not to be mistaken,__or a paleness or greenness, visible only when the eye is examined in particular directions, constituting amaurosis with gl.mcoma. This appearance evi- dently arises from deficiency of the pigmentum nigrum, and incipient dissolution of the hyaloid membrane ; and when it amounts to a high de- gree, constitutes the cat's-eye amaurosis of Beer. 65. Mr. Mackenzie remarks on this subject, that attention to the following circumstances will generally enable the observer to distinguish glau- comatous amaurosis and cataract : — 1st, The opacity in glaucoma is always greenish, whereas in incipient cataract it is always grayish. 2d, The opacity in glaucoma appears seated at a consider- able distance behind the pupil, or deep in the vitreous humour ; whereas in lenticular cataract, the opacity is close behind the pupil. In posterior capsular cataract, the opacity is deep in the eye, but is always streaked ; whereas the glaucomatous reflection is always uniform, never spotted, nor radiated. 3d, Upon close examination of the surface of lenticular opacity by means of a double convex lens, it is seen slightly rough, somewhat dull, never smooth or polished — forming, in these respects, a striking contrast to the appearances presented by glaucomatous opacity. 4th, The eyeball, in glaucomatous amaurosis, always feels firmer than natural ; while in cataract it presents the usual degree of firmness. 5th, Glaucoma proceeds very slowly in its course, scarcely in- creasing for years ; whereas the vision, in cataract, much more rapidly declines, and keeps pace with the growing opacity. 66. (D) The mobility of the iris is a principal source of diagnosis. For, in incipient cataract, the contractions of the pupil are as extensive and as vivid as in health ; but, in incipient amaurosis, the pupil is either dilated and fixed, or its motions limited and slow. Also, in the latter disease, the movements of the eyeballs and eyelids are often imperfect, or difficult; whereas no impediment of this description exists in cataract. In many cases of amaurosis, we observe a want of direction in the eyes, or a slight degree of strabismus, not infre- quently with a want of power over the motions of the upper lid, —symptoms that never occur in cataract. 67. VI. Prognosis. —This is unfavourable. When the cause of the disease is evident, and it is merely functional, or simply congestive or in- flammatory, and the p itient young, or in the prime of life, but under middle age, a complete cure is not infrequent. This may be obtained although much more rarely, even when the loss of sight is total. But in every case the predisposing and exciting causes, and the effects of remedies, must be taken into account in forming our prognosis. Much more commonly only partial amendment is produced. Amaurosis is generally less unfavour- able when suddenly, than when slowly induced. When the pupil is only slightly dilated, still moveable,'of its natural form, the eyeball neither firmer nor softer than in health, and no glaucoma present, the prognosis is obviously more favourable than when the pupil is fixed in the states either of expansion or contraction, or when the eyeball is either boggy or preternaturally hard, or when the bottom of the eye presents a greenish opacity. 58 AMAUROSIS — Treatment. 68. If the attack has been sudden, and nearly complete, or if objects are seen in a perverted or distorted form or double ; if the amaurosis be at- tended with want of power in the muscles of the eyeball or eyelids, we should suspect that the cause consists of general or partial pressure, or other organic disease, within the cranium, which, although indicating both danger and the permanent loss of sight, will sometimes be removed by ener- getic treatment. If one amaurotic and paralytic symptom slowly supervene on another, we should dread the gradual developement of tumours, cysts, exostosis, &c. within the head, the situation and nature of which can be suspected only, and chiefly from the nature of the attendant or pre- ceding symptoms. But in all these the prognosis is necessarily very unfavourable. 69. VII. Treatment. — In order to employ remedies in this affection with any degree of benefit, it will be necessary to direct them with a very particular reference to the pathological con- ditions of the eyes, the brain, and system general- ly, as now pointed out. Having separated the disease into the foregoing species or varieties, in order that the treatment may be pointed out with greater precision, I proceed to detail the measures which I consider appropriate to each, conformably to the most experienced authors, and to my own observation. 70. A. Of the first species. The treatment of this, the most strictly functional form of the disease, should have strict reference to the causes which induced it, — whether those acting directly on the organ, or those which act indirectly, and in consequence of inducing disorder of other parts. When amaurosis proceeds from direct causes, either of a depressing or an exhausting nature, the appearance of the eye, as well as the charac- ter of the symptoms, require an attentive examin- ation, chiefly with a view to ascertain the existence of inflammatory action, or even active congestion of the internal parts. A complete removal of the causes must be insisted on ; and, if no symp- toms indicative of inflammation (§ 46.) exist, but, on the contrary, debility, a languid circulation, musce volita/ites, or dark spectra, &c. (§ 39.), tonics and stimulants, both internally and exter- nally, are required. A light, nutritious, and invigorating diet, with change of air, repose of the organs, moderate exercise, vegetable, and af- terwards mineral tonics, and the usual means of improving the digestive organs, and promoting the functions of the bowels and secreting viscera, are in these cases chiefly to be depended on. Small dosas of strychnine, or of the extract of mix vomica, may also be given (Form. 541.565.). When, however, we find evidence of congestion or increased vascular action of the interna! parts of the eye to have been induced, the means to be employed in the next species must be resorted to. 71. When this species of amaurosis proceeds from interruption or disorder of the digestive func- tions, as 'indicated by the symptoms'of such dis- order, by a foul tongue, acidity and flatulence of stomach, and torpid bowels (§ 39.), emetics, as re- commended by Richter.Otto.Schmucker, Flemming, Scarpa, and Mackenzie, may be exhibited ; but, unless the symptoms of inter- rupted digestion, or of indigestible and injurious substances remaining upon the stomach, or of biliary obstruction, be unequivocally present, little advantage will be derived from them : in p'ethoric persons, or where these causes of disorder do not exist, they may be even injurious. Amaurosis from disorder of the digestive organ is generally imperfect, and sometimes slight ; and its progress slow. In this form, Scarpa recommends full vomiting to be produced by the patient taking a spoonful, every half hour, of a solution of three grains of tartar emetic in four ounces of water ; and, on the following day, opening powders to be commenced with, consisting of an ounce of supertartrate of potash and one grain of tartarized antimony, divided into six equal parts. T he pa- tient is to take one of these parts in the morning, another four hours afterwards, and a third in the evening, for eight or ten successive days. The effects of these are, nausea, and increased evac- uations from the bowels ; and, in the course of a few days, vomiting. If, during their use, the pa- tient should complain of a bitter taste in the mouth, vain efforts at vomiting, and no improvement of sight, the emetic, as at first directed, is to be again taken ; and this is to be repeated a third or fourth time, if the bitter taste, acid eructations, nausea, &c. continue. 1 he repetition will often at last succeed in procuring the discharge of a yel- lowish or greenish matter from the stomach, to the relief of the head and eyes. 72. The stomach, and through it the liver, having been thus acted upon, the following re- solvent pills of Schmucker are to be taken, to the extent of fifteen grains, night and morning. No. 11, R Gum. Sagapen., Gum. Galbani, Sapon. Venel. aa § j- j Khei 3 js*. ; Antimonii Tartarizati gr. xv.; Succ. Liquor. 3 j. 1 ivi le in Pilul. gr. ')■ These pills are to be continued for four or six weeks. Instead of these, the pills recommended by Richter may be prescribed. No. 12. R Gum, Ammoniaci, Gum. Assafcetid., Sap. Venet, Rad. Valerian., Summit. ArniciE, aa 3 ij- ; Anti- monii Tartar, g . xv.j. ; Syrup, q. s. M. et divide in Pil la gr. iij. From twenty to thirty grains are to be taken three times a day for some weeks. 73. If these succeed in improving the state of the stomach and sight, Scarpa directs means cal- culated to strengthen the digestive organs, and nervous system : such as the daily exhibition of bark and valerian, more particularly in periodic amaurosis ; a light, digestible animal diet, with a moderate quantity of wine, and wholesome air and exercise. He further prescribes, as advised by Thilenius and Moriggia, the vapour of liquor ammonie directed to the eye, with the view of exciting the nerves of the organ ; and em- ployed, tliree or four times a day, so as to occa- sion each time a copious secretion of tears. In con- junction with the use of this vapour, other external stimulants, as blisters to the nape of the neck, behind the ears, or to the temples ; irritation of the nerves of the nostrils by sternutative powders; and, lastly, sparks of electricity may be resorted to. Various volatile substances, spirituous, saline, and oleaginous, have been recommended to be appli- ed to the eyes, either in a state of vapour, or of solution and dropped into them, by Warner, Sagar, Manardus,Dunckler, Chomel, St. Yves, and Schmucker ; but these require to be cautiously resorted to. Substances of a like description have also been prescribed in the form ofcollyria, in this species of amaurosis. Plenck recommends for this purpose a drachm of the AMAUROSIS —Treatment. 59 crocus metallorum dissolved in rose water; or a portion of the following:— No. 13. R. Spirit. Lillior. Conval., Spir. Lavand.,Spir. Rorismar., Muriatis Ammon., aa 3j-j Spir. Bals.Vitae Hoff- man. 3 s9- M. to be poured in the palm of the hand, and held before the eyes. The application of cold and slightly stimulating washes and baths to the eye, and bathing the whole head, or eyes, in cold wa- ter, have been approved by Richter and Beer. Mr. Travers, however, states, that he has nev- er obtained any decided advantage, in amaurosis, from applications made directly to the eyes. Both electricity and galvanism have received the recom- mendation of Ware, Lentin (Beytrdge, iv. b. p. 102.), andOssiANDER (Abhandl. Med. Soc. zu Erlang., i. b. No. 8.). Moxas applied in the course of the facial nerves have been used by Larrey ; and the actual cautery behind the ears by Khlodovitch. (Archives Ginir. de Med., t. xvi. p. 452.) 74. In this species of amaurosis, both in cases of the above description as well in those which proceed from the over exertion of the sight, the external application of strychnine promises to be of considerable advantage. Mr. Liston, Dr. Short (Lond. Med. Gaz., vol. v. p. 541.), and Dr. Heathcote (Medico-Chirurgical Rev., July 1830.), have thus employed it with decided benefit. After blistering the temples, and remo- ving the cuticle, from one eighth to one fourth of a grain of pure strychnine was applied to the de- nuded surface on each side daily, and the appli- cation renewed each day, and gradually increased to a grain. In one case the quantity was in- creased to three grains, but it is seldom requisite, and it may sometimes not be safe, to exceed half this quantity. In some cases it will be necessary to re-blister, oftener than once, the surface, after repeated applications of the strychnine. Cata- plasms of capsicum have also been employed with advantage to the temples. Gahn mentions them with approbation; and I have seen them used in amaurosis with decided benefit by the native doc- tors in warm climates. Hoffmann and Trew employed the cajeput oil in this manner, and Warner the animal oil of Dippel. 75. Mr. Travers and Mr. Lawrence are not advocates for the use of emetics. The former prefers to remove the gastric disorder by a course of blue pill, with gentle saline aperients and vege- table tonics. He recommends the combination of blue pill with colocynth, rhubarb, and aloes ; and of soda with columba, gentian, or rhubarb ; with the view of promoting or regulating the ab- dominal functions. After these he advises the use of general tonics, as the mineral acids, bark, steel, and arsenic. Mr. Lawrence chiefly ap- proves of attention to the general health, by resi- dence in a pure air; out-of-door exercise; mild, plain, but nutritious food ; gentle aperients, and occasionally an active purgative; repose of the affected organ; counter-irritation by a succes- sion of blisters, an open blister, or setons. Beer is also against the use of emetics. He prefers the employment of brisk cathartics; followed by the use of anthelmintics, when we suspect the pre- sence of worms in the bowels. Rubefacients, stimulants, and blisters to the temples and eye- brows, are favourably mentioned by him. 76. There can be no doubt of the propriety of the measures recommended by the above writers: but are we to remain content with them alone, in cases where amendment from them is either slow or not apparent ? I think not; and therefore are we required to devise additional means. Those already recommended by the eminent Continen- tal authorities, as stated above (§ 71, 72.), and the external medication already described (§73 74.), have both authority and reason in their fa- vour, if duly followed. But it may be useful to suggest others. For, in cases of this disease, the practitioner will have reason oftener to regret the want, than to be perplexed by a diversity, of ra- tional resources. 77. After having had recourse to evacuations, to emetics with great caution, and under the cir- cumstances stated above (§ 71.), always to ape- rients, alteratives, and occasionally to brisk pur- gatives, promoted by enemata, suited to the pecu- liarities of the case, and repeated as long as the secretions are impeded, and the evacuations of- fensive, or of an unhealthy colour, other internal means must besought for, if necessary. Amongst these, in this species of the disease, camphor, combined with arnica, and inconsiderable doses, has been recommended by Flemming (Hufe- land's Journ., $c, Jan. 1810, and May 1812.); the rhus toxicodendron, or the rhus radicans, in the form of tincture, by Basse and Hufeland (Journ. der Pract. Heilk. $c, Jan. 1811.); and phosphorus, by Loebel (Horn's Archiv., Nov. 1812, p. 397.) Musk, castor, assafoetida, valerian, and zinc, have also been favourably noticed by Beer. 78. It is chiefly in this form of the disease that advantage, if any, will be derived from the use of aconitum, which, however, has received the ap- probation of Boehmer, Collin, Stoeller, Reinhold, Gesner, and other respectable au- thorities, particularly when the affection is connec- ted with chronic rheumatism, or atonic gout, or oc- curs in the gouty and rheumatic diathesis. Guaia- cum has been recommended by Wintring ham; and, under the circumstances of disease now allud- ed to, particularly when combined with camphor and ammonia, and given after due alvine evacua- tions have been procured, is calculated to prove beneficial. The arnica montana, which has been prescribed by Baldinger, Collin, Franck, Thilenius, and Angeli, is applicable to this form of amaurosis only. It is most probably from having employed it in very diflerent states of the disease,—in the inflammatory, or those depending upon organic change within the head,—that it has been disapproved of by Richter and Sch- mucker. 79. The chief complications of functional amau- rosis require no very different treatment to that which has been described. The not infrequent association of the disease with worms demands the use of anthelmintics, followed by purgatives, and the administration of vermifuge enemata, &c. (see Art. Worms.), and afterwards by vegetable or mineral tonics. But, in the majority of cases of even functional amaurosis, the use of the pre- parations of iron requires caution. When the disease is occasioned by lead, or accompanied with the lead colic, or attended by paralysis of any other parts of the body, the exhibition of calomel, with camphor and small doses of opium, followed by purgatives, and antispasmodic and aperient 60 AMAUROSIS —Treatment. enemata, is extremely serviceable. After the se- cretions and functions of the abdominal viscera are restored by these means, strychnine, or the extract of mix vomica, may be prescribed both internally and topically. (Form. 542. 565.) The connexion of the disease with hysteria, hypo- chondriasis, obstructions of any of the abdominal secretions, chiefly requires the combination of antispasmodics with aperients; chlorine, iodine, or sulphureous baths; the occasional exhibition of a brisk purgative; and, afterwards, the warm salt water bath, tonics with stimulants, and strict attention to the secretions and functions of the digestive organs, and to diet, air, and exercise. After all obstruction is removed, cold bathing, or chalybeate or salt water baths, followed by fric- tions of the cutaneous surface, may be used. 80. B. Of the second species. When amau- rosis is attended with those symptoms which I have described as marking active congestion of the internal parts of the eye, or of the head or thoracic viscera (§ 41.), a very different treat- ment to that enjoined above is requisite. In the first species of amaurosis, blood-letting is gener- ally prejudicial—it has even caused the disease: but in the congestive species, blood-letting, either general or local, or both, according to the cir- cumstances of the case, is indispensable. In every form of the disease the means of cure must be regu- lated by the apparent vascularity of the eye, the plethoric state of the countenance and body, and by the state of the arterial pulse, examined not only at the wrists, but also in the carotids and temples. After depletion, to an extent which the well in- formed practitioner will be led to adopt according to the particular characters of the case, the pro- motion of the alvine discharges, and of the cutan- eous and alvine secretions, will next require his at- tention, as salutary modes of derivation and eva- cuation; and afterwards the application of blisters, setons, issues, and other counter-irritants, behind the ears, or to the nape of the neck, will generally be necessary to complete, or to render permanent, the cure. The tartarized antimonial ointment, moxas, the mezereon issue, the actual cautery to the nape of the neck, or to the occiput, and err- hines, have severally been recommended by emin- ent Continental writers in this state of the disease. 81. The shower bath, sponging the head with cold water night and morning, the cold douche, or the effusion of a stream of cold water on the head, are means which ought not to be neglected in those cases in which the congestion is of an active character, or approaches to the inflammatory state. When this form of the disease is consec- utive of interrupted or suppressed discharges or evacuations, the restoration of these must be at- tempted. If the menses be suppressed, leeches to the pudenda, or the insides of the tops of the thighs; or bleeding from the feet; the prepar- ations of iodine, aloetic purgatives, and other em- menagogues; stimulating pediluvia, and the hip bath, with the other means usually resorted to in cases of amenorrhoea, are to be employed. If it proceed from suppressed haemorrhoids, leeches may be applied to the vicinity of the anus, and purgatives, with calomel, colocynth, and aloes, prescribed. If it supervene on the disappearance of gout or rheumatism, sinapisms and irritating cataplasms may be directed to the extremities, and free alvine evacuations procured; after which colchicum, combined with alkalies or magnesia, and, in some cases, with ammonia or camphor, may be exhibited, or aconitum combined with antimonials, and purified sulphur; and rubefa- cients applied behind the ears, or to the temples. When it appears after the suppression of eruptions, and healing of old ulcers, the use of the tartar emet- ic ointment, setons, and perpetual blisters behind the ears, are particularly indicated. If it follows a suppressed cold, Weller recommends weak sternutatories, with calomel or hellebore. 82. Mr. Travers has very justly remarked, that a loss of balance of the circulation, produc- ing undue determination of blood to the head, of- ten exists independently of general plethora, and is aggravated by sanguineous depletion. It is some- times even met with in corpulent persons; and is not infrequent after over-excitement and chronic inflammation. Instead of requiring loss of blood for its removal, this state of the disease demands an equalization of the circulation, by promoting the various secretions, and the derivation of the excessive supply to other parts by the means now stated, assisted by an abstemious and regular diet, gentle exercise in the open air, the promotion of the functions of the liver and bowels, and the means usually employed to benefit the general health. Even in some of these cases, the local means noticed above, as the vapours of ammonia, &c. (§ 73.), may be serviceable in restoring the tone of the vessels of the eyes. 83. C. Of the third species. Inflammation of the internal parts of the eye, particularly of the retina, requires decision, in the more intense cases, and a vigorous but judicious application of the usual antiphlogistic remedies. In the slighter cases, the exact nature of the disease may be mistaken for either of the foregoing species. Slight or slow inflammatory action may exist without any material affection of the pulse, or pain of the organ; but the appearance of the blood-vessels of the sclerotic, and the state of the iris, will often indicate its presence when other signs are wanting. When the attack is acute, both general and local depletions are required. In these cases Plenck has advised the perform- ance of arteriotomy; Spigelius and Hoff- mann, of blood-letting from the frontal vein; and Sauvages, from the jugulars. But vascular depletion is not to be relied upon alone. Active evacuations from the bowels, determination to the skin by small and repeated doses of antimo- nials, and the use of the tartar emetic blister or plaster, behind the ears, or to the nape of the neck, are to be also adopted. 84. If these means fail of producing a very decided improvement in a very short time, we must endeavour to affect the mouth slightly with mercury, without producing salivation. In order that this may be done with rapidity, and with aa little mercury as possible, the preparations of this mineral to be employed will be advantageously combined with James's powder, or antimonial powder, and small doses of camphor. The treat- ment is, in such cases, similar to that usually resorted to in iritis. Much of the advantages to be procured from the use of mercury in this form of amaurosis, as well as in iritis, depends upon the promptitude with which it is employed. In this, Travers, Lawrence, Mackenzie, and oth- ers agree. Indeed, the use of calomel, and other AMAUROSIS—Treatment. 61 preparations of mercury, either alone, or com- bined with other substances, has been adopted in the inflammatory states of amaurosis, from the time ofHeister and Boerhaave. Bang, Hude- mann, Schmucker, Zuicken, and Breit- ing, agree in recommending them. Boettcher advises the combination of calomel with belladon- na; and Hey, calomel with camphor: both being judicious modes of combining this medicine. MEAD,STAHL,HoFFMANN,andIsENFLAMM, advise the production of salivation; but I agree with Travers in considering the affection of the mouth as sufficient. The use of mercury is much praised by Beer in such cases, as well as in those of a syphilitic origin, or which are complicated with engorgement of any of the abdominal vis- cera. Care should be had not to employ it in debilitated or scorbutic persons, and when the eye is soft or boggy. Many of the Continental wri- ters, and Mr. Ware, prefer the sublimate to other preparations. It is best exhibited, as recommend- ed by Van Swieten, dissolved in brandy, and taken in a basin of sago or gruel. It may be continued for six weeks, or even longer. 85- The success which has resulted from the exhibition of the oleum terebinthine in iritis in- duced me to prescribe it, after depletions, in two cases of this form of amaurosis; and with satisfactory results in both. In persons far advanced in life, in scrofulous subjects, and in debilitated persons, this oil is certainly a less hazardous medicine than the mercury exhibited so as to affect the system. 86. In the slighter or more chronic inflamma- tory forms of amaurosis, particularly when met with in the description of subjects just now al- luded to, much circumspection is necessary in the use of depletions : general bloodletting is here inadmissible, particularly when this class of pa- tients are iff fed, and live in close and ill venti- lated streets and apartments in large towns, and local depletions only are indicated. In cases of this description, and under these circumstances, the oleum terebinthinae will prove a valuable me- dicine; and even, although we may deplete thus locally, the internal exhibition of tonics, with a nutritious diet, attention to the alvine secretions and evacuations, and a wholesome air, will prove the most beneficial remedies. 87. This form of amaurosis, as well as the preceding, will occasionally supervene from sup- pressed evacuations and eruptions, and more rarely from misplaced gout and rheumatism. (§ 48.) In such cases, the treatment already recommended, as appropriate to each of these (§ 81.), will be equally applicable here. 87. Besides the above means, it has been re- commended by Bromfield, to insert an issue in the scalp; by Hoffmann, to apply leeches to the insides of the nostrils; by numerous authors, to employ errhines and sternutatives, with the view of provoking a copious secretion from the Schnei- derian membrane; and by as many others, to use the actual or potential cautery, setons, moxas, &c. to the nape of the neck, or to the occiput. Leeches and counter-irritants are safe, and some- times useful, remedies in this and the preceding species; but errhines and sternutatives may be hurtful, unless the affection has arisen from sup- pressed discharges from the nostrils. They are most serviceable in the functional state of the dis- ease. The safest that can be employed in this spe- j cies of amaurosis is the one recommended by the late Mr. Ware. It consists of ten grains of the hydrargyrus sulphuratus, well mixed with a drachm of common sugar: a small pinch of it generally pro- duces a copious discharge of mucous from the nose. 89. D. Of the fourth, and remaining species. When we have reason to suspect that the amau- rosis depends upon advanced organic lesion of the internal parts of the organ consequent upon inflammation, we should still bear in mind that, with the supervention of such lesion, whatever it may be, the inflammatory action seldom alto- gether subsides, but continues, more or less, in a chronic, atonic, or disorganizing form. There- fore the propriety of still having recourse to local depletions, particularly if these have been neg- lected early in the disease, to purgatives, deriva- tives, or revulsants; the cold douche to the head; and, afterwards, to the use of stimulating vapours, when we have reason to suspect that the change continues rather in consequence of lost tone of the vessels, and inaction of the absorbents, than from increased action. Under such circumstan- ces, the vapour of camphor and acetic acid, or of the liquor ammoniac, may be tried. 90. a. If the amaurosis have arisen from exter- nal injury of the ball of the eye, or concussion of the organ (§51.), the chief indication is to pre- vent, or to repress, increased vascular action, by the means already recommended; to attend to diet and regimen, and to keep the organ in a quiet inactive state for sometime; after which, if the affection still continue, the treatment must be directed according to the particular lesion, func- tional or organic, that may have been primarily or consecutively produced. 91. b. When the history of the case leads us to suspect the dependence of this affection upon disease within the head (§ 52.), or tumours press- ing upon the optic nerve, &c. (§ 56.), the treatment must necessarily be directed, accord- ing as the symptoms referrible chiefly to the head may lead us to infer the nature of the pri- mary lesion. If such symptoms, particularly the temperature of the head, and the action of the carotids, indicate the existence of congestion, interrupted circulation, or increased action, the treatment must be accordingly. But under almost every circumstance, counter-irritation, and exter- nal as well as internal revulsants, will prove safe, and sometimes serviceable, means of cure. 92. If we have reason to suspect the formation of tumours; thickening, or other change, of the membranes or of the bones, particularly as a consequence of syphilis; and extravasations of blood, or of serum, within the cranium, or in the course of the optic nerves, &c. (§ 52.), the internal use of the preparations of iodine, and particularly of the hydriodate of mercury or of potash (see Form. 323,324.), should not be over- looked. I have employed these preparations with much benefit in three cases of amaurosis connected with paralysis; two of them consequent upon apoplectic seizures. In the interval between the courses of iodine, deobstruents, and alterative doses of blue pill, with the extracts of sarsaparilla and taraxacum, or with the decoction or other preparations of sarsaparilla, should be prescribed. 93. c. When the affection seems connected with lesion of the other nerves subservient to vision (§57.), the treatment must necessarily depend 62 ANGINA PECTORIS —Symptoms. upon the seat and nature of this lesion, and, in some rarer cases, upon the state of the associated de- rangement. Ifit be connected with neuralgia of the nerves of the face, disorder or irritation of these nerves may exist at their origin, or in their course through the membranes and bones of the cranium. The cause may also be external—in a diseased tooth or stump, or a partially separated external branch of the opthalmic trunk of the fifth nerve. In all such cases, as well as in the other forms, states, and associations, of the fifth, sixth, seventh, and eighth species, which have been enumerated, the treatment must vary in each, and be directed according to the very nu- merous pathological conditions, which the well- informed pathologist will detect, either as their efticient causes, or as their related effects. 94. Tlnoughout the treatment of this disease, the practitioner should keep the following facts in recollection :—1st, An appropriate, and hence successful, method'of cure should have an inti- mate relation to both the remote and proximate causes of the disease, and the natural or morbid diathesis of the patient: 2d, It must be directed after a minute inspection of the eyes, and exam- ination into symptoms connected with the head and the digestive viscera: 3d, It must be modified according to the nature of its related, associated, and symptomatic disorders: and, 4th, That much of the success will often depend upon the strict regulation of the patient's digestive and organic functions; upon diet and regimen; and upon a regulated exercise both of the organ of sight and of the body, with a pure and temperate air. Keeping these indications in recollection, the practitioner will modify and adapt the treatment to the • presumed nature, seat, complication, and relations of the disease. Bibliography—Cradok, Generalia circa Suffusionem, Guttam Serenam, et Inflam., &.c. Leid. 1693.—Heister, Apologia et Uber. Ulustratio Systematis sui de Catar., Glaucom., et Amaurosi. Alt. 1717, 12mo.—(Ehme, De Amaurosi. Leip. 1748, 4lo.—Warner, Descript. of the Human Eye and its Diseases. Lond. 1754.—Sproegel. in Miscel. Berol. t. vi. p. 64.—Sauvages, Nosol. Meth. t.i.p. 746.—Trinka, Historia Amauroseos, Vindob.1781.—Plouc- quet, De Amaurosi. Tubing. 1139.-Schmucker, Chirurgische Wahrnehmungen. Ber. 1774.—et Vermische Chirurg. Schrif. 1786.— Richter, Anfansgriinde der Wunderzneik. Goet. 1790.—Scarpa, Osservasioni sulle Malattie desli Occhi. Venet. 1802 ; 2d ed. 1816.—Flajani, Collezione d'Osservazioni. Rom. 1803.—Wenzel, Manuel de l'Ocu- liste, &x. Paris, 1806.—Kiesser, Ueber die Natur, Ursa- Chen, Kennzeichen, und Heilung des Schwarze Staars. Goet. 1811.—Beer, Lehre, von den Augenkrankheiten, &c. Wieu. 1817.— Wardrop, On the Morbid Anatomy of the Human Eye, 2 vols. 8vo. Lond. 1818.— Travers, Synopsis of (he Diseases of the Eve, &c. Lond. 1820, Ryo".—Ste- venson, On the Nature, Lc. of the different Species of Amaurosis. Lond. 1821.—Demours, Precis Theorique et Pratique sur les Maladies des Yeux. Paris, 1821.— Weller, Manual of the Diseases of the Human Eye : by Mon- t,eal5;, ,G1?S5- 182l> 2 ™'s- 8vo.—Rayer, Archives Gener. de Medecine, t. vi. Paris, 1823.—Marjolin, art. Amau- rose, Diet, de Med., t. ii. Paris, 1822.—Sanson, art. Amaurose, in Diet, de Med. et Chirurg. Pratiques, t. ii. Paris, 1829.—Lawrence, Lectures on Diseases of the Eye! Lancet, vol. x., 1^29.—Benedict, art. Amaurosis, in En- cyclopadisches Wdrterh. derMedicinischen Wissenchaften b. ii. Berl. 1828.—Mackenzie, Practical Treatise on the Diseases of the Eye. Lond. 1830, 8 vo. AMENORRHCEA. See Menstruation. AMNIOS. See Dropsy of the Amnion. ANAEMIA. See Blood, Deficiency of. ANESTHESIA. See Sensations, Morbid States of. ANASARCA. See Dropsy of the Cellu- lar Membrane. ANEURISM. See Aorta, Aneurism of; and Arteries, Morbid Structures of. ANGINA. See Croup. Fauces,Inflammations of. Larynx, Inflammations of'. Pharynx, Inflammations of. Throat, Inflammations ANGINA PECTORIS. Syn. Cardiogmus Cor- dis Sinistri, Sauvages. Angina Pectoris, Heberden. Asthma Arthriticum, Schmidt. Diaphragmatic Gout, Burton. Asthma Dolo- rificum, Darwin. Syncope Anginosa, Parry. Angor Pectoris,]. Frank. Asthma Convulsi- vum, Eisner. Pnigophobia, Swediaur. Ster- nodynia Syncopalis, Sluis. Asthenia Pecto- ralis, Young. Stenocardia, Brera. Asthma Spastico-Arthriticum, Stoeller. Sternalgia, Baumes and Good. UAngine de Poitrine, Fr. Brustbraune, Herzklemme, Brustklem- me, Ger. Angina di Petto, Ital. Suffocative Breastpang, Eng. Classif. 2. Class, Diseases of the Respi- ratory Function; 2. Order, Affecting the Lungs, their Membranes, or motive Power (Good-). II. Class, I. Order (Author, see Preface). 1. Defin. Acute constrictorypainat the low- er part of the sternum, inclining to the left side, and extending to the arm, accompanied with great anxiety, difficulty of breathing, tendency to syncope, § feeling of approaching dissolution. 2. This affection was not recognised as a distinct disease by medical authors, until Dr. Heberden described it as such in the Medical Transactions of the London College of Physicians (vols.ii. and iii.); but the works of Morgagni and Hoffmann show that they were not unacquainted with it in practice. It was also noticed byPoTER (Opera, No. 22. p. 302.),under the head " Respirandi diffi- cultas, qua? per intervalla deambulantibus incidit;" and he remarks respecting it, that the attacks were sometimes so severe that persons had been sudden- ly carried off by them. Obscure notices of affec- tions, which probably were of this nature in some instances, may also be detected in authors from Hippocrates downwards. From amongst these, the reader may refer to Aretjeus (Opera, p. 7. Oxon. 1723.), CozliusAurelianus (lib. ii.c.i. p. 348.), Barteletti (Meihodus in Dyspna- am, Bon. 1632.), and others, adduced by Zechi- nelli (Sulla Angina di Petto, Pad. 1813.), who supposes that the case ofSENECA( Ope ra, L ii. p. 136.), which he has himself described by the term suspirium, was actually this malady. Dr. Cullen has passed Angina Pectoris over in his work; but it has been well described by Drs. FOTHERGILL, WALL, DuNCAN, BUTTER, Percival, Darwin, Macbride, Hamil- ton, Macqueen, Johnstone,Haygarth, Parry,Nicholl, and Good, in this country; and by Jurine, Brera, Lentin, Despor- tes, Kreysig, Ritter, Zechinelli, and Stoeller, on the Continent ; and by Dr. Chapman in America. 3. Pathology.—I. Symptoms. An attack of this disease is often preceded by considerable derangement of the digestive organs, especially by flatulence, acid or acrid eructations, or other symptoms of indigestion, with torpid bowels, pains in the limbs, and occasional spasms about the chest: but it frequently also attacks a patient, particularly when walking or ascending an emi- ANGINA PECTORIS —Causes. 63 nence, without any, or with but slight, premoni- tion. 4. A. In its acute form, the patient is seized with a sense of painful constriction of the chest, particularly at the cardiac region, about the lower part of the sternum, inclining to the left, and ex- tending to the left, occasionally also to the right, arm—at first, no further than the insertion of the deltoid muscle ; but the pain often successively reaches to the elbows, wrists, and sometimes even to the fingers. This is the mildest form of the disease, and soon subsides with the disappearance of its exciting cause. 5. In the more violent form of the attack, the pain and sense of constriction in the chest, and pain in the left arm, which also frequently ex- tends to the right, amount to excruciating agony ; being likened, by Laennec, to the piercing of nails or the laceration by the claws of animals. This feeling is accompanied by a sense of syncope or suffocation, sometimes with suffocative orthop- ncea, convulsive dyspnoea, and palpitations; al- ways with extreme anxiety, and a sense of ap- proaching dissolution. The suffocative sensation is characterized by concomitant tightness and fulness of the chest, and flatulent distension of the stomach, and irritative feeling in this organ, Which is relieved by eructations. During this fieriod the pulse is variously affected, sometimes ittle changed, at other tunes extremely weak, irregular, or intermittent ; and occasionally it is full, active and bounding. If the attack has been induced by walking or exercise, the patient sud- denly stands still, from a feeling that perseverance in either would produce a total suspension of living power. In the slighter attacks, or early in the disease, rest merely will often immediately remove it ; but this is seldom the case in the protracted and severe forms in which it frequently occurs. 6. The paroxysm continues from a few minutes to one or more hours, according to the severity and the duration of the disease. When the mal- ady has assumed a chronic form, and its attacks occur during the night, or when the patient is at rest, the paroxysm is less violent, but generally of much longer duration ; whereas, when it is in- duced by exertion, &c. it is of extreme violence, but of short continuance : the average duration of the fit may be about half an hour. Upon its cessation the patient merely retains a slight feeling of the various symptoms, with numbness of the arms, particularly the left. When the disease is of short standing, the paroxysms occur at long intervals, which are gradually shortened, until there is but little exemption from them, and the affection assumes a less acute character. 7. B. The chronic form of the disease is char- acterized by the circumstance of its being frequent- ly a consequence of the acute ; by the occurrence of the fit from the slightest causes, and after short or imperfect intervals of exemption ; by its recur- rence when the patient is at rest, or asleep ; and by its much longer duration, but less extreme violence. Even if this form be induced by exer- cise, rest has little influence in shortening its duration, as in the preceding ; and the paroxysm has been protracted not only for some hours, but even for several days. Palpitation of the heart, irregular and intermitting pulse, are more fre- quently concomitants of this state of the disease, than of the other. In the case of a very eminent j and learned member of the profession, whom I long attended in this form of the disease, the attack has often continued as now described, with little remission for several weeks. Sometimes the irregularity of the pulse is observed only during the paroxysm ; but in some cases it is continued, \ as Dr. Fothergill has correctly remarked, during the intervals, particularly when they are marked by imperfect relief. 8. This form of the disease may also occur primarily. It has twice presented itself to me in this manner. During the severity of the attack, leipothymia, a feeling of dissolution from the in- tense agony, and these followed by palpitations, and an irregular state of the pulse, generally oc- cur. In some cases the agonizing pain extends not only to the arm or arms, but ascends also up the throat and lower jaw, accompanied with a se- vere sensation of spastic constriction. In the ma- jority of cases the above sensations are only pre- sent, when excited by motion, by assuming sud- denly the erect posture, or even by attempting to read ; a neuralgic kind of pain generally, however, being felt under the sternum, and extending to the arms : but in some cases, and in two which oc- curred to me, the exacerbations were often refer- rible to no very evident cause, they sometimes occurring during the night, although the above causes generally induced them. 9. Notwithstanding the remarkable distress characterizing the paroxysm, this disease, par- ticularly in its acute state, sometimes does not early affect the constitution, or entail any per- manent lesion ; the patient often enjoying toler- able health in the intermissions, and perform- ing all his functions naturally, and without em- barrassment, until shortly before an attack. After its protracted continuance, however, the vital energies of the frame, particularly as they are manifested in the digestive and circulating organs, give way. Marked disorder of the chvlopoietic viscera, attended with various dyspeptic symp- toms, occasionally with great irritability of the stomach and bowels, impeded respiration, anxious and pale countenance ; flabby state of the integu- ments and muscles ; marked derangement of the circulation, oedema, dropsy, &c. ; at last super- vene. But it more generally happens that the patient is carried suddenly off by a paroxysm before this state of the system is occasioned ; or he sinks under the complicated derangement proceeding from an attack, and from someone of the organic changes which the continuance and repeated fits of the disease had induced. 10. II. Causes.—1. Predisposing. This dis- ease usually attacks the middle aged, and those beyond it ; aac /3ien much more frequently than women. Of nearly one hundred cases, about sev- enty were upwards of fifty years of age; an# seven- ty-nine out of the number were males; nearly one half terminated fatally, and almost the whole of them suddenly. It has been said also to occur more commonly in robust and corpulent persons with short necks. But Jurine and Chapman dis- pute this. My own experience agrees with theirs in respect of its being equally common in persons of a spare as of a full habit. It is most prevalent in those of gouty and rheumatic diathesis, and who lead an indolent, or studious and sedentary life, or who have been subjected to much and continued anxiety and distress of mind, or in- 64 ANGINA PECTORIS — Diagnosis — Prognosis. dulged in much food, and spirituous or other liquors. Jurine and Parr state that they have scarcely met with it under fifty years of age. The most violent and distinctly marked case of it which ever came before me, occurred in a gentle- man at the age of thirty-four. During 1821, I attended an unmarried lady, aged twenty-six, who laboured under it in a slighter form ; and re- cently, in 1830, another single female, at the age of twenty-five, came under my care, with the dis- ease in its most violent grade. In both these females, it seemed perfectly unconnected with uterine disturbance, menstruation being regular, and no tendency to hysteria having at any time evinced itself, or could be detected, my attention having been directed to this point. They both ultimately recovered after a long treatment, and the employment of very decided measures. Nearly all the cases which have come under my obser- vation were more or less referrible to mental causes, particularly to disappointment, anxiety, and other depressing passions. Dr. Hamilton conceives that there is an hereditary disposition to the affection. If we consider it to be of gouty origin, as contended for by Butter, Mac- queen, Ritter, Stoeller, Thilenius, Elsner, and Chapman, an hereditary disposi- tion may be also conceded. But, although very satisfactory proofs have been adduced by these au- thors, and particularly by Dr. Chapman, in an able paper he has recently published on this disease (American Journ. of Med. Sciences, No. xiii. p. 67.), yet it does not seem always to depend upon gout. Of the four cases which occurred to Dr. Black, of Newry, one only'was subject to gout (Med. Chir. Trans, vol. vii.). 11. 2d, The disease is usua lly excited by walk- ing, especially walking against the wind, or up hill ; by ascending a flight of stairs, or any ac- clivity, particularly when the stomach is full or distended by flatus. It is also readily induced by either the exciting or the depressing passions, and by whatever perturbates the mind, or occasions emotion. It may also be induced by the most trifling causes, in some susceptible and irritable habits, as by gentle walking, coughing, speaking, or reading aloud ; by suddenly assuming the erect posture ; by straining at stool ; or even by a meal, however moderate, &c. It may also oc- cur in a state of absolute repose, particularly when the disease has become chronic ; and the patient may be roused from sleep by an attack. 12. I have seen it occasioned by rapid changes of temperature, particularly by a rapid change to great cold ; but different persons seem differently affect- ed by extreme states of atmospheric temperature. In some slight cases the fit has been shortened, by the patient struggling to overcome it, by frequently attempting to make a full inspiration ; but this has also failed. The patient is incapable of mak- ing this attempt in the more severe paroxysms. 13. III. Diagnosis.—Angina pectoris is more liable to be confounded with asthma, than with any other disease. But a close attention to the phenomena attending upon both affections, will readily disclose a very great difference between them. The paroxysms of asthma always come on during the night, or at the close of the day : they are characterized by a heavy dyspnceaj wheezing, and cough ; are relieved by expector- ation and exposure to fresh air, and subside gra- dually towards morning. They are not excited in the same way, nor by similar causes, nor marked by the acute and peculiar pain in the sternum and left arm, which is distinctive of angina pectoris. The stethoscope and percussion furnish us with no signs peculiar to the disease under consideration, unless it be complicated, as is sometimes the case, with organic lesion of the heart and lungs, or with effusion of fluid within the cavity of the pleura or pericardium, when they materially assist us in ascertaining the nature of the complication ; and they also serve, by ena- bling us to ascertain other affections of the heart, to distinguish between it and them. 14. IV. Prognosis.—In recent cases, of no very violent character, recovery will frequently take place under judicious management. But when the disease has become inveterate from neglect, or from being associated with, or from having given rise to, organic lesion, and when it has ap- peared in a decayed constitution, or has been preceded by other diseases of the heart or lung3, an unfavourable result should be apprehended sooner or later to take place : but the period of its occurrence is uncertain ; and the event is gen- erally sudden—sometimes like an electric shock; the movements of the heart being instantly arres- ted. This issue is often occasioned by a full meal, or by exercise or mental emotions; but it also occurs in old or chronic cases, when the patient is at rest, and apparently uninfluenced by any circumstance or occurrence. When it is follow- ed by symptoms of effusion of fluid within the thorax, or oedema of the extremities, a fatal ter- mination is seldom far distant. 15. V. Proximate Cause, &c. Notwith- standing the number of examinations which have been made after death from this disease, but little light has been thrown upon it. This is not so much owing to the absence of morbid appearances, as to the extreme diversity of those which have been observed. Like epilepsy, or dyspnoea, it has presented almost every lesion, to which the organs which it affects are liable. Many of these may be viewed as accidental concomitants, or as con- current causes ; and not infrequently as results of the repeated functional disturbance occurring during repeated attacks. In several instances, not the slightest morbid appearance could be detected : but more frequently the heart and the large vessels in its vicinity have presented marks of disease, generally varied in its nature, and oppo- site as to its characters. The most common of these are ossification of the coronary arteries ; ossification of the valves of the heart, or of the arterial trtmks; enlargement of some of the cavities of the heart, either with diminished or increased thickness of their parietes ; but most frequently with softening, paleness, and tenuity ofthe muscular structure ofthe organ; varicose dilatation of the coronary veins (Brera); depositions of adipose matter, to the extent of impeding its functions; effusions of serum, blood, &c. into the pericardium or cavity of the pleura, &c. (Fothergill, Black, &c.) It has justly been remarked, by my friend Dr. Uwins, " that there is scarcely any mal- formation of the heart, or its blood-vessels, that has not been occasionally found after death, from what would be considered angina pectoris : while, on the other hand, individuals have fallen victims to the affection, fully marked, and the most accu- ANGINA PECTORIS —Pathological Condition. rate post mortem examination has not been able to detect the slightest indication of structural de- rangement." (Compend. of Theoret. and Pr'act. Med.) In some cases, the only morbid appear- ances observed have been in other, and distant organs, from that which seems to be, if not the chief seat ofthe disease, at least the organ chiefly affected in its functions by it — the heart and large vessels having been altogether exempt from lesion. These appearances were adhesions of the serous surface ofthe lungs to adjoining parts; se- rous effusions into the pleura ; thickening of the respiratory mucous surface ; dilatation of the bronchi; oedema of the intervesicular cellular tissue of the lungs ; abscess and tumours in the mediastinum ; ossification of the cartilages of the ribs (Wichmann, Jahn); tubercles, en- largement, scirrhosity, &c. of the liver (Perci- val, Latham, Brera, and Walker) ; scirrhus ofthe pylorus, &c. 16. These lesions serve less to throw light on the precise nature ofthe disease than an attentive examination of the morbid phenomena during the life of the patient, and a calm appreciation of their relations, particularly with respect to the agents tending to diminish, remove, or to ex- asperate them. This affection has been considered by many authors as spasmodic, " although the part immediately concerned seems not to have been designated or understood." Dr. Chapman remarks, that this hypothesis is rendered probable, by the general complexion of the disease — its causes, symptoms, and cure—and by its analogy to other disorders confessedly of this character. 17. Dr. Fothergill supposed it to be occa- sioned by obesity, and particularly by a collection of fat about the heart; he also considered that it was sometimes symptomatic of water in the peri- cardium or cavity of the thorax. Parry, Jen- ne.r, Burns, Kreysig, Bostock, and some others, have viewed this affection as a species of syncope occasioned by the accumulation of blood in the heart, from an ossification of the coronary arteries. Drs. Hosack and Forbes conceive that it most frequently arises from a plethoric state of the blood vessels, more especially from a dis- proportionate accumulation of blood in the heart and large vessels. To the first and second of these opinions it may be objected, that there is no obvious connection between the effect and the cause ; for, as the cause is permanent, the effect should be continued, or at least present but little abatement, whereas the intermissions be- tween the paroxysms are often characterised by a return ofthe healthy functions. It may be further stated, in opposition to this hypothesis, that many fatal cases have occurred in which this par- ticular lesion was not found on dissection. La- ennec states that he has examined several sub- jects who had laboured under this disease, and in none of them did he find the coronary arteries ossified. Besides, cases are recorded by Mor- gagni, Senac, Watson,Corvisart, And- Ral, and others, in which ossification of these vessels were not productive, during life, of the suf- ferings characterising this disease. Indeed the coronary arteries are often found ossified in old persons, who had not complained during life of any affection ofthe heart, and who certainly never were attacked by this malady. As to the last of the above opinions, viz. that adopted by Dr. j the attack, which occasionally happens." 6* 65 Hosack, Dr. Chapman has very justly obser- ved, " that even allowing the fulness and irregu- larity of the circulation contended for, which I am by no means disposed to do, as uniform concomi- tants, these I should take to be rather the effects of previous irritation or excitement, than the cause of the disease. Do we not also know, that such a condition of the vessels can exist without inducing angina pectoris ? Were fulness and irregularity in the circulation only required for the production of the disease, instead of a rare, would we not have it as a daily occurrence ? The fact, more- over, is, that angina pectoris, though oftener, per- haps, attacking the plethoric, is to be met with, as I have before said, in the feeble and attenuated." I may add to this, that the severest case of the disease which has ever occurred to me was that of a gentleman who had suffered severely from re- peated and profuse haemoptysis, and other symp- toms of disease of the lungs. All these disappear- ed, but were followed, after some time, by angina pectoris. He was feeble and attenuated ; but it was considered advisable to try the effect of blood- letting to a moderate extent: this gave no relief; it was repeated, but the symptoms were evidently aggravated by the measure. 18. Dr. Jurine considers the disease as a ner- vous affection ; and he supports this opinion by referring to the sudden and unexpected manner of its attack—to its sudden termination in death, or restoration to health — the nature of the ex- citing causes of the paroxysm — the equality and regularity ofthe pulse, in the majority of cases, during the paroxysm — to the state of the respir- ation — to the painful sensation extending to the upper extremities—and lastly, to the circumstance of antispasmodics being beneficial in its treatment. The proximate causes, he adds, consists of an affection ofthe pulmonary nerves, disturbing the functions of the lungs, impairing the decarboni- sation of the blood, and producing the pain in the sternum. This affection of the pulmonary nerves is communicated to the cardiac plexus, and de- ranges, secondarily, the heart and large vessels. The imperfect decarbonisation of the blood di- minishes its stimulating influence on the heart and lungs, giving rise to repeated attacks, until it occasions the death of those organs, and then of the brain. 19. MM. Desportes and Laennec have adopted a nearly similar view of the disease, with this difference, that they consider its particular seat may vary according to circumstances. Thus, M. Laennec states, that when there exists, simul- taneously, pain in the heart and lungs, we may presume that the affection is seated chiefly in the pneumo-gastric nerves ; but where there is sim- ply stricture of the heart, without pulmonary pain or difficulty of breathing, its site is in the nerves which the heart receives from the great sympa- thetic. But he supposes that other nerves may also be implicated at the same time, either by direct anastomosis or by sympathy ; and that the branches of the bronchial plexus, particularly the cubital, are nearly always so affected. " The anterior thoracic originating in the superficial cervical plexus are, moreover, frequently impli- cated ; and this is sometimes further the case with the branches derived from the lumbar and sacral plexuses, when the thigh and leg participate in 66 ANGINA PECTORIS—Treatment 20. Brera, Zechinelli, Averardi, and some others, consider the disease to be occasion- ed by pressure of enlarged abdominal viscera on the heart, particularly of enlarged liver. Joseph Frank conceives it to proceed from congestion of the cavities of the heart, occasioned by defec- tive nourishment of its muscular structure ; this defective nutrition itself resulting from previous inflammation, or from metastasis of gout or rheu- matism, or from disease of the coronary arteries. (Prax. Med. Univ. Precep., t. ii. p. 260.) Re- specting these, it may only be added, that the symptoms of angina pectoris are very seldom asso- ciated with enlargement of the abdominal viscera ; and that, although they are much more fre- quently connected with the lesions alluded to by Frank, this connection is by no means uniform, and is obviously not one of cause and effect ; these lesions being rather coincident and partial results ofthe morbid state ofthe nerves, the altered sensibility of which constitutes one of the chief characteristics of the disease. It may be further stated, that Dr. Darwin views it as a particular species of asthma, producing cramp of a peculiar kind in the diaphragm, or the other muscles of respiration ; and Dr. Butter, while he conceives it to be of gouty origin, also refers it to the re- spiratory organs, particularly to the diaphragm. On these opinions it is unnecessary to comment. 21. Dr. Chapman, to whose valuable paper I have already referred, states, ' That the disease is a species of neuralgia, I am entirely persuaded, commencing for the most part in the pneumo-gas- tric nerve, and spreading in different directions, as other nerves may become involved. The de- rangement of the heart and other structures, with which it is sometimes associated, I hold to be coincidences or effects, and not the cause ; since, among many reasons which might be adduced in corroboration of it, the disease has undoubtedly prevailed independently of such organic lesions, and, conversely, these have existed without occa- sioning it. But what is the immediate cause of the irritation of the nerves, inducing this neuralgic condition, giving rise to the subsequent phenomena of the disease ? This Is a question, which hith- erto has not been clearly answered. My convic- tion is, that it is derived from irregular gout, which misplaced, thus operates as an irritant of the nerves, and probably first of those of the stomach.' 22. It will be remarked from the foregoing, that Jurine, Desportes, Laennec, and Chapman agree so far as to impute the disease to a species of neuralgia ofthe pulmonary and cardiac nerves, affecting the functions of the heart and respiratory organs, and extending by nervous con- nection to other parts ; the organic lesions found in fatal cases being either coincidences, or effects of the disease ; and after an attentive examination of the phenomena attendant on several cases of the affection which have come before me, I see no reason for differing materially from this opinion. With regard to the origin of this affection of the nerves in misplaced gout, I cannot so implicitly agree with Dr. Chapman. The connection had been previously remarked by several physicians, as I have already stated, particularly by those whose names have been adduced, as well as by Schmidt and Burton,'—a circumstance favourable to the idea that it is founded in truth ; and evidence of it may even be found in Dr. Musgrave's very excellent, but now scarcely ever noticed work, on Anomalous Gout. Wichmann, however, has disputed this connection, and apparently with much reason. The notice which had been taken of this morbid relation is very candidly referred to by Dr. Chapman, who has adduced the partic- ulars of six cases in which this affection was evi- dently connected with gout, and in which recovery took place, after means had been successfully employed to invite this disease to the extremities. In the majority of those cases the patients had never previously suffered a gouty attack, and yet the means employed were successful in causing it to appear in the lower extremities. 23. But whether this disease is merely a form of misplaced gout, or an affection sui generis, which, when occurring in persons of a gouty dia- thesis, the induction of the regular gouty parox- ysm in the extremities generally removes, my experience does not enable me to decide. In two persons whom I was lately called to treat, and with whom I have been long acquainted, I have no reason to suspect a gouty tendency ; but the connection so satisfactorily established by Dr. Chapman is evidently by no means infrequent, and is one which ought never to be overlooked during the treatment of this most distressing and dangerous disease. I believe that, in addition to the nervous character of the malady, the sub- stance of the heart is often weak, thin, pale, and attenuated, or even softened, as if its substance were imperfectly and unhealthily nourished ; and that its cavities, consequently, become occasion- ally dilated and congested. This view is accord- ant with the treatment generally found most successful in removing it. In a great proportion ofthe cases before referred to (§ 10.), of which I had made notes, chiefly collected from authors, dissection had been made in about fifty of those which were fatal ; and out of this number nearly forty presented some degree of disease of the heart or large vessels ; —most frequently ossifica- tion of the valves, coronary arteries, and aorta ; and softening and emaciation of the heart. But whether these lesions were rather the consequence than the cause of the disease may be disputed. 24. VI. The Treatment of this disease necessarily respects, 1st, the measures which may be adopted during the paroxysm ; and, 2d, those which should be resorted to in the intervals, with the view of effecting a perfect cure. 25. 1st, In respect of the means which may be employed during tlvefit, with the view of dimin- ishing its duration and violence, no very precise or dogmatic direction ought to be given. Much will depend upon the peculiar characters ofthe case. The patient should always be placed in a state of tranquillity ; and, particularly, if the countenance be pale, and the carotids pulsating feebly, in the supine or reclining position. The propriety of bleeding in the fit has been discussed by several physicians, and depends entirely upon the partic- ular features of the attack. Where the symp- toms are urgent, the patient plethoric or vigorous, or the pulse full and possessed of tone, there can be no doubt as to the propriety of the measure. Dr. Read (Dub. Med. Trans., vol. i. p. 105.) has recorded a case which well illustrates the good effects of this treatment during the paroxysm. In more questionable cases, where the pulse is weak, ANGINA PECTORIS—Treatment. 67 and the countenance is collapsed, bleeding from the arm ought not to be had recourse to. It is doubtful whether or not cupping even should be employed; but where this latter state is not ex- treme, and especially in cases of intermediate grades of severity, cupping between the shoulders, to a small or moderate extent, as the case may seem to require, will generally afford relief, par- ticularly if used simultaneously with derivatives to the extremities. 26. But in nearly all cases, and still more par- ticularly in those characterized by syncope, and an imperfect action of the heart, frictions with stimulating and irritating substances ought to be previously employed over the anterior parts of the thorax, and stimulants and antispasmodics, ex- hibited internally. As to the extent and repetition ofthe blood-letting, whether general or local, the practitioner ought to be able to decide, being guided in this, as in other remedial means, by the apparent energies ofthe constitution, and the state ofthe vascular system; if these admit, and espe- cially if signs of plethora, or of congestion of the cavities of the heart and large vessels of the chest, exist, the depletion may be carried to a considerable extent, or repeated, according to the relief obtained. The object here is to reduce the body to be moved to a nearer relation to the state ofthe moving power, at the same time that we endeavor to increase the energy of the latter. 27. I should add, that the propriety of bleed- ing, in the paroxysm particularly, has been much disputed; and especially by Continental authors. Where the pulse is feeble and soft, and the action of the heart weak, it is generally inadmissible; but, wherever we entertain doubts respecting it, the external and internal use of stimulants and antispasmodics, with frictions, should be cautiously premised, and only local depletions adopted; or depletion of every kind should be entirely omit- ted until after the paroxysm, when either general or local blood-letting, according to the particular circumstances of the case, may be practised with necessary precautions. I have employed moder- ate blood-letting in three cases, in which the pro- priety of the measure seemed questionable, the patients being of spare habits of body, and weak- ened states of system; but every precaution was taken to prevent immediate ill effects from the operation. In one of the three relief was afford- ed; in another, the advantage was very doubtful; and, in the third, the disease was evidently exas- perated by it, although slight benefit seemed to result from it at the time. In one of those cases the serum of the blood had a milky appearance, from the presence of an oily matter, resulting from imperfect assimilation. From this evidence, therefore, I infer, that, where there are no signs of vascular plethora or cardiac congestion, or where the vital energies of the patient are depress- ed, and we presume the substance ofthe heart is attenuated and imperfectly nourished, we should be extremely circumspect in having recourse to vascular depletions of any description, and should particularly avoid bleeding from a vein; but, at the same time, we should be equally careful not to administer too active stimulants. 28. Next to the employment of depletion, un- der the above restrictions, in suitable cases, and with the concomitant means recommended, the bowels may be opened by a purgative medicine, | combined with some warm antispasmodic and carminative, as ether, spiritus ammoniae romati- cus, camphor, musk, castor, spiritus anisi, &c; and these may be given, at intervals, subsequently. In the slighter attacks, and where the state of the vascular system and constitutional energies render it prudent to withhold depletion, friction, with stimulating liniments over the thorax and epigas- trium, (as the following:— No. 14. R Linimenti Camphorae Comp., Linira. Am- monia fort., aa 3j-> Tinct. Capsici 3'j.M.) the internal administration of antispasmodics, and the exhibition of a purgative medicine, will be sufficient to give some immediate relief. The following will generally fulfil the intention :— No. 15. RInfus. Valerianae 3xj-j Spirit. Ammoniae Foetid. 5ss-j Tinct. Castorei gss. M. Fiat Haustus bis terve in die capiendus. No. 16. R Infus. Sennae Comp. §jss.; Tinct. Sennae 3>j.> Spirit. Amnion. Arom. 3s5-> Tinct. Cardamom Comp. jj. M. Fiat Haustus statiui sumendus, et repel. si sit occa.io. Or the following:— No. 17. R Mist. Camphorae %].; Licj. Ammon. Acet. 3 ij.; Spirit. TEther. Sulph. Comp. 3j-> Tinct. Campho.ae Comp. 3j.; Syrup. Papaveris 3J-M- 29. Emetics have been spoken favourably of by Dr. Good (Study of Med., t. i. p. 667.). In a case of great severity, in which vomiting occasion- ally occurred when the paroxysm was excited by taking food into the stomach, I was induced by this symptom to try the effect of an emetic during an attack, but no benefit was derived from it. 30. The employment of derivatives to the extremities, particularly the lower, is generally beneficial; and ought not to be omitted in the paroxysm, whether we adopt the opinion as to the gouty origin ofthe disease or not. Stimulating pediluvia, and sinapisms or blisters, with all the other measures employed under similar circum- stances in irregular or misplaced gout, had the effect, in the six cases of the disease published by Dr. Chapman, of inducing the regular gouty paroxysm, and of affording speedy relief. The affusion of cold water has been recommended by some authors, but it is a dangerous remedy in this disease. Cold epithems to the head have been mentioned by J. Frank (Prax.Med. Univers., part ii. p. 273.), as having been used with advan- tage; they seem less objectionable. A similar remark may be applied to the tepid affusion on the head. 31. 2d, Tlte means which may be employed during the intervals or remissions between the paroxysms are either general or topical. With respect to the first of these, a most studious atten- tion to avoid the exciting causes of the disease must be inculcated. Next to this, all existing dis- order of the digestive organs should be attended to and removed; and the diet and regimen of the patient strictly laid down and enforced. As the powers of the digestive organs are generally di- minished, and the bowels either costive or irregu- lar, vegetable bitters, with an occasional alterative aperient, either given alone, or in combination with an antispasmodic or anodyne, will often prove beneficial. With the view of thus strengthening the digestive organs and removing spasm, Schjef- fer (Volkskrankheiten, Jun. 1807, recom- mended vegetable bitters with opium, musk, cam- phor, or assafcetida, and Elsner prescribed the muriate of ammonia with Hoffmann's anodyne. 68 ANGINA PECTORIS —Treatment. Sulphate of zinc, recommended by Perkins (Mem. of Med. Soc. of Lond., v. iii), in doses of a grain, with a quarter of a grain of opium, given twice a day, has a similar action: but it genenilly is nec&ssary to give it more frequently, and to increase the doses. With the same view I have given the prussic acid, either simply, or combined with the oxide of zinc, forming a prus- siate of zinc, and in one case particularly, with greater advantage than from any other means. I have reason to believe that the prussiate of iron will prove equally beneficial; but my expe- rience of its effects is too imperfect as yet to allow me to speak decidedly as to its merits in this disease. 32. In a case which occurred to me a year since, I employed the preparations of iron, par- ticularly the carbonate, being led to adopt them by the neuralgic characters of the case, and cer- tainly with apparent advantage; but I should add, that local means were also in operation at the same time. Wherever we have reason to suppose that the heart is debilitated, imperfectly nourished, or attenuated, the employment of tonics, particularly bark, and the preparations of iron, either alone or with antispasmodics, is particularly indicated, with strict attention to diet and regimen. Auscultation will be found of service, by intimating to us the particular state of the heart, which must in a great measure regulate our practice. 33. In a case of the disease which came under my care in 1824,1 prescribed the nitrate of silver triturated with a vegetable extract, as recommend- ed by Sementini. This substance was continued in increased doses, until it occasioned an eruption, resembling nettle-rash, on the skin,—an effect no- ticed by this physician. The relief afforded by it, after this eruption began to appear, was decided. The patient is, at the present time, in the enjoy- ment of tolerable health. At the period of my prescribing this substance, I conceived that its ex- hibition in this disease had originated with myself; but I subsequently found that it had been given in two cases of angina pectoris, with advantage, so long ago as thirty years, by Dr. Cappe (Dun- can's Annals of Med., vol. iii.). 34. Arsenic, in the form of Fowler's solution, had been recommended in this disease by Dr. Al- exander (Med. Comment., vol. xv. p. 373.), at a period antecedent to the introduction of the nitrate of silver into practice, as an internal me- dicine; and subsequently by SirG. Blane, who gave it with advantage, combined with digitalis and mercury (Med. Chir. Trans., vol.iv.p.136.). 35. Besides these, preparations of bark, and other vegetable tonics, have been recommended, either alone, or in combination with antispasmo- dics and anodynes. The hydrosulphuret of am- monia, in gradually increased doses (from ei°fit drops to thirty) twice or thrice daily. The differ- ent preparations of valerian, the cuprum ammo- niatum, and sulphate of quinine, have likewise been employed, and occasionally v/ith decided advantage: from the last of these, combined with an anodyne, particularly with opium and cam- phor, I have observed much benefit to be derived. The following formulae may be employed. No. 18. RInfus. Rosar. Co. 3vj.; Quinines Sulph. gr. j.—ij.; Aridi Sulph. Arom. Tt] *.; Spirit, .tether. Sulph. Comp. 3j.; Tinct. Opii, TT] xij. M. Fiat Haustus bis in die capienam. Or, No. 19. R Extract. Anthemid. 3 iji.jQuinins Sulph. | I jr. xij.; MassiC Pilul. Galban. Comp. 3 j.; Camphore Suhai-is, gr. xv.; Syrup. Papaveris, q. s. Misce bene et divide in Pilulas xxiv., quarum capiat ucani a 1 binas vel tres bis lerve quotid e. Having derived much advantage from the inter- nal use ofthe sub-borate of soda in dyspeptic irri- tability of the alimentary canal, I was induced to employ it in a case of this disease which occurred to nie a few years since, in doses of from twenty to thirty grains, given in the decoctum althaese. It produced some relief; but the case was of the greatest severity, and little benefit, at least of a permanent description, was derived from any means which were adopted, excepting from the prussic acid. 36. Mercurials have received the sanction of Brera. I have employed them in two cases: at first as an alterative; five grains of blue pill hav- ing been directed occasionally at bed-time, and subsequently so as to affect the mouth. In one of these the alterative dose had a beneficial effect upon the state of the stomach and bowels; but this was of short duration. When, however, pushed further, so as to affect the gums, great irritability of the system, fever, restlessness, and increased pain, anxiety, and sinking, were occa- sioned by it. In the other case, evidently con- nected with hepatic disorder, the blue pill was also at first given as an alterative, on alternate nights. It affected the gums after a few doses, and afforded relief. It was now pushed with the intention of inducing salivation; and a somewhat violent effect was produced on the mouth, which was relieved upon exciting the salivary glands. Decided advantage was now procured; the bowels were kept open by means of a stomachic ape- rient, an issue inserted in one of the thighs, and change of air recommended. This patient per- fectly recovered. 37. Where plethora exists, blood-letting in the intervals will be serviceable, with a light abste- mious diet. When the paroxysms are apt to oc- cur during the night, I have found an opiate given at bed-time, as recommended by Dr. He- berden, of great service. In one case of this description I gave the acetate of morphine, in the dose of an eighth of a grain, but it occasioned such distressing feelings of sinking, and general depression of the powers of life, that stimulants were required; yet the same patient had expe- rienced relief from opium combined with camphor. On one occasion I tried the effects of iodine in the form of the tincture; but although its use was adopted with great caution, seven drops only hav- ing been given three times a day, it occasioned an increase of all the symptoms, apparently owing to its irritating effects on the digestive mucous sur- face, and the idiosyncrasy of the patient. I may here notice the practice recommended by Schle- singer (Hufeland's Journ., vol. i. p. 57.), con- sisting in the exhibition, every two hours, of the extract of the lactuca tirosa, in doses of two grains, with half a grain of digiialis. What effect may we expect from the use of colchicum'! Where the disease seems to originate in gout, the colchicum might be tried; but its use would re- quire great circumspection. In my opinion, it should only be given in combination with stimu- lants, or antispasmodics and tonics, the spiritus colchici ammoniati being the most promising preparation of it in such a case. 38. Although the patient labouring under this ANGINA PECTOR disease is generally incapable of any, excepting the most gentle, exercise; yet this should be taken under favourable circumstances; and change of air, particularly to healthy, dry, and elevated situations, should not be overlooked. It will generally be observed, that persons labouring un- der the worst form of the disease, incapable even of walking or sitting upright for any time, will bear well, and even be benefited by, rapid travel- ling in a carriage. This was first evinced to me by the case of a gentleman of great scientific and literary attainments, residing for a time at Paris, where I was called to him in the summer of 1829. He was anxious to return to England, from a dread of dying abroad. He undertook the jour- ney with me, and was better during it than either previously or subsequently. He has since taken long journeys, with similar advantage, but no means which have hitherto been employed have afforded him more than temporary relief. 39. Secondly, Much benefit will be often re- ceived from topical means. Under this head issues and setons deserve particular notice. They have been employed on the insides ofthe thighs by Macbride and Darwin. Kreigelstein and Wolff also have observed advantage to be derived from them, when inserted either in this or in other situations. I have resorted to a peculiar form of issue in several cases of tins disease, and, upon the whole, with much benefit. In one case, however, it failed of having the least good effect. 40. The form of issue to which I allude, and for the knowledge of which I am indebted to my learned friend Dr. Hutchinson, is the bark of mezereon root, deprived of its external cuticle, and, after having been soaked for some time in a little water, placed upon the surface of the part from which we wish to procure a discharge. This bark should be confined to its place by means of adhesive plaster, spread on paper of larger dimen- sions than the part covered by the mezereon bark. The bark may be renewed every night, until it procures a copious discharge. In some cases the effect is produced in a single night, or in twenty- four hours. When the discharge becomes copious the bark may be renewed less frequently. The adhesive plaster serves both to keep the mezereon in its situation, and to retain the discharge, so as to preserve it from soiling the clothes. When it is abundant the plaster may be renewed, and the secretion removed, as its occasional acrimony often tends to heighten and to extend the irritation. In a severe and chronic case of this disease, which occurred to me lately (in 1830), I employed this form of issue, and kept a surface of about four inches square over the left small ribs discharging as long as the patient would endure this treatment. The disease disappeared, and up to this time it has not returned. The advantages of this issue are, that the patient can manage it from the be- ginning with great ease; and it may be readily increased to any extent, and the discharge aug- mented, according to the exigencies of the case. 41. Artificial eruptions, from the tartar emet- ic ointment or plaster, have now usurped the place of setons and issues; but, from a very extensive experience of the former, both previous and sub- sequent to the publication of an article on them in the London Medical Repository for April 1822,1 consider them of inferior efficacy in some diseases, and particularly in tliis, to the pea-issue, or the issue 69 now described. It is singular that the advantages to be derived from the production of artificial pus- tulation, in the treatment of various disorders, were so little known or appreciated until the appearance of Dr. Jenner's pamphlet on the sub- ject, since the practice had been recommended long previously in the Lectures of the second and third Monros on Morbid Anatomy, as being fre- quently preferable to the use of blisters ; and had been found serviceable by Goodwin, Auten- rieth, and Kreigelstein, in this affection, in which it had been employed by them at the end of the last century. 42. Blisters, either frequently repeated, or kept discharging for a longer or shorter period, have received the sanction of Percival and many others. But little benefit will be derived from them, unless they be used in the way now named. Thilenius recommends (Med. und Chir. Be- merkungen, i. p. 183.) repeated blisters applied between the shoulders. I agree with him in the selection of this place in preference to others for their application, as well as in the propriety of repeating them frequently. M. Laennec states that he has derived great advantage from magnet- ism, used in the following manner, both in alle- viating the paroxysm and in preventing its acces- sion:—He applies " two strongly magnetized steel plates, of a line in thickness, of an oval shape, and bent so as to fit the part,—one to the left precordial region, and the other exactly opposite, on the back, in such a manner that the magnetic current shall traverse the affected part." (Dis- eases ofthe Chest, p. 705.) 43. When the affection is complicated with other diseases, particularly with organic lesions of the heart, or enlargement of the liver, the treat- ment should be modified accordingly. In order to ascertain the nature of such complications, aus- cultation may be resorted to ; for, although it gives us no information respecting the simple dis- ease, it often enables us to detect the lesions with which it is sometimes associated, and to direct our means of cure more appropriately, and with happier results, than we could otherwise do. When the substance of the heart is weakened or attenuated (§ 23.) tonics, particularly sulphate of quinine, sulphate of zinc, and the various prepara- tions of iron, given in decided doses, are particu- larly indicated. In other cases, as well as when the liver is affected, issues are generally servicea- ble. When the disease is connected with enlarge- ment, &c. ofthe liver, mercury is almost indispen- sable. In all cases, whether simple or complicated, attention to diet and regimen, a pure air, amuse- ment without excitement, and an equable and con- tented state of mind, are not only requisite to recov- ery, but are also necessary to render it permanent. Bibliography. Sauvages, Nosologia Methodica, tom.iv. p. 120. edit. 8vo.—Htberden, Medical Transactions of the College of Physicians, vol. ii. p. 59. 1768.—Eisner, Ab- hanlung Uber die Braustbraune. Kcenisb. 1778.—Schaffer, Dissertat. de Angina Pectoris. Gottine. 1787.—Butter, Treatise on the Disease commonly called Angina Pectoris. Lond. 1791.—Schmidt, Dissert, de Angina Pectoris. Gott. 1793.—Parry, An Inquiry into the Symptoms and Causes ofthe Syncope Anginosa. Lond. 1799.—Hesse, De Angina Pectoris. Halle, 1800.—Darwin, Zoonomia, vol. iv. p. 42. 1800—.S«oeKe»-,Journ.der Pract.Heilkunde von Huffeland, 17 b. 1803.-,/aAn,Ueber die Syncope Anginosa,(Hufeland's .V. Journ. 1806.—Beaumes, Traite El£mentaire de Noso- logic. 1806.—Despoi-tcs, Traile de l'Angine de Poitrine. 1811.—Blackul, Observations on the Nature and Cure of Dropsies, &.c. Lond. 1813.—Kreysig, Die Krankheiten des Herzens. 8vo. Berl.—Zechinelli, Sulla Angina di Petto IS — Treatment* 70 AORTA — Nervous Pulsation of. Pad. 1813.—Jurine, Memoire sur l'Angine de Poitrine, couronn£ par la Society de Medicine de Paris. 1815.— Laennec, Traite de l'Auscultation Mediate. Paris, 1826.— Chapman, American Journal of Medical Sciences, vol. vii. Phil. 1831.—Jolly, in Dictionnaire de Medicine et Chirurg. Pralines, Sec, torn. ii. Paris 1829. ANIMATION, SUSPENDED. See Asphyxy. ANTIPATHY. Syn. >Arri;ia/>>(c,Gr. Antipa- thia, Lat. Der Widerwille, die Antipathie, Ger. Antipathie, Fr. Antipatia, Avversione, Ital. Antipathia Sensilis, et A. Insensilis, Good. Classif.—4. Class; 4. Order (Good). I. Class; IV. Order (Author). 1. Defin. Internal horror and distress on the perception of particular objects, with great restlessness, or with fainting. 2. This singular affection has merely been men- tioned by Collen: it has, however, received more attention from Sauvages, Linnjeus,Vo- gel, Ploucquet, Passament, and Good. The last named writer has needlessly divided it into two species—sensileand insensile antipathy; the former arising from objects or subjects which strike some one of the senses; the latter from the presence of an object, as soon as it comes within the sphere of some unknown influence, although Unperceived by any of the senses. 3. There are numerous instances of singular antipathy on record; and most persons of observ- ation have met with others in the course of their experience. The vulgar explain them generally by considering that the mother had experienced a fright from the objects of antipathy during the early months of pregnancy—and there are, no doubt, some facts which countenance the sup- position. Thus, James the First could not endure the sight of a drawn sword : Rizio was killed at the feet of Queen Mary when pregnant with him; and many other instances are mentioned by wri- ters : but more frequently the persons themselves, who are thus affected, have experienced frights during the early months of infancy, or have had their minds early and indelibly impressed by cer- tain subjects. Peter the Great had a fall from a bridge into the water, when an infant, and he could not afterwards endure to hear the rattling of a carriage passing over a bridge. Persons often retain the antipathy to the sight of crabs, lobsters, &c. which had been occasioned by fright from them in infancy or childhood. A man-servant in the author's family, advanced in life, had so great an antipathy to the sight of a mouse, that he would fly as fast as he was able from the place where one was seen; and become quite frantic at the sight. He stated that his mother, who likewise had an antipathy to mice, had been distressed by one thrown upon her when pregnant of him. Some persons cannot endure certain odours, from the faintness, or sickness, or sense of anxiety and dis- tress they occasion. This appears to proceed from peculiar idiosyncrasy. I have likewise seen persons who could not touch certain smooth ob- jects without feeling a peculiar shudder or horror, followed by faintness in some. This appears to arise from associations excited in susceptible or sensitive minds. 4. The most singular instances of antipathy are those which occur at the presence of objects unperceived by any of the senses; forming the insensile antipathy of Dr. Good. Thus, a cat concealed in a room has been known to produce a most indescribable distress or horror in a person who has not perceived it by any one sense, and has been,in nootherway, informed of its presence. Some singular idiosyncrasy, doubtless, exists in such cases. Sauvages conceives that an effluvium pro- ceeds from the animal, which, combining with that emanating from the person thus affected, occa- sions the unpleasant sensations upon his peculiar organization or idiosyncrasy. This is, perhaps, the only opinion that can be formed on the subject 5. The Treatment to be adopted for the re- moval of antipathies consists chiefly of resolute endeavours to overcome the morbid impression, by gradually accustoming the mind to its influ- ence. Indeed, this is the only remedy that can be resorted to. Its adoption, successfully or otherwise, will entirely depend upon the mental energy of the patient. But there cannot be a doubt, that all impressions, however unpleasant or distressing, may be ultimately overcome by repetition, and a firm resolution either to endure, or not to be affected by them. The following works will furnish some curious information on this subject, with much trifling, silly hypothesis, and irrelevant matter:— Bibliography.—Lipsius, Diss. Antipathic Singulares, &c. Jen. 1678.—S. Rattray, Aditus Novus ad Occulta) Svmpathiae et Antipathia? Causas. Glasg. 1658.—K. Digby, Theatr. Sympathet, p. 138.—Rudolph, De Antipathia Humana. Basil, 1700.—Schurig, Chylologia, p. 96. et 163. etseq.—Mentz, Disser. Antipathiae Plus. Phcnom. ad suas Causas Revocata. Lips. 1708.—Du Voisin. De Antipathia Humana. Basil, 1701.—Zwinger, De Antipa- thia Humana, Fascic. Dissert. Select., n. 1.—Sskwimmtr, De Antipathia. Jena;, 1669.—Hcrmstaedt, "Wunderhare Kr'&fte der Nalur durch die Symp. und Antipathie. Rotenb. 1776,8 vo.—P> Syrup. Tolutan. 5j. M. Fiat Haustus. No. 27. R Infus. Calumbas (vel. Infus. Valeriana?), Mist. Camphorae, aa 3y.; Sodas Sub-carbon, gr. x.; Spirit. -Ether. Sulphur. Comp. 3j- M. Fiat Haustus, bis terve in die sumendus. Before I proceed further, in noticing the other remedies which may be resorted to, or have been recommended, I will state the means which are most appropriate to the weaker states of the dis- ease, and when the system is greatly depressed by the shock of the local lesion, or before in- creased action has taken place. 148. b. Treatment of the depressed slates of apoplectic seizures.—It will be apparent from the particular details I have given of the symptoms, causes, and pathological states of the disease— 1st, That much depression or exhaustion of the vital powers of the brain exists in some cases throughout the attack, even rapidly terminating in death without any effort at vascular reaction, particularly when this state is mistaken, and treated by depressing remedies; and, 2d, That this depression is often analogous to concussion of the brain, owing to the extent of the local lesion; and, like this result of external injury, is frequently followed by reaction of the heart and arteries (§ 111—118.), when the lesion constitu- ting the seizure is not so great as to overwhelm the powers of life. 149. It is owing, in my opinion, either to the employment of too large blood-lettings in such cases, to the having recourse to them at all in others, or to practising them without sufficient regard to this period of the seizure, and before the occurrence of reaction,—the time when they are imperatively called for,—has supervened, that the practice has disappointed many who have adopted it, and led others to employ an opposite mode of treatment in an equally exclu- sive, and hence dangerous, manner. The judi- cious use of gentle stimuli during this state of de-. pression will have the effect in some cases of bring- ing about a moderate reaction, when death would be the result of other means; and, by diminish- ing and shortening the stage of depression in others, and thereby lessening the congestion of the capillaries of the brain, that inordinate degree of arterial action consequent upon the obstruction, and indirectly produced by it, will be prevented. In some more doubtful cases, as when the pallor ofthe countenance is connected with a natural, or APOPLEXY —Treatment of. 103 not very depressed state of the pulse, and temper- ature of the head, and when there are vomiting and other symptoms, indicating that haemorrhage and laceration of a portion of the cerebral struc- ture have occurred, blood-letting may be advan- tageously conjoined with cordial remedies, calcu- lated to restore the tonic contractility of the ves- sels ofthe brain. 150. It will appear from what has been stated, that those who deny the efficacy of blood-letting are in some respects justified by the frequent de- ficient vital energy of the brain, and by the in- jurious effects of the remedy in some cases, whilst they err in a too general recommendation of opposite means. Both parties, however, place great dependence upon active purgatives, and I believe that much of the success obtained by the abettors of both modes of practice is to be ascrib- ed to them. 151. In apoplectic cases, therefore, with signs of deficient vital energy of the brain and consti- tution,—and, when we refer to our experience, or consider the nature of many of the exciting causes, as well as the very far advanced ages of the great majority of apoplectic patients, the num- ber of such cases will appear by no means small, —and at the commencement of some seizures, be- fore reaction has supervened, when the counte- nance is pallid or sunk, the pulse of the carotids weak or small, the temperature of the head not increased, and profound sopor, rather than very stertorous or strong breathing, is present, gentle restoratives, administered either internally or ex- ternally, are the most serviceable.* The pro- priety, then, of attending to the fact, that apo- plexy often is originally dependent upon the state of the sensorium—upon the depressed vital energy ofthe encephalon, as well as upon extravasation, or primary or consecutive vascular turgescence, and increased action—is manifest. And hence will appear the reason that restorative measures are required in some cases and not in others, or at one stage of an attack and not at another ; physicians being led, by the success obtained from one method of cure on some occasions, to * Travelling in the Bummer, in one of the short stages, I sat opposite an aged and corpulent man, who, very soon after our leaving town, suddenly lost his consciousness and power of motion. His countenance became first pale, then bloated and inexpressive, his breathing slow and slightly stertorous, all his muscles completely re- laxed, and he fell, in a few seconds, upon those sitting around hiai. We were only a few doors from a chemist's shop ', the coach was stopped, and he was carried thither. He was now profoundly apoplectic ; a copious perspiration flowed from his face and forehead, the veins of which were distended, and all his senses were completely abo- lished. There was no sign of hemiplegia,—but there was general and complete loss of motion and sensation. His neckcloth having been removed, the pulsation of the carotids was found to be slow, and of natural strength and fulness. Whilst he was held in a sitting posture in a chair, cold water was poured gently over his head from a sponge, and his head frequently sponged with it; volatile salts also were held for a short time, and at intervals, to his nostrils. The power of deglutition was at this time abolished, so that it was impossible to administer a draught, chiefly consisting of a small quantity of spirituous ammonia; aromaticus and camphor mixture, which was pre- scribed. In a verv few minutes his consciousness return- ed, he took the draught, and, in a short time afterwards, he walked to a coach, in which I accompanied him home. He now complained onlv of very slight confusion of ideas, with scarcely anv headach, but his carotids beat more firm- Iv. One full blood-letting, and an active purgative, were now directed. The next day he was perfectly well, and has continued so. What would have been the result if he had been largely blooded previously to the reaction ? employ it too generally, and hence in many in- stances in which it Is inappropriate. 152. The restorative means that may be resort- ed to, scarcely admit of particular notice. The practitioner must be guided in his choice of them by the circumstances of the case. Where there is sopor, or coma, or lethargy, without much stertor of breathing, and when hemiplegia or pa- ralysis is not present, camphor in moderate doses, either alone, or combined with ammonia or the spir. eth. sulph. comp., the spir. lavand. comp., and various others, may be adopted. It is only in such cases, and when the action ofthe carotids is weak, the head cool, and the countenance sunk, that the infusions of arnica or of serpentaria, which have been recommended by Quarin, Aaskow, Werner, and Thomann, are ad- missible. In more doubtful cases, the prepara- tions of ammonia, the spiritus etheris nitrici, the infusion of valerian, may be cautiously exhibited. In some, particularly at the commencement of the seizure, volatile substances, such as the prepara- tions of ammonia, and aromatic vinegar, held to the nostrils occasionally, will be of much service. Where the attack is either preceded or accom- panied by hemiplegia or paralysis, (§ 31—43.), stimulants, whether exhibited internally, or held to the nostrils, may be more hurtful than bene- ficial. In these, even the use of cold applications to the head, excepting there be marked increase of temperature, is seldom productive of much ad- vantage. Purgatives are, however, required, but the choice and repetition of them should entirely depend upon the state of the secretions, the tor- por ofthe bowels, and the character of the stools. 153. c. Remedies which have been recommend- ed, and are admissible in certain states of either the sthenic or asthenic forms of attack.—Emetics are amongst the remedies, the admissibility of which has been most questioned. The young practitioner will, if he have recourse to written authority, be quite bewildered by the diversity of opinions respecting them in this disease. He will find Sydenham,Pitcairn, Kirkland,Selle, Fothergill, Colombier, Conradi and Fa- bee, in favour of them; andHAGENBORN, Bor- SERI, Q.UARIN, WALTHER, CuLLEN, TUES- sink, Richter, Portal, and Cheyne, oppos- ed to them. But, when the attack has been brought on by an overloaded state of stomach, by intoxication, narcotic poisons, or other hurtful in- gesta, and more especially when hemiplegia is not present, or if the attack be of the active kind, and full depletion has been performed, emetics may be both safely and advantageously administered. This opinion seems agreeable to the recommend- ations of Hippocrates, Morgagni, Stoll, Blane, and the late Professor Gregory. 154. The propriety of having recourse to blis- ters has likewise been questioned. The great majority, however, of authorities are favourable to the practice in some state or other of the dis- ease, the situation, the period, and form of at- tack, being the chief points of dispute. Bar- tholinus, Candler, Cullen, and many oth- ers, recommend them to be applied to the head. Whilst Tode, Baglivi, Stoll, Portal, and Picq,ue consider them injurious in this situation. In the active states of the disease, in those forms which are complicated with hemiplegia, or are preceded by it, blisters on the head seem hazard- reatment of. 104 APOPLEXY — ' ous remedies, and are, moreover, in the way of more appropriate means ; but in the weakest forms of the disease, when, from the depressed state of vital energy of the brain and lowered ac- tion ofthe carotids, the sensorium requires to be excited, they may be of service. AVhere, how- ever, there is any doubt respecting the propriety of applying them in this situation, it will be better to omit them, or to direct them to another part. When stupor or coma exists, and the symptoms are not of the strong character, they may be ap- plied to the nape ofthe neck, between the shoul- ders, or insides ofthe thighs or legs, after general or local blood-letting has been practised. 155. Sinapisms, or stimulating frictions, and liniments, applied to the lower extremities, are very generally applicable, particularly after re- sorting to pediluvia, care being afterwards taken to preserve a continuance of the increased flux of blood to these parts, when thus procured, either by warm applications, or by a frequent renewal of the above means. Sternutatories have been considered injurious by Baillou, Morgagni, Buchner, and others, and I conceive with great justice. A nearly similar opinion may be given respecting electricity and galvanism, which have been recommended to be tried by some authors. 156. The exhibition of mercury, chiefly in the form of calomel or blue pill, in large doses, so as to act upon the biliary secretion and bowels, and subsequently to excite salivation, has been recom- mended by DoljEus, Schurig, Ghisi, and Horn. My experience of the practice has led me to think favourably of it in most of the apo- plectic states, when the powers ofthe constitution are not far reduced, and the patient is not very old. Antimonial preparations have already been prescribed, and are of much service in the more active or strong forms of the disease, whether ac- companied with hemiplegia, or without it. They are not so admissible, however, in the very de- pressed states of vascular action, and in the forms of attack which commence slowly, or are pre- ceded by, or attended with, paralysis, indicating softening and infiltration of the cerebral substance. James's powder, and the tartarized antimony, are the best preparations : the former of which may be advantageously combined with calomel ; the latter with saline medicines. (See R. 21, 22, and F. 854.) 157. Setons, issues, and moxas have also been advised, particularly when stupor continues after the more urgent symptoms have been mitigated. I concur with Lancisi and La Motte in con- sidering them very deserving of adoption in such cases. Moxas applied on the occiput produce a more rapid effect, and are therefore preferable during the period of attack; setons are more suit- able in the prophylactic and consecutive treatment. The actual cautery and moxas have been strong- ly recommended by Albucasis, who directed them in the course of the coronal suture ; by Marcellus Donatus, who prescribed them to the occiput; by Scheihammer, to the vertex ■ by Schreiber, to both the vertex and soles of the feet; by Mistichelli, to the feet; and by Thilenius and Severinus. These means are very generally applicable, and may be resorted to in the worst cases of apoplexy, particularly those complicated with hemiplegia, and when brought in aid of appropriate means. 158. Incases characterised by a full, tumid, flushed, and livid countenance, full or strong pulse in the carotids, heat of head, with or with- out hemiplegia, I prefer, after copious general depletion, scarifications of the scalp, more or less deep and extensive, to be made over the oc- ciput, so as to allow of a free sanguineous dis- charge. The practice has been recommended by Hippocrates and Morgagni. Cupping glass- es may be also applied over the scarifications, when we desire to procure a more copious dis- charge. In the low or weak states of the disease, dry-cupping on the nape of the neck may be tried, as advised by Aret.eus. 159. After the attack has been so far mitigated that the patient has recovered the faculty of de- glutition, I have often seen decided advantage derived from a draught consisting of equal quan- tities of the oleum terebinthina and oleum ricini, particularly when the bowels required to be fully acted upon. If the attack possess the sthenic character, and signs of fulness of blood about the head still continue, about half an ounce of each may be exhibited on the surface of mint water ; and, if necessary, repeated a second or third time, from twelve to twenty-four hours in- tervening between each dose. This will promote a more complete revulsion from the head than any other means that can be employed, particu- larly when preceded by calomel, or other cathar- tics, or followed by the enema prescribed above. (§ 144.). In the weaker states of attack, when we wish the medicine to act partially, by being absorbed into the circulation; and in cases where, from the mode of seizure and progression of the disease, we suspect haemorrhage or infiltration of blood in the brain, the following draught may be exhibited ; I have found it serviceable in such cases, even in some attended with the most un- favourable symptoms ; as very frequent, small, and intermitting pulse, and unconscious dis- charges, &c. :— No. 28. R Olei Ricini, 01. Terebinth., aa % ss.—3 ij.; Tinct. Capsici Annui TT) "•—xvj.; Olei Cajeputi IT) iv.—vj.; Aq. Mentli. Virid. g jss. Fiat Haustus, omne bihorio su- mendus ad secundum, tertium, vel quartum vicem. In some instances, where the lethargy has been profound, and the constitutional powers far de- pressed, I have derived much advantage from camphor, ammonia, and ether, given in suitable doses in the intervals, and continued after the above medicine had been carried as far as was considered either necessary or prudent. 160. It is generally requisite to have the hair of the patient cut very close, or shaved off, as soon after the seizure as possible ; and to attend to the injunction of Morgagni, never to omit enquiring after the state of the urinary discharge, and examining the hypogastrium, lest accumula- tions of urine take place, which should be im- mediately removed by the catheter, to prevent their injurious effects on the disease, and on the bladder. 161. d. Of the treatment of the consecutive and complicated states of apoplectic seizures.—A great majority of such cases requires but very slight modifications of the measures already stated. The importance of directing our means so as to restore suppressed discharges, &c. when the at- tack arises from this cause, has already been point- ed out. When it proceeds from the extension of APOPLEXY — Treatment of. 105 inflammatory action to the brain, and its termina- tion in abscess, effusion, &c, the principles stated above are still applicable. If the disease possess either a gouty or a rheumatic character (§92,93.), bleeding from the feet, local depletions, sina- pisms, or other rubefacient applications, &c. to the lower extremities, or to the joints or parts antecedently affected by gout or rheumatism, active purgatives, and the preparations of colchi- cum combined with soda, and moderate doses of camphor, are the most advisable remedies. In most cases of this description great accumulations of morbid sordes have formed on the digestive mucous surfaces, and thick or viscid dark bile in the gall-bladder and hepatic ducts ; therefore, after cupping on the nape of the neck, active cal- omel purges, promoted by enemata, are to be given, previously to having recourse to colchicum, which ought to be combined with alkalies,—with ammbnia or other restorative medicines, if the at- tack presents the asthenic character, and with aperients ; active revulsants being simultaneously employed. 162. When the apoplectic state arises from erysipelas of the head and face, incisions made into the scalp ofthe occiput, so as to allow a free discharge; cupping on the nape of the neck; ac- tive purgatives, consisting first of calomel com- bined with the tartrite of antimony or with James's powder, and compound extract of colocynth, fol- lowed by the draught of turpentine and castor oil advised above (§ 159.); and saline medicines, with the vinum antimonii ; are the means most to be depended upon. In cases of this descrip- tion the most active purgatives are required, and must be frequently repeated. The croton oil may be here exhibited, as already advised (§ 144.), and enemata should be administered from time to time. These already prescribed (§ 144.), or F. 141. 151. are most to be depended upon in this state of disease. Revulsants, and rube- facient pediluvia, are also serviceable aids. 163. When the apoplectic attack occurs on the invasion, or in the advanced stages of fevers (§ 94.), the general principles of treatment al- ready laid down cannot be departed from. When it comes on at the commencement of fever, gen- eral or local depletions are required, with cold affusion to the head, purgatives, saline medicines, and counter-irritation. But even here, the pro- bable state of the circulation within the head should be enquired into previously to the adoption of the means of cure; for, if the head be cool, the action of the carotids natural or below the healthy standard, and the attack be unattended by paralysis, restorative measures are called for, although the subsequent occurrence of reaction will afterwards require active antiphlogistic meas- ures. When the attack occurs in the last stages of continued or eruptive fevers.it most frequently presents the asthenic character, and is often an aggravated state, or a modification merely, of coma, unless hemiplegia accompany it. In these cases, local depletions from the occiput, the neck, and behind the ears ; active purgatives ; revulsants and counter-irritants, as blisters or sinapisms to the lower extremities, nape of the neck, or epigastrium ; camphor, combined with ammonia, aether, and liquor ammoniae acetatis, particularly when the head is cool, and the puls- ation or the carotids is neither full nor strong ; and, in the most asthenic cases, camphor in larger doses, the infusions of arnica, or of serpentaria (F. 222. 262.), are chiefly to be depended upon. After local depletions and revulsants have been prescribed, and one or more doses of calomel and rhubarb premised, the draughts directed above (R 23. 26, 27, 28.), or F. 270. 863., followed by enemata (F. 138. 149.), may be exhibited. 164. The association of apoplectic seizures with disorders of the digestive organs, particularly those of the liver (§ 97, 98.), requires local depletions from the right hypochondrium and epigastrium, followed by blisters in this situation, and a strenu- ous use of purgatives and mercurial preparations, until the secretions assume a healthy appearance. When the attack proceeds from impeded circula- tion through the lungs and right side of the heart (§ 95, 96.), local depletions, counter-irritation, and diaphoretics, are chiefly to be depended upon. But in these cases care must be taken not to de- plete too much, as the circulation may be still more impeded by the loss of power thereby pro- duced. In some instances of this kind, it will even be necessary to support the vital energies by suitable means, and to deplete the vascular system at the same time. When the attack is occasioned by hypertrophy of the left ventricle, general and local depletions are better borne than in the foregoing cases, and may be carried to a considerable extent. In both descriptions of cases, revulsants and counter-irritants, particular- ly by issues, and the tartar emetic ointment, are beneficial. 165. When the attack is occasioned by nm~- cotics or spirits taken in immoderate quantities, the stomach should be emptied by the stomach- pump, or by an emetic, a moderate blood-letting having been premised ; and afterwards, the cold affusion to the head ; internal stimuli, as cam- phor, ammonia, and ether; warm, strong coffee; and purgative enemata, should be prescribed. The occurrence of the seizure, also, during child-la- bour, or after epileptic or hysteric convulsions, requires large blood-lettings, preferably from the feet, the cold affusion to the head, cathartic in- jections, &c* 166. Attacks consequent upon colica-pictonum (§99.), two instances of which have occurred to me, generally require local depletion, full doses of calomel, followed by active purgatives and enemata (§ 142.). The draught of castor oil and turpentine (§ 144.), or the croton oil, followed by injections, are here chiefly to be confided in. If purgatives given by the mouth are thrown off the stomach,'—a circumstance which not infre- quently occurs in these cases,—a large dose of calomel will generally be retained ; and will al- * I was lately called to a case of puerperal convulsions which had terminated in the apoplectic slate. When I saw the patient, the labour had not proceeded so far as to admit of delivery by means of instruments. The pulse was slow and full; the breathing slow, laborious, and stertorous; the lips puffing and frothy, the countenance tumid and livid ; all the limbs flaccid, insensible, and incapable of motion. She had been blooded largely before I was called. The feet and legs were directed to be placed in a pan of hot water, and the saphenae veins to be opened. Whilst the blood flowed, the cold affusion on the head was employed. These means were evidently beneficial, though insufficient. A cathartic enema (F. 149.) was thrown up immediately, and with great difficulty : consciousness slowly returned ; when the decoc- tion of the secale cornutum, with as much boras sodas as it could dissolve, was administered. Uterine action afterwards came on, and the patient recovered. 106 APOPLEXY — Treatment of. lay the irritability of the stomach: other medi- cines may be afterwards exhibited, or a mixture of croton and castor oils rubbed over the abdo- men, and cathartic injections thrown up. The other states and complications of the disease must be treated according to the views and principles already explained, and with due reference to the nature of the pre-existing disorder, when it ap- pears to be a consecutive affection, or a principal part of a complicated state of disease. 167. C. Treatment subsequently to the ATTACK, OR THE CONSECUTIVE TREATMENT.-- The symptoms consecutive of apoplexy have a strict relation to the changes which take place in the seat of lesion. The absorption of the blood, and the process of cicatrization, require several months for their completion. During this time great care should be observed to prevent inflam- matory action from taking place around the extra- vasated blood, arid a return of the haemorrhage. This object is best obtained by adopting very nearly the same measures as have been recom- mended to prevent the accession of the attack (§ 126. et seq.). A too sedentary or studious mode of life, watchfulness, much indulgence of sleep, frequent stooping, and all the remote causes of the disease, must be carefully shunned. The strictest temperance and moderation, in respect both of eating and drinking ; moderate exercise in the open air ; tranquillity of mind, sedulously avoiding the least approach to bodily or mental fatigue, and excitement of the feelings or passions; the preservation of a free state of the alvine se- cretions and excretions, by means of mild and deobstruent purgatives and cathartic enemata; general or topical blood-letting, particularly every spring and autumn, with low living or a vege- table diet, when there is a tendency to vascular plethora; caustic issues, or setons in the nape of the neck, or in the course of the cervical spine; the use ofthe tartar emetic ointment, so as to keep out for a considerable time a pustular erup- tion on the part to which it is applied ; sleeping on a hair mattress, with the head and shoulders slightly elevated, and early rising ; are amongst the most efficacious means that can be adopted. 168. For persons who are prone to plethora, in addition to periodical depletions and low diet, the following pills and electuary may be taken on alternate nights :— No. 29. R Pilul. Hydrarg. Submur. Comp. gr. iij. ; Pulv. Jacobi Veri gr. ij.; Saponis Castil. gr. iv. M. Fiant Pilula; ij. h. s. s. No. 30. R Potassae Supertart. 5j- i Sodas Sub-boratis gr. x. (vel Magnesias Bj); Confectionis Senna;, Syrup. Zingiberis, aajj. M. Fiat Electuarium, pro dose,"hora somni, alternis noctibus sumendum. 169. When the disease is connected with the gouty diathesis, vegetable diet, the sub-carbonates of the fixed alkalies, with the extract of taraxa- cum or the preparations of aloes, the occasional use of an active cathartic, and the other prophy- lactic measures recommended in the article on Gout, are requisite. In all cases, as much ben- efit will now accrue from a strict attention to reg- imen and diet, as from medicine. The food should be light and digestible, of very moderate quan- tity, chiefly farinaceous, and taken at regular hours. Suppers should be avoided, or be ex- tremely light, and taken a considerable time be- fore the usual hour of repose. Fish, and ripe fruits, may be partaken of in moderation; and the waters of Cheltenham occasionally tried, or the following used as a substitute:— No. 31. R Magnes. Sulph. Jss.; Potassa; Sulph. g ij. j Infus. Rosar. Co. et Mist. Camphorae aagiijss. M. Capiat Coch. iij. ampla primo mane quotidie. 170. After attacks of the more asthenic states of apoplexy, a more tonic regimen than that di- rected above may be adopted ; but it should be conjoined with the same attention to the digestive, secreting, and excreting functions. Attacks of this description most commonly proceed from de- pressing or exhausting causes, which ought either to be avoided or counteracted ; and when they are not characterised by plethora, or disposition to iucreased action, gentle tonics, combined with aperients, a light strengthening diet, the occa- sional 'Use of the preparations of strychnine, or iodine, as recommended in the article on Palsy, and the mineral waters of Bath, Leamington, or Buxton. The following may also be occasionally taken:— No. 32. R Potassae Sulphatis gij-—.3»j-5 Infus. Rosar. Co. §vijss; Acidi Sulphur. Arom. 3j■ 5 Tinct. Aurantii Co. ^ss. M. Capiat Coch. iii: ampla primo mane. 171. In all cases of the consecutive treatment, the progress of the paralytic or hemiplegic affec- tion towards removal should receive attention. In the more favourable cases, as the period of attack recedes, first sensation, and afterwards motion, return in the paralysed limbs ; and gen- erally the lower extremity experiences the amend- ment before the upper. As recovery proceeds, the patient should always wear his hair cut short, and sponge his head with spring water night and morning. In summer he may use the shower bath daily, if he be not far advanced in life, or much debilitated. As much of the treatment de- scribed in the article Palsy, as may suit the cir- cumstances of the case may also be adopted, for the removal of this common sequela of the attack. (See also Asphyxy, and Poisons.) Bibliography.—Hippocrates, neQi i aaotv, lib. iii. p. 488. et Aphor., sect. vi. 57.—Aretceus, Be Sign, et Caus. Diut. Morb., 1. i. c. 7.; Curat. Acut., 1. i. c 4 —Galen, De Locis Affect 1. iii. c. 10. 14—^tius, Tetrab. ii. Serm. ii. c. 27.—Ccelius Aurelianus, Acut. Morb., 1. iii. c. 5.—Ori- basius, Synop., 1. viii. c. 6.—Forestus, Opera, 1. x. obs. 69. et seq.—Avicenna, Canon 1. iii. tr. 5.—Schenck, He Apo- plexia. Jen. 1582.—Wepfer, Anat. de Apoplexia, p. 437. —Bonet, Sepulchretum Anat., 1. i. sect. ii. obs. 37. 57.— Sydenham, Opera p. 577.—Baglivi, Prax. Med., i. c. 9 — Rolfinck, De Apoplexia. Jen. 1630.—Lancisi, De Subit. Mort., p. 120.—Seiz, Apop. Fein, et Mort. Erudit. Morb. Alt. 1714.—Morgagni, De Sed. et Caus. Morb., epist. ii. iii. v. xi. xxvi. lx. lxii, lxiii, et lxvii. — Hoffmann, De Apoplexia. Hala?. 1728. ; et Opera, sup. ii. p. 2.—Juncken, De Apoplexia ex Podagra Retrograda, &.c. Giess 1733. — Musgrave, De Arthritide Anomala, c. 15.—Borseri, De Apoplexia, p. 82.—Sauvages, Nosologia Method., t. i. p. 848. — Mistichelli, Trattato dell' Apoplessia. Romas. 1750.—Bong-, in Act. Reg. Soc. Med. Havn.,vol. i. p. 118. 251.—Weickard, Vermischte Schriften, v. i. et ii p- 21. et seq.—Fothergill, in Med. Observ. and Inquiries, vol. vi. and Works., vol. iii. p. 214.—Sel/e, Med. Clin., p. 40 — Schurig, Spermatologia, p. 261. et seq. — JValther, De Scarificatione Occipitis, plur. Cap. Morbor. Auxilio. Lip* 1741.—Pitcaim, Elem. Med., 1. ii. c. 2.—Cullen, Outlines, &c, vol. iii. p. 182.—J. Hunter, On the Blood, &.C. 4to. ed. p. 213.—Boerhaave, De Morb. Nervorum, p. 640.—Diemcrbr^ek, De Morb. Capitis, N. 12. — De Haen, De Apoplexia. Leid. 1745.; et Rat. Med. p. iv. c. 5, —Stoll, Ratio Medendi, p. iii 133. ; et Praslect., p. 367. — Mangold, Apoplexies plures, praster Sanguineam et Scrosam, Sic. Erf. 1765.—Marquet, Traite de 1' Apoplexie. Paris, 1770.—Niemann, De Apoplexia? Path, et Therap. Halae, 1772.—Lieutaud, Histor. Anat. Med., 1. iii Ob. 177. 263, kc. — Thilcnius, Med. und Chir. Bemerkungen, p. 76.—Quarin, Animadversiones, cap. 1.—Penada, Osser- vazioni v. Weigcl's Ital. Bibl. iv. b. i. p. 119.—Hosier, Von den Arten und ursachen der Schlagfllissc. Landsh. 1787.—Ingenhousz, De Apop. ejusque Spec. Var. Leid. APPETITE, MORBID. 107 1793.—Kirkland, On Apoplectic and Paralytic Affections. Lond. 1792. — Andrews, On the Apoplexy. Phil. 1793.— Reil, De Locis in Apop. Affectis. Hal. 1795., et Memorab. Clin., fas. iv. n. 4. — Ploucquet, De Vi Vitali in Apoplexia. Tub. 1796. —Portal, Anatomie MfSdicale, t. iv. p. 99.; et Sur 1'Apoplexie. 8vo. Paris, 1811.—Hecker, Brownii Senten. de Apop. Examen. Erf. 1800. — Crowfoot, Observ. on the Opinion that Extrav. is the Cause of Apop. &.c. Lond. 1801. — Boucher, Journ. de Medecine, t. xlviii. p. 76. Darwin, Zoonomia, vol. ii. p. 402. — Fodere, De Apoplexia. Aven. 1808.—Montain, Traite de 1'Apoplexie. Paris, 1811. — Cheyne, On Apoplexy and Lethargy. Lond. 1812. — Riobe, Sur 1'Apoplexie, et Epanchement de Sang dans le Cerveau, kc. Paris, 1814. — Cheyne, in Dublin Hosp. Rep., vol. i. p. 315.—Powel, On the Pathology of the Brain, Med. Trans, of Lond. Col. of Phys., vol. v. p. 198. 1815.— Moulin, Traite de 1'Apoplexie, kc. Paris, 1819. — Cooke, On Nervous Diseases, vol. i. Lond. 1820.—Duncan, in Edin. Med. and Surg. Journ., vol. xvii. 1821. — Cruigie, in Ibid., vol. xviii. 1822. — Copland, in Lond. Med. Repos., t. xviii. p. 20.—Serres, Nouvelle Division de? Apoplexies, Annuaire Mt-d. Chirurg. des Hop. Paris, 1819.; et Anat. Comp. du Cerveau, t. ii. Paris, 1826. — Bricheteau, Sur l'Apop. in Journ. Complement, du Diet, des Sciences Med. t. i. p. 129. 289., et t. iv. p. 17. Paris, 1819. —J. Frank, Interp. Clin., vol. i. p. 139.; et Praxes Med. Universal Prascep., pars ii. vol. i. sect. i. p. 330. et seq. — Krilof Journ. des Progres, kc, t. xii. p. 248. — Johnson's Med- ico-Chirurg. Review, vol. i. p. 1.; Edin. Med. Chirurg. Journ., vol. xxvii. p. 83.—■ Good, Study of Med., edit, by Cooper, vol. iv. p. 625. — Prichurd," On Diseases of the Nervous System. Lond. 1822.—Lallemand, Recherches Anat. Path! sur l'Enceph. et ses Depend. Paris, 1820 — 1829. — Rochoux, art. Apoplexie, Diet, de Med., t. ii.— Kellie, in Med. Chirurg. Trans, of Edin., vol. i. — Mills, On Morb. Appear, in Disord, of the Brain. Dub. 1826.— Bouillaud, Mtm. de la Soc. Med. de l'Emulat., t. ix p. 147. Paris, 1826. — Hooper, On the Morbid Anatomy of the Brain. Lond. 1826. — Abercrombie, Researches on Dis- eases of the Brain, kc Edin. 1828. p. 201.— Cruveilhier, art. Apoplexie, Diet, de Med. et Chirurg. Pratiq., t. iii. Paris, 1829. — Bright, Medical Reports, vol. ii. p. 266. et seq. Lond. 1831. — Kreyssig, Encyclop'adisches Wtirterb. der Med. Wissen., b. iii. p. 94. 1. APOPLEXY of New-born Infants—Ge- nerally proceeds from a protracted or difficult par- turition, particularly when the infant is large and plethoric, or when the cord has passed around the neck, occasioning both interrupted circulation in the cord, and obstructed return of blood from the brain. The apoplectic state in new-born infants is accompanied with tumefaction of the face, head, and neck, which, with the whole sur- face ofthe body, is generally of a bluish or violet colour. The muscles are flaccid, the limbs flexi- ble, and the body warm. The pulsations of the heart and of the cord are generally obscure, or not to be felt; respiration is suppressed; and death soon takes place, in extreme cases, if judicious means of restoration be not resorted to. 2. Upon examination of fatal cases, the vessels of the encephalon are engorged with blood; and occasionally blood is extravasated in the sub- stance of the brain, or between the membranes. The lungs are also generally congested. It is evident that the pressure of the turgescent ves- sels and extravasated blood upon the brain, and origin of the respiratory nerves prevents the res- piratory actions from taking place, and that all attempts to excite respiration will be ineffectual until the pressure is removed. The umbilical cord should therefore be immediately divided, and allowed to bleed to the extent of two or three spoonsful, according to the size and strength of the infant. When the apoplectic state is oc- casioned by congestion of the vessels merely, respiration will take place as soon as the vessels are unloaded, if no mechanical obstacles to the entrance of air into the lungs exist. Mucosities should be carefully removed from the throat, mouth, and nostrils; and, if the respiration does not spontaneously take place, insufflation of the lungs, as recommended in the article on Asphyxy of New-born Infants should be performed. 3. When the circulation is so torpid that the blood will not flow from the portion of umbilical cord attached to the infant, the little patient should be placed in a warm bath, rendered more stimulating by some salt, or by a little mustard; the portion of cord attached to the abdomen, or the abdomen itself, may be pressed momentarily, at several times, and in the direction of the divi- sion. If these means fail of procuring blood, one leech may be placed behind each ear. In some cases the apoplectic symptoms return after respi- ration has been established. This is generally owing to some interruption to the circulation through the lungs. In these cases of secondary attack, the application of one, or generally two leeches, placing the body or the lower part of it in a warm bath, and, if requisite, inflation of the lungs, and the other measures advised in the ar- ticle on Asphyxy, must be resorted to; and they will be successful it the case admit of recovery. Bibliography. — Gardien, Traite d'Accouchemens et Maladies des Femmes et des Enfans, t. iii. p. 130. — Desor- meaux, Diet, de Midecine, t. xv. p. 153. APPETITE, MORBID. Classif. 5. Class, Local Diseases; 2. Order, Depraved Appetites (Cullen). 1. Class, Diseases of the Digestive Functions; 1.' Order, Affecting the Alimentary Canal (Good). II. Class, I. Order (Author). 1. Defin. — Excessive craving for food, or desire for improper substances. 2. In this genus may be included two species, viz. 1st, Excessive or insatiable craving for food; and, 2d, A desire for improper substances, or what is not food. These states of function occur in practice variously associated and, although ap- parently different in themselves, yet they are often individually connected with similar states of the constitutional energies, and dependent upon near- ly the same state of lesion, whether functional or organic. It would seem that manifestations of function often differ most essentially, in different persons, or under different circumstances, owing to causes which are so slightly dissimilar as not to admit of distinction, or even, in some cases, to appear very nearly the same. In all, or the great majority of cases belonging to these forms of morbid function, the general pathological states of the system are nearly the same; the difference, even when it is most marked, being chiefly refer- rible to variations in grade, and to states of the stomach, in respect of its sensibility, its secretions, tonic contractions, and states of its villous mem- brane, which can only be matters of inference, but seldom of demonstration. As regards their nature, these affections are much more frequently symptomatic of lesion of function or structure in some other organ, than idiopathic, or constituting primary disease of the stomach itself. 3. Spec. I. Insatiable Appetite. — Syn. Bulimia (from pov, the augmentative par- ticle, and Xiubc, hunger), Fames Canina, Limosis ovens, Good. Bulimus, Polyphagia, Lycorexia, Cynorexia, Auct. Lat. Faim Ca- nine, Fr. Der Heisshunger, Ger. Dyspepsia Bulimia, Young. Gluttony, Canine Appetite. 4. Defin. A craving for food beyond the natural wants of the system, sometimes most ex- cessive in degree. 108 APPETITE, MORBID—TJauses of. 5. I. Varieties. An inordinate appetite is sometimes observed in the course of fevers and other acute diseases, particularly in convalescence from them; and in the progress of a number of chronic diseases. It is not infrequent in cases of extreme exhaustion, from whatever cause; and it may depend upon an acquired habit. But in or- der to consider it with some degree of precision, I will offer some remarks, 1st, upon habitual in- dulgence in an excessive quantity of food, or glut- tony; 2d, an insatiable appetite from exhaustion; 3d, on the excessive appetite, which, from the extreme voracity of the patient, has been called canine; and, 4th, on the voracity which is fol- lowed by vomiting. These constitute varieties of nearly the same disease. 6. A. Habitually excessive appetite, the Buli- mia Helliconum of Cullen. — In some cases^ the excessive indulgence of food has been of so long duration, and seemingly attended with so good a state of the general health, as not to appear in the light of a disease; but the results ultimately are, the production of so great vascular plethora, and disorder of the secreting functions, that, as soon as the vital energies begin to languish, apo- plectic, paralytic, or other maladies supervene. This variety of morbid function may be heredita- ry, but it is oftener acquired. It is not infrequent- ly observed in persons, originally of a strong con- stitution, who have indulged in large and frequent meals from having little else to engage their minds, and thus the vital energy has become con- centrated towards the stomach and the rest of the digestive organs, exalting all their functions. Per- sons of this description usually become large, bulky, or corpulent; and if they take much ex- ercise, the great indulgence of their appetite may not materially shorten their lives: but when se- dentary habits and indolence are conjoined with it, apoplexy and organic disease of the liver, stomach, bowels, &c. are the common results. 7. B. Inordinate appetite from exhaustion. — This is often a symptom of other diseases, and is chiefly dependent upon altered sensibility of the nerves of the stomach, proceeding from weaken- ed vital power. In many cases, however, it ap- pears as the chief ailment, as after great fatigue of body and mind; after excessive venereal indul- gences; in cases of great emaciation, sometimes without any evident cause; and during convales- cence from fevers and other acute diseases. It is very often observed as an attendant upon organic diseases of the stomach, pylorus, mesenteric glands, liver, uterus, &c. It has also been re- marked in cases where due nourishment could not be conveyed into the system, owing to dis- ease of the absorbent system; and it is frequent in the last stages of chronic maladies, when about to terminate fatally. In many of such cases the craving for food is attended with a distressing feel- ing of inanition, sinking, and faintness. Some of the cases of excessive appetite that occur in preg- nancy, or from the presence of worms, may also be referred to the debility and altered sensibility of the nerves of the stomach. And those which accompany inanition from a defective supply of chyle to the blood, may be attributed partly to the same cause, and partly to the instinctive wants of the system. 8. C. Voracious or canine appetite, the Buli- mia Syncopalis of Cullen. —This extreme form I of the disease is generally dependent upon some organic change of the stomach; but this is more a matter of inference than of observation. The chief seat of disease may even be some other organ. The quantities of food, particularly ani- mal food, cooked or raw, taken by some persons afflicted by this disease, are truly surprising.* One of the most remarkable cases in record is that published by M. Percy (Diet, des Sciences Med., art. Cas Rares). Both Cullen and Good are incorrect in stating that this form of Bulimia is attended with faintness. This is only an occasional symptom, which was absent in both the cases that occurred to me, as well as in that recorded by Dr. Crane. (Lond. Med. Repos., vol. xvii. p. 293.) 9. D. Voracious appetite followed by vomiting, the Bulimia Emetica of Cullen. — This variety of bulimia frequently proceeds from inflammatory irritation about the pylorus, but more commonly of the mucous surface of the stomach itself. The quantity of food devoured in this description of cases is often as large as in the last variety; but, shortly after having been taken, it is either alto- gether, or in part, thrown up, very little altered, and thus the patient continues alternately to crave for and to reject his food. This form of the dis- ease has generally been imputed to a scirrhous state ofthe pylorus; but the case of Dr. Crane, already alluded to, was evidently independent of such a cause. 10. II. Causes.—a. The remote causes of bulimia are chiefly hereditary predisposition; the habit of eating largely, voraciously, and without due mastication; chronic debility arising from obstruction of the mesenteric glands, liver, &c; the suppression or disappearance of chronic erup- tions, the healing of old ulcers, or the suddenly arresting habitual discharges, and the pathological conditions noticed in the foregoing remarks. 11. b. The immediate cause, or state ofthe or- gan on which it depends, seems to be somewhat different in the different varieties, even whilst the state of the constitutional or vital power may be considered to be, in the great majority of cases, very nearly the same. I believe that in many instances the voracious appetite is owing to an irregular distribution of the vital energy, and its concentration in the stomach, the nerves of this * I have met with two very remarkable instances of this affection in children, — the one of seven years of age, tha other of nine. In both these, but in the younger especially, the quantity of food devoured was astonishing. Every thing that could be laid hold of, even in its raw state, was seized upon most greedily. Besides other articles, an un- cooked rabbit, half a pound of candles, and some butter, were taken at one time. The mother stated, that this little girl, who was apparently in good health otherwise, took more food, if she could possibly obtain it, than the rest of her family, consisting of six besides herself. In both this and the other case, the digestion seemed to be good. Three or four large feculent motions were passed daily, and a nauseous smell emanated from their bodies. These children, who were both very intelligent, complained of no other un- easiness than a constant gnawing or craving at the pit of the stomach, which was never altogether allayed, but which, shortly after a meal, impelled them irresistibly to devour every thing that came in their way, in the shape of food, however disgusting. Nearly twenty years ago I saw, for a short time, a case of this description, which, occurred in a child of about the same age, and occasioned alarm owing to the circumstance of a large quantity of raw fish having been devoured by it. The result in this case did not come to my knowledge, but the former cases, which occurred at the In- firmary for Children, recovered by means of the treatment which will presently be noticed. APPETTTE, MORBID—Treatment of. JQ9 viscus being morbidly sensible, the muscular coats more irritable, particularly in the fourth variety of the disease; and the mucous coat in a state of erythism, or vascular excitement, and yielding a much larger quantity of its proper fluids than in health. The excited state of the nerves of the organ, will necessarily be followed by in- crease of its secretions, greater vascularity of its inner coat, and a disposition of the muscular tunics to react upon the enormous quantity of food which distends them; and thus there will result the craving of extreme hunger, a rapid solution of the food, and a quick transfer of it into the duo- denum ; or, if the reaction takes place suddenly, either vomiting or simple regurgitation of it, as in cases of rumination, which is sometimes compli- cated with bulimia. The more remote effects of this state of the organ are, torpor, debility, and a sense of faintness arising from the concentration of the vital energy, and determination of the circulation and secreting function towards the stomach and associated viscera, and the propor- tionate abstraction of vital influence from the brain and heart; imperfect assimilation; irritation ofthe digestive mucous surface, from unwholesome and unchanged food; an impure state of the blood, disorder ofthe secreting organs and morbid secre- tions,—all tending to disorganization, and to the destruction of life. 12. c. The morbid appearances found ondissec- tion consists chiefly of inordinate distension of the stomach and duodenum; a vascular and corru- gated state of their mucous surface, constituting complete hypertrophy of these viscera; a flabby, softened, and sometimes thickened appearance of all these tunics (Hagstrof.m); displacement of the right extremity or the greater part of the stomach low in the abdomen (French); indur- ation and thickening of its coats (Goudret); the insertion of the common bile-duct into its pyloric extremity (Vesalius and Bonet); dilat- ation of the oesophagus (Schurig); tamia in the bowels; lumbrici in the stomach and duodenum; en'argement and other organic lesions of the liver; scirrhus, thickening, and even dilatation (ILuysch), ofthe pylorus; thickening of all the coats of the duodenum, forming hypertrophy of this part; and various organic changes in the mesentery, its glands, the pancreas, spleen, and very generally in the mucous surface of the small and large intestines. M. Beclard observed, in a case of bulimia, the valvuke conniventes as large as in carnivorous animals. And M. Landre- Beauvais found, in a case complicated with pul- monary consumption, an unusually large size of the small intestines, and the gall-bladder wanting. 13. d. Symptomatic bulimia.—Inordinate appe- tite has sometimes been observed in cases of chronic disease of the brain, particularly in slow inflammation of its substance, threatening, or ter- minating in, insanity. A very marked case of this description, and two or three slighter in- stances, have come before me in the course of practice. I have also met with it at the com- mencement of hydrocephalus, and in epilepsy. When thus dependent upon disease of the brain, the inordinate indulgence of the appetite is often followed by vomiting. In the case of epilepsy, however, in which I met with it, vomiting never took place, although the quantity of food some- times taken was most excessive. The first, or 10 slighter variety of the malady, is not uncommon in epilepsy, particularly in the hereditary epi- lepsy of adults; the second variety sometimes occurs in hysteria, chlorosis, and pulmonary con- sumption ; and the fourth, occasionally, in chronic encephalitis. 14. Bulimia is more frequently met with, par- ticularly in its slighter forms, in pregnancy and in verminous affections, and is then very generally attended with an urgent feeling of inanition and faintness. When it occurs in pregnancy, there is usually a fanciful longing for particular articles of food, of which an enormous quantity is de- voured. A remarkable excitement of the nerves of the stomach may be inferred to exist in these cases, greatly augmenting the secretion of gastric juice. When the affection proceeds from worms, it may be imputed to the irritation of the nerves and mucous surface of the stomach and duode- num, whereby the circulation of, and secretions poured into, these viscera, are much increased, whilst the vital actions of the rest of the frame languish more or less. 15. III. Treatment. — The means of cure should have strict reference to the immediate cause to which we attribute the disorder. A. In theirs* variety of the disorder, it is generally in vain to state any means of cure. They entirely rest with the patient, by whom medical advice will seldom be followed. I have great doubt of a single glutton having been deterred from the habit he has acquired, by the injunctions of his medical adviser, until an attack of illness occasioned him alarm. The cure is sufficiently simple, and may be comprised in the single recommendation of employing his mind and body more, that he may abuse his stomach less. 16. B. In the second variety, great attention is re- quired to adapt the treatment to the circumstances in which it presents itself. The nature of the malady of which it is most commonly a symptom, must necessarily be our guide; and as the means should be strictly appropriated to the peculiarities of the case, no general rules can be stated with propriety, further than that the effects of whatever is employed should be carefully watched, and that more mischief will result from indulging the crav- ing complained of, than from opposing it, and allowing no more nourishment than the nature of the case, or the system, may seem to require. In the bulimia that occurs in convalescence from acute diseases, the wants of the economy are gene- rally greater than in other cases, and here more may be allowed: if fever or disorder follow the indulgence, a purgative will, generally remove it. 17. C. The preceding observations apply likewise to the third and fourth varieties of this disease, The cases which occurred in my practice were cured by an active course of nauseating purga- tives, consisting chiefly of the oil of turpentine with castor oil. In one of the cases, where the voracity was almost incredible, the first dose of the turpentine was followed by the sudden ap- pearance, over the whole trunk ofthe body, of a most copious and thick eruption, more nearly re- sembling porrigo favosa than any other, and by the equally sudden relief of the symptoms. This treatment was left off; when, after a few days, the eruption disappeared, and the voracious ap- petite returned. It was ultimately removed per- manently by the hydrarg. cum creta, combined 110 APPETITE, VITIATED —Causes of. with soda, taken at bed-time, and a turpentine draught in the morning of each third or fourth day. Leeches were applied over the epigastric region; and either the tartar emetic ointment, or liniment, was nibbed upon the same situation till a copious eruption of pimples was produced. The strictest regulation of the diet was enjoined. 18. D. In the variety attended with partial or general regurgitation, or vomiting of the food taken in excessive quantity, the best effects will result from obliging the patient to abstain almost altogether from food, or to take a small portion of nourishment in the least possible bulk. Great distress from hunger will be felt for a few days, but this will gradually subside. In the instructive case published by Dr. Crane, this plan was per- sisted in; and portable soup, made into pills, was given, as the only nourishment, for several weeks: the patient recovered perfectly. A nearly similar treatment had been previously employed by Mr. Wastell with success. (Mem. of Med. Soc. of Lond., vol. iii. No. 2.) Where, however, the stomach is not so irritable as to tlnow off any portion of the ingesta, and has become distended and enlarged from habitual ingurgitation, a gradu- al diminution of the food will be better borne, and perhaps be more efficacious, than its sudden reduction. The propriety of employing deob- struents, small doses of the blue pill, combined with ipecacuanha, active cathartics, either by the mouth or in the form of enema, and external irri- tants and revulsants, in cases of this description, cannot be questioned. Exercise, where it can be taken; and employment for both body and mind, as far as circumstances will permit; are also most useful adjuncts. Bibliography. — N. Jossius, De Voluptate, Dolore, Fame, kc Rom. 1580___Van der Meer, Diss, de Fame Canina. Lugd. Bat. 1660.— Vesalius, Anatom., 1. v. c. 3. 8. — Bouet, Sepulchretum Anat., 1. iii. sec. ii. obs. 1. et 3. — Schurig, Chylologia, p. 2— 17. —De Reus, De Bulimo et Appetita Canine" Lei3. 1673. — Moi-timer, in Philos. Trans., No. 176. —Rivinus, De Fame Canino, et Buhmo. Lips. 1716.—Sauvages, Nosol. Meth. t. ii. p. 215.—French, Memoirs of Med. Society of Lond., vol. i.—Hagstroem, Kiihn Repertorium, b. iv. p. 630. — Cullen, Synopsis, ci.— A. F. Walther, De Obesis et Voracibus, kc. in Delect. Opuscul.Med. Col. a J.P.Frank, p. 236. Lips. 1791__J. M. Good, Study of Medicine, vol. i. p. 142.—Landre-Beauvais, art. Boulimie, Diet, des Sciences Med., torn. iii. Spec. II. Vitiated or Depraved Appe- tite.—Syn. Pica, Citta, Malacia, Pseudo- rexia, Limoxis Pica, Good. Dyspepsia Pica, Young. Der Sonderbare Appetit, Ger. 1. Defin. An appetite for substances which are not food. 2. Causes,—This state of the appetite some- times occurs in children, from an early acquired habit; and it is frequently observed in idiots, from want of ability to discriminate what is or is not food, or from perversion of taste. Various substances also, which are abhorred in one cli- mate, constitute the chief articles of diet in another. Thus, the Californians live on snakes, rats, lizards, &c, and numerous tribes of Africans on monkeys, dogs, snakes, &c It is very frequently observed in pregnant, hysterical, and chlorotic females, and it is sometimes connected with certain kinds of mental emotion. I have met with several instances of it in females at the age of commenc- ing puberty, when neither hysteria, in any of its forms, nor clilorosis, existed. In these, and per- haps in the great majority of cases, it is altogether a symptomatic affection, arising from altered sen- sibility of the nerves, and modified state of the se- cretions of the stomach, occasioned by imperfect function, or changed condition, of a related organ, particularly of the uterus, ovaries, large bowels, and brain. 3. When it is observed as the primary disorder, it has generally been owing to a habit, commenced at first with the view of improving the shape and complexion. Females early in life sometimes have recourse to acids, particularly vinegar, and chalk, for this purpose. The form of the disease, which has been described by Dr. John Hunter as dirt-eating, by the negroes in the West Indies, and which has even assumed an epidemic charac- ter, is, perhaps, more than other forms of it, de- serving of being considered as idiopathic. The earth they devour chiefly consists of a loam or clay, and may possibly be taken by them from the circumstance of their having found it assuage the painful sensations produced in the stomach by acidity. This affection is much more frequently met with in the female than in the male sex; but instances of its occurrence in the latter are not rare. I have seen several instances of it in males; and in females it is often practised in so concealed a way, as not to come to the knowledge of the medical attendant. 4. The substances which occasionally become the objects of desire are sufficiently numerous. Medical records abound with them. Cinders, spiders, lice, flies, insects, toads, serpents, wood, hair, paper, earth, clay, chalk, vinegar and other acids, and even ordure, have all been devoured in cases of this disease. Various other substances have been swallowed, more as singular exploits than from actual longing for them. Thus we have accounts of persons taking into their stomachs clasp-knives, musket bullets, billiard balls, gold watches, and Louis-d'ors; and, what is still more singular, generally discharging them by stool a few days afterwards. Knife-eating seems to have been no uncommon feat, as we have instances recorded of London, Prussian, Bohemian, North American, and Brazilian knife-eaters. Our friends of the United States seem to have surpassed all others in the rapacity which their knife-eater exhibited; for in June, 1822 (New York Med. Repos.,Oct. 1822), after having been duly ini- tiated in the art, by swallowing a gold watch, chain and seals, billiard balls, and various other arti- cles, at different times, which had passed through his callous digestive tube, he swallowed fourteen knives in the course of the day. This was his great, but his last exploit, for he died two months afterwards; having passed two of the knives by stool, the remaining dozen being found in the body, — eleven in the stomach, and one in the oesophagus. 5. The articles most commonly fancied by young females are paper, cotton, thread, chalk, vinegar and other acids. I once saw a sickly-complexioned lad, who was in the habit of eating sand; and a robust seaman, who occasionally would devour a whole wine or ale glass, having previously crushed it in small pieces with his teeth, and yet no bad effects resulted, at least for many months after- wards. (Lond. Med. Repos. vol. xviii.) The only other instance on record, where this most danger- ous feat has been performed, is given by Came- ra rius (Memorab. cent. v.). 6. When pica is complicated with bulimia, as ARTERIES — Ls sometimes observed, most singular and even astonishing feats in the way of devouring sub- stances ofthe most unsuitable kind are on record, —many of them also so large, that the possibility of their being conveyed into the stomach, if they had not actually been found there, might have been doubted. Some really astonishing and au- thentic instances of this kind have been related by M. Fournier (art. Cas. Rakes, Diet, des Sciences Mid. t. iv. p. 135.). 7. Treatment.—The means of cure must, of course, have strict reference to the morbid condition of the system, of which it is so frequent- ly a symptom. If it accompany pregnancy, I be- lieve that the axiom which M. Francier adopts as the title of a treatise on the subject should be adopted, viz. A pregnant woman affected with pica should be well purged. If it be attendant upon chlorosis, aloetic purgatives, with emmena- gogues, and these followed by or given alternate- ly with tonics, are the most suitable means, and are equally beneficial in the pica which occurs about the period of puberty. In hysteria, similar measures, combined with valerian, asafoetida, camphor, and other antispasmodics, are indicated. In these three symptomatic forms of the disease, any of the Formulae for those medicines in the Appendix may be adopted. 8. When the affection presents an idiopathic, which is comparatively rare, it is most common- ly owing to a weakened state of the digestive or- gans, with, perhaps, an altered sensibility of the nerves, and acid state of the secretions of the stomach. In these cases, the combination of vegetable tonics with alkalies, and attention to the alvine secretions and excretions, are chiefly to be attended to. The treatment of cases of the affec- tion induced early in life from habit, will be un- satisfactory, or without avail, until the cause is removed ; but it differs in no essential particular from that now stated. In many cases the per- nicious habit has commenced with early puberty, and, as well as in the cases associated with chloro- sis, hysteria, pregnancy, and irregularity of the menstrual discharge, is evidently dependent upon the state ofthe uterine functions. (See Chloro- sis, Menstruation, &c. Bibliography. Francier, Ergo Gravida? Pica Labo- rautes Purgandae. Paris, 1615.—Beck, Dissert, de Pica Pracgnantum, 4to. Lugd. Bat. 1653.—Schuster, De Pica seu Malacia. Arg. 1658. 4to.—A. Castro, De Morbis Mulierum 1. iii. p. 389.—Forestus, Opera, 1. xviii. obs-. 7., et 1. xxviii. obs. 65.—Scheider, De Appetitu Gravidar. Wit. 1670. 8vo.—Horstius, Opera, vol. ii. p. 160—Sau- vages, Op., t. ii. p. 212.—Meyer, Diss, de Pica et Malacia. Erf. 1702.—Schurig, Chylologia, pp. 38. 45. 49, &c— Scheidemantel, Beytritge zur Arzneykunde, No. 5. et ]N"o. 34.— Gruner, Dissert, de Pica et Malacia. Jenae, 1791.—Hunter, On Diseases of the Army in Jamaica, 8vo.—Cullen, Synopsis, c. iii.—Good, Study of Medicine, vol. i.—Gardien, Traite Complet d' Accoucneme s, et des Maladies des Filles, des Femmes, et des Enfans. Paris, 1826. ARTERIES, their Diseases.—Syn. 'Aor^o/a, Gr. Arteria, Lat. Artere, Fr. Eine Schlagader, Pulsader, Ger. Arteria, Ital. Artery, Eng. 1. The morbid conditions of arterial vessels cannot be appreciated, either in respect of their causes, symptoms, or consequences, unless their organization and connections with other systems of the frame be clearly understood. It does not fall within my limits to notice all the connections which these vessels present with other parts of the body ; but there are a few to which I will briefly allude, as most material in the causation seir Diseases. \\\ of their diseases, and of certain sympathetic affec- tions with which these diseases are related. 2. I. Organization.—The arterial tubes are essentially constituted, 1st, Of an external and adventitious tunic, consisting of a very delicate and condensed cellulo-filamentous tissue. This tissue is never infiltrated by serum, nor loaded by fat; and possesses the greatest degree of resist- ance of all the other coats of the vessel. 2d. Of a proper coat, consisting of fine circular fibres placed closely together, and forming a strong tissue of a dun yellowish colour. The nature of this tissue has been a matter of much dispute with pathologists. It certainly does not possess the physical and chemical properties of the fibres of voluntary muscles, from which it chiefly differs in being much more close in its structure, and more elastic and fragile than they. It more near- ly approximates to the fibres of involuntary and hollow muscles, as those of the intestinal canal. 3d, Of a very delicate cellular tissue, like a fine pellicle, the second cellular tunic of Haller, interposed between the fibrous or proper coat and that next to be described. It is in tins fine mem- brane that the minute vessels supplying the arte- ries, and which proceed from the adjoining parts, terminate; and here also the ultimate distributions ofthe arterial nerves may be supposed to ramify, although they cannot be clearly traced further through the coats of the vessel than the proper fibrous tunic where I have distinctly followed them. This is the most vascular of the tunics strictly constituting arterial vessels ; and one in which many of those changes which will fall under consideration commence. 4 th, Of an in- ternal membrane, presenting no linear or fibrous structure, semi-transparent, more readily detach- ed from the one next to it in the longitudinal thaa in the transverse direction, and fragile. This delicate membrane is not possessed of ves- sels carrying red blood in the healthy state, but it is penetrated by minute red vessels when in- flamed. It lines, with scarcely any perceptible modification, the canals of all the vessels convey- ing red blood, and the cavities ofthe heart. 3. The arterial vessels thus formed are sur- rounded by a sheath of loose cellular tissue, more or less abundant in some parts than in others, permitting the vessels to accommodate themselves to their varying state of dilatation, constriction, &c, and transmitting the vessels which are em- ployed in their nutrition. The elastic properties, also, ofthe proper coat ofthe vessels, serves also to accommodate their capacity to the state of the circulating fluid ; and as it is generally supposed that they are in a certain degree of distension during life, owing to the quantity of blood con- stantly being impelled through them by the heart's contractions, so it is believed that the contractions which they display on the removal of this fluid is at least partly owing to the abstraction of the dis- tending cause. 4. No trace of longitudinal fibres can be de- tected in arteries. The elastic properties which they present in the direction of their axis, when extended beyond their natural limits, and their retraction upon their division, are chiefly owing to the dense cellular coat immediately surrounding the proper fibrous structure of the vessel. The different degrees of tenacity presented by the va- rious structures composing the parietes of these 112 ARTERIES —Inflammation of. vessels, acting conjointly with the elasticity of the proper coat, have been considered by many as sufficient to account for the absence of haemor- rhage after laceration of these vessels. Doubt- less these circumstances contribute, but I con- ceive that they are insufficient of themselves to account for this and other phenomena, which will be noticed in the sequel. 5. The arteries are surrounded by the ganglial nerves, which form a reticulum around them ; and from this reticulum very minute fibrillar are given off, and dip into their fibrous tunic. This disposition of the ganglial nerves on the arteries ought to be kept in recollection when we enquire into the functions and diseases of the latter. How far it is necessary, not only to the discharge of the most manifest actions which the arterial sys- tem performs, but also to those changes which the blood undergoes in disease, and to the as- similation ofthe chyle, and other absorbed fluids, I have ventured to state in the article on the Pa- thology ofthe Blood. It is evidently to the very Ultimate connection of this class of nerves with the arteries, and the effects resulting therefrom, that we must impute those changes, whether functional or organic, which take place in the latter, and which influence the state ofthe blood, and the circulation through them. (See the Au- thor's Appendix to Richerand's Physiolo- gy, p. 556. 613.) 6. II. Nervous Affections of Arteries. —II. Class, I. Order (Author). 7. There is sometimes disorder referrible to a particular artery, or arteries, evidently depending on an affection of the nerves supplying them. Of this description are, 1st, Neuralgia ofthe arteries; 2d, The violent pulsations sometimes felt in a large arterial trunk. 1st, Laennec admitted the existence of neuralgia of arteries, and considered it to be characterised by acute pain in their course, with increase of their pulsations and the bellows sound ; and to be independent of inflammation, as shown by the sudden accession and remission of the symptoms, and their periodic recurrence. That this affection is sometimes connected with irritation, or with an inflammatory state of its nu- tritious vessels, may or may not be the case ; but it is certainly not always so connected. 8. 2d, Violent pulsation of arteries is more commonly observed unaccompanied with exces- sive pain. In these cases a loud bellows sound is often heard in all the principal arteries, particular- ly those in which the increased pulsation is felt. This affection generally supervenes and disap- pears suddenly in nervous and debilitated persons, particularly after large losses of blood. Morbid anatomy has not as yet thrown any light on its na- ture ; and therefore we can only refer it to some peculiar influence exerted by the nerves supply- ing the vessels thus affected, and probably de- pending originally upon the state of the vital ener- gies of the frame. It is sometimes associated with hypertrophy of the heart. In this case, it is in a great measure to be imputed to that disease. 9. Treatment of these affections.—When neu- ralgic pain is felt in the course of arteries, and is quite unaccompanied by inflammation, the same treatment which is recommended in the article on the painful affections o/Nerves may be adopt- ed. After morbid secretions and intestinal col- luvies have been carried off by purgatives, tonics combined with antispasmodics may be employed. The preparations of iron, the sulphate of quinine, ammonia, camphor, alone or combined with opium, colchicum, belladonna, or prussic acid ; the external application of the acetate or muriate of morphine, or the cyanuret of potassium, &c. may be tried. In the cases of inordinate pulsa- tions, unassociated with pain of the arteries, atten- tion to the alvine secretions and excretions, and the use of tonics and antispasmodics, will general- ly be productive of advantage. As these func- tional disorders are generally consequent upon disturbance of some internal organ or part, some- times a distant or remote effect of pre-existing disorder, the seat and nature of such disturbance should be investigated, and the treatment directed accordingly. In all such cases, residence in a dry and salubrious air, occasional change of air, gentle and regular exercise, and a light and nutritious diet, will be of much service, (see Art. Aorta, § 2—6.) 10. III. Inflammation of Arteries.—Syn. Arteritis, or Arteriitis ; Artereitis, Hilden- brand. L'Arttrite, Fr. Pulsader —, Ar- teri —, Schlagaderentziindung, Ger. Classif. III. Class, I. Order (Author, see Preface). 11. Defin. Great and tumultuous vascular excitement, jialpitations, anxiety, sense of heat and throbbing in the course of the principal ar- teries, followed by collapse of the vital energies, and occasionally by gangrene of a limb. 12. This disease was not entirely unknown to the ancients, as ARETiEus makes mention of in- flammation of the aorta. But notwithstanding the incidental notice which was taken of inflammation of arteries by Morgagni, and Boerhaave, and afterwards by Grant, the attention ofthe medi- cal practitioner was never directed to the subject, until J. P. Frank noticed it in a particular man- ner. It is, therefore, to the last-named author that we are chiefly indebted for the numerous re- searches of pathologists, respecting it in modern times. Since the appearance of Frank's work, arteritis has received due notice from Testa, Kreysig, Reil, Baillie, Burns, Corvisart, Schmuck, Portal, Scarpa, Hodgson, Tra- vers, Ribes, Laennec, Breschet, Dal- bant, Vaidy, Bertin, Bouillaud, Guthrie, Trousseau, and several others, and it is now generally recognised as a specific and most im- portant disease, sometimes occurring primarily, occasionally consecutively and conjoined with other diseases, by no means of rare occurrence, and, in whatever form it presents itself, always threatening the most serious consequences. 13. Pathology of Arteritis.—Arteries, being composed of distinct tissues, may be sup- posed to be liable to all those kinds of inflamma- tory action, to which each of their constituent parts are most disposed. However frequently in- flammatory action may originate in one rather than in more of the coats of an artery, it seems seldom to continue thus limited, but soon affects the rest to a greater or less extent. It may even seize simultaneously upon all the coats ; but this is, I think, of comparatively rare occurrence. The individual tissues of an artery most frequent- ly inflamed, in a primary manner, are the inter- nal membrane of the vessel, and its connecting cellular tissue. ARTERIES — Inflamm 14. Arteritis may be partial or general, as re- spects its extension through this class of vessels -? and it may present every grade of activity, from the most acute to the most chronic form. It gen- erally attacks one or more of the arterial trunks and larger branches. When it affects the arterial capillaries, it constitutes, in the opinion of some pathologists, inflammation itself; but whether it can be demonstrated as existing in this latter class of vessels, or in what respects it may either differ or agree with inflammation when it does thus exist, are points which have not been yet settled by the few pathologists who have agitated the question. 15. Inflammation may possibly, however, seize npon a number of arterial ramifications in an organ, especially in an unhealthy habit of body, or in a part injured by external violence or exces- sive cold ; but, when it is thus seated, all circu- lation through the part is quickly interrupted, owing to the effusion which takes place and de- stroys the permeability of the vessels. The con- sequences in such cases are, 1st, sphacelus and gangrene of an extremity or part, as we observe in cases of frost-bite ; and, 2d, when the inflam- mation is limited to the capillaries of a circum- scribed portion of an organ, particularly when this portion is surrounded by healthy structure, a breaking down of the texture, and its conversion into a fuetid purulent-like matter, as in gangrene of the lungs, and some kinds of abscess formed in the parenchyma of several organs. 16. In constitutions possessing the power to limit the inflammation, which has thus seized upon a congeries of arterial vessels, by throwing out coagulable lymph, the extension of the in- flammatory process to the larger branches and trunks is prevented ; and, if the part already af- fected be an extremity, a distinct line of separation is thus drawn, or if it be situated in the centre of an organ, a cyst is thus formed by the lymph ef- fused, tending both to the limitation of the inflam- mation, and to exclude, as it were, the parts which the loss of circulation has deprived of vital- ity, from the surrounding living textures, and from the contamination which the defect of this natural partition would allow to take place. 17. When the constitutional powers and vital energy of the vessels of the part are insufficient for the formation of the means of limitation here pointed out, the inflammatory action ofthe small- er arterial vessels extends itself to the larger trunks; and the affection of these, in addition to the preexisting inflammation ofthe small branches, increases the mischief; the gangrene extending itself without any line of separation being formed. In this case the constitutional powers fail rapidly, owinf to the contamination of the surrounding structures and circulating fluid, from the absorp- tion of the products of inflammation through the venous capillaries of the part, which seldom escape participating in the disease. 18. Such seem to be the results of inflamma- tion affecting a congeries of arterial vessels, or the arterial branches and their ramifications through- out an extremity; and 1 conceive that those in- flammations which are rapidly followed by spha- celation and gangrene, as well as some lesions con- sidered under different heads, and which have been generally referred to the common seat and conse- quences of inflammation, are of the nature now 10* pion of, its Pathology. U3 described. It seems extremely probable that sev- eral lesions of a disorganized and disorganizing description, following rapidly upon the first devel- opement of deranged circulation, arise from the source now contended for ; or, in other words, that some of the consequences usually referred to common inflammation, in conjunction with pecu- liarity of habit and of the part affected, actually spring from inflammation and obstruction of the arterial vessels, and cannot be otherwise satisfac- torily explained. 19. Inflammation of arteries, like inflamma- tions of all other parts, may, however, give rise to effects which will vary according to the degree of intensity of the morbid action, the coat or coats of the vessel in which it originates, or to which it extends, and the habit, diathesis, and constitu- tional energy of the patient. The duration of this disease, as well as its constitutional effects, will also depend upon the above circumstances ; and in inflammation of this part of the system, more perhaps than in the inflammation of any other part ofthe body, excepting merely the rest ofthe circulating organs, the primary effects and pro- ducts of the inflammatory act will be rapidly productive of ulterior effects, serious in their na- ture and results, even after the morbid action which originated them had altogether disappeared, and could be recognised only in those remoter but palpable consequences, some of which have been alluded to in the preceding paragraphs, and which will be more fully referred to in the sequel, particularly in the section on the morbid structure of arteries (§ 38.). 20. Causes.—1st, The predisposing causes of arteritis are generally those of inflammation in general ; but those which seem especially to fa- vour the production of this disease, are the gouty and rheumatic diathesis ; the middle and advanc- ed epochs of life ; certain constitutions ofthe at- mosphere, or epidemic influence ; peculiarity of climate, and whatever occasions a diminution of the crasis of the blood, or imparts to it an ex- citing influence on the vessels ; indulgence in the use of mu^h animal food, and vinous and spirit- uous liquors; a plethoric habit of body, partic- ularly when conjoined to the sanguine and irrita- ble temperaments ; prolonged high temperature ; intemperate and luxurious habits ; the constitu- tional effects of syphilis or mercury ; the suppres- sion of accustomed discharges, particularly the sanguineous ; reiterated or prolonged attacks of nervous, convulsive, or spasmodic diseases ; and deficient secreting powers of the various emunc- tories, as the kidneys, liver, &c. 21. 2d. The exciting causes of this disease, be- sides those which are more commonly productive of inflammation, are congelation of parts from great cold, and the sudden exposure to a higher temperature; insolation ; punctured, incised, lac- erated, or contused wounds ; surgical operations; ligatures of arteries after the operation for aneurism (Cline, Abernethy, &c), or amputation, and from tying the umbilical chord (Oehme); exces- sive suffering from long-continued operations; con- tinued and fatiguing exertions ; sudden and violent muscular action ; the sudden extension of a part occasioning the elongation ofthe vessel and rupture of its internal coat; pressure in the course of arte- rial vessels ; violent fits of passion ; great mental emotions; exhaustion of the vital powers; puru- 4tion of, its Pathology. 114 ARTERIES —IxFLAMMi lent and morbid secretions ; animal matters and poisons absorbed into the circulation ; chemical agents of any description introduced into the vascular system ; and the sudden repulsion or suppression of exanthematous fevers and eruptive diseases. Portal records an instance of the disease which was occasioned by the repulsion of the eruption of measles. I met with an instance of inflammation of the internal membrane of the heart and arteries, in a fatal case of malignant scarlatina, with an imperfect and evanescent erup- tion on the skin. M. Breschet details seve- ral cases in which the disease was consequent upon erysipelas and chronic abscesses. I have found the internal surface both of the arteries and of the veins dark red, and softened, in two fatal cases of puerperal fever, characterised by evident signs of absorption of sanious matter from the uterus. A case also lately came before me of erysipelas followed by gangrenous escars on the sacrum, where the internal surface of the sanguiferous system, and particularly of the aorta and large arteries, as far as they were examined, presented a similar appearance. In all these cases the inspection had been made within eighteen hours after death. 22. The causes of arteritis consist, therefore, 1st, of those which act externally as respects the vessels; and, 2d, of those which irritate in a di- rect manner the internal surface of the arteries themselves, by being conveyed into the circulat- ing fluid, the properties of which they may have previously changed. But, in whichever of those ways they may act, their first effect seems to be to change or influence the vital energies of the organic nerves ramified to the coats of this sys- tem of vessels. 23. 3d. Anatomical characters.—As to the par- ticular tissue of the arteries, in which the inflam- mation originates, I am of opinion that a careful examination of the phenomena of the disease in connection with its causes and complications will warrant the inference, that, when it arises from those causes which act exteriorly to the vessels (§ 21.), and which are chiefly local in their operation, the inflammation is generally limited as to its extent, being confined to a part only of the arterial system, or to two or more considera- ble branches ; that it often affects more than one of the coats of the vessel in this case ; and that it generally assumes the sthenic characters, giving rise to those changes which usually result from this form of inflammatory action, such as the efiusion of coagulable lymph, forming fibrinous concretions and false membranes in the interior of the vessel, obstructing or obliterating its cavi- ty; red vascular injection, thickening and soften- ing of its tunics; and suppuration, with or without ulceration of its internal membrane. 24. On the other hand, when the disease ori- ginates from causes existing within the vessels, and acting through the medium of the blood itself, and more especially when it is complicated with malignant and eruptive fevers, with erysipe- las, &c, or is caused by the absorption of morbid secretions, &c. into the current ofthe circulation, the vascular excitement is rapidly followed by symptoms of an ataxic or asthenic character ; the inflammation is chiefly confined to the internal surface of the vessels, but it extends more or less throughout the whole arterial system, and, in many cases, also to the inner lining of the cavi- ties of the heart, and even of the veins. In cases of this description, the lesions of the arte- ries which it occasions consists chiefly of a dark red or violet-coloured injection of the inner mem- brane and connecting cellular tissue ; great soft- ening and friability of those tissues, with slight sanious infiltration of the walls of the vessel in different parts. 25. It should not, however, be overlooked, that the inflammation of an artery may frequently commence from local causes, and originate in, and be for a time confined to, a particular trunk or its branches, presenting all the signs of the sthenic form of inflammatory action, and yet, ow- ing to causes lowering the vital energies of the frame, or to the absorption of the matters secreted from the inflamed vessel into the current of the circulation, or to both, may pass into the gene- rally diffused and ataxic state of the disease. 26. Symptoms of Acute Arteritis.— These will necessarily vary according to the stage of the disease, the severity and activity ofthe attack, and the organic changes which the inflammatory action has occasioned in the affected vessels. [ shall therefore adduce, first, those symptoms which characterise the disease previous to the superven- tion of those changes which affect this system so as materially to impede its functions, or to change the condition of the circulating fluid ; and next, those signs which indicate important changes in the state ofthe vessel, and ofthe blood itself. 27. The first stage is one frequently of much obscurity; and when the inflammation is limited to the vessels of a single limb or organ, it is very difficult to distinguish it from the common inflam- mation ofthe part. While the internal tunics of the vessels are yet the chief parts affected, and the effusion of lymph into their interior has either not supervened, or not obstructed their canals, the patient generally feels, either after a rigor, or at first alternating with rigors, an increase of the pulsations of the vessels of the part, with a sens- ation of heat, uneasiness, or pain. When arte- ritis is more general, and particularly if it be connected with inflammation of the heart's inter- nal surface, as occasionally occurs, the symptoms are those of fever of an extremely inflammatory type, as has been remarked by J. P. Frank (De Cur. Horn. Morb. t. ii. p. 175.) and M. Bouil- laud (Traite Clin, et Exp. de FUvres, p. 175.); commencing in rigors, at first alternating with, and followed by great anxiety, irritability, rest- lessness, uneasiness, a sensation of burning heat, and remarkable pulsation, with increased sensi- bility in the course of the large arteries. The patient complains of general and unremitting throbbing throughout the system, sometimes felt more intensely in one part than in another. The surface of the body is hot, tumid, and injected ; the tongue red, the papillae erect, and its base furred and loaded ; the bowels are costive ; thirst is urgent and unquenchable; the urine scanty, voided with a sense of scalding, and high-colour- ed; the patient is distressed with palpitations. The pulse at this stage of the disease is strong, tu- multuous, throbbing, full, and frequent; and the contractions ofthe heart hurried and tumultuous. To these are sometimes added cough, occurring in paroxysms, with fits of dyspnoea. When the inflammation extends to the aorta and internal ARTERIES—Inflammation of, its Pathology. 115 lining of the heart's cavities, the characteristic symptoms of inflammation of those parts (see Aortitis, &c.) are superadded to the above. 28. The second stage is chiefly characterised by the greater severity of the symptoms, indi- cating that serious changes are advancing in the internal coats of the vessels, and influencing not only the state of the vital energies of the sangui- ferous system, but also the state ofthe blood. At this period of the disease, the pulse generally be- comes extremely frequent, and often wiry, weak, and irregular; whilst the palpitations, anxiety, and paroxysms of dyspnoea increase. The tongue is either dry, the papilla? erect, and its centre furred with a dark mucus or sordes ; or it is smooth, glossy, and of a dark tint. The patient is liable to startings and spasms in different parts, of the body. The desire for drink increases; the strength sinks; the countenance at first shrinks, is pallid or haggard, but, towards an unfavourable close of this stage, it often becomes somewhat bloated, oedematous, or cadaverous, occasionally injected, and the lips purplish. The extremities are frequently cedematous; and they, as well as other parts of the body, are sometimes affected with wheals, ecchymosis, phlyctenae, or large vesications. In some cases, effusions of sero- albuminous fluids take place in some of the shut cavities; the surface of the body is covered by a cold perspiration; the extremities become cold, and sometimes of a purplish red colour; and a low muttering delirium appears during the night, from which, at last, the patient is never entirely exempt. To these often supervene a tendency to syncope upon raising the head; irregular palpi- tations ; weak, irregular, hurried, and quick pulse; and a quick, short, and difficult respiration; some- times orthopnoea and distressing cough. Hiccup and convulsions at last appear, and the patient expires. 29. If the inflammation be seated in large trunks, the serum effused from the internal sur- face of the inflamed vessel necessarily comes in contact with the circulating fluid; but I believe it does not readily mix with it in persons of a sound constitution, or whose vital energies have not been materially affected, but forms a coagu- lum, which either sheaths the internal surface of the vessel, partially obstructing it, or altogether filling up its channel. In this case, the symptoms indicate interruption of the circulation through a considerable branch of an artery: the limb be- comes oedematous, cold, leucophlegmatic, or purplish coloured, with irregular phlyctenae and large vesications on its surface, which sometimes go on to gangrene; especially when the disease has extended to the collateral arteries, which, if they had remained unaffected, would have per- formed the functions of the inflamed and ob- structed trunk. 30. When arteritis occurs in a weak or cachectic habit of body, the fluid secreted from the inflamed internal surface of the vessels, owing to the state of the constitutional powers, will not coagulate, but, being of a dissolved and sanious quality, readily mixes with the blood, and no interruption to the circulation through the inflamed vessels oc- curs: but the energies of life become depressed from the morbid state of the vital current thus occasioned, and many of the symptoms of ataxic or malignant fever manifest themselves;—such as great prostration of the powers of the frame; low delirium; an impeded and morbid state ofthe secretions and excretions; weak, quick, and ir- regular pulse; a cadaverous and lurid countenance; accumulations of dark mucous sordes about the tongue and mouth; flaccidity of the soft solids, with the rest of the phenomena described as con- sequent upon inflammation of veins. 31. Chronic Arteritis.—The more acute and active states of arteritis, although frequently admitting only of a doubtful recognition during the life ofthe patient, are more readily ascertained than the chronic forms ofthe disease. These latter, how- ever, seem more frequently limited to particular arteries than the acute, and hence oftener produce local effects; but these are generally so slight, and of so equivocal a character, that they com- monly escape detection, and are unattended to by the patient until the lesion on which they depend arrives at that degree of advancement which seriously disturbs the functions, and even the vitality, of the part. A very large proportion of the lesions which will be described hereafter (§ 38.) seem to originate in chronic states of in- flammation; and, if not actually commencing in these states, they are frequently complicated with them. It will be unnecessary further to notice those symptoms which seem to indicate the pre- sence of chronic arteritis, than to state that they consist of many of the signs already adduced as attendant on the acute forms of the disease, but in a much slighter degree; and frequently no functional lesion can be remarked. When, how- ever, the circulation through the vessel becomes impeded or obstructed, we may infer chronic dis- ease of the arteries, from the inequality or entire absence of the pulsation in these arteries supplying the part whose functions are most affected; from oedema, coldness, discolouration, vesications, or from signs of the gangrasna senilis in a limb; or from a feeling of weakness, and a state approach- ing to paralysis of an extremity or part. 32. Complications.—The states of morbid association of which arteritis forms an especial part have been more frequently disclosed to us after death than recognised during life; nor is it to be expected that, in some ofthe associations in which it has presented itself, it can be ascertained by the most diligent investigation ofthe case pre- vious to dissolution. We are still so much in want of faithfully observed cases of the disease, even in its simple and unmasked forms, and of correct information on various topics respecting its history and pathology, as to render our diag- nosis imperfect and doubtful; and how much more difficult must be our attempts to recognise it in its complicated forms, when it is masked by other diseases, the phenomena of which obscure it from the observation ofthe practitioner, and even abstract the attention of the patient himself from the feelings it may awaken. In noticing, there- fore, the complications of which this disease often forms a part, it is with the sole view of turning attention to their importance, and in order that the circumstance may receive due consideration, when we give our prognosis respecting those ma- ladies with which it has been found associated, and when we devise means for either their relief or their removal. 33. Inflammation of the arteries has been ob- served in fatal cases of inflammatory and malignant bid Structure of. 116 ARTERIES —Moi fevers, and in those which have been character- ised by great vascular excitement at their com- mencement, with symptoms of ataxy during their progress. In the great majority of such cases, it is a consecutive affection occasioned either by a greater concentration of the morbid action in a particular system, as explained when treating of fevers; or by an alteration of the properties of the blood, owing to hurtful materials having ac- cumulated in it from deficient action of the eli- minating organs, or to a morbid state of the ner- vous influence imparted to the blood from the vessels in which it circulates. (See the article Blood.) 34. Owing to similar causes, arteritis is some- times consecutive of eruptive fevers, particularly when the eruption, and the morbid evacuation of which it consists, are imperfectly developed or prematurely suppressed; or it may supervene to small-pox, occasioning the most dangerous part of the symptoms forming the secondary fever of this disease. In cases of this description, the arteritis is almost always general, chiefly limited to the serous membrane of the arteries, but extending also to the same membrane of the veins ; and evidently induced by the altered state of the blood, and the presence in it of hurtful materials. To this cause chiefly is to be imputed its occa- sional occurrence during erysipelas, phlebitis, and as one of the chief lesions observed in fatal cases of those diseases to which the term puerperal fevers has been applied. The complication of arteritis with phlebitis is one of the most frequent which occurs. That this should be the case, we might infer from the circumstance of the same causes generally acting upon both divisions of the vascular system, particularly those which act through the medium of the circulating fluid. M. Breschf.t found inflammation of the internal surface of the veins in a very large proportion of the cases (8 in 13) of arteritis which he has de- tailed at length in his interesting memoir. 35. Arteritis has likewise been found associated with inflammation of the heart, with that of the lungs, and with tetanus, particularly traumatic te- tanus. A case of this last complication is alluded to by the writer of an able article in the second volume of the Medico-Chirurgical Review. It has also been observed, although rarely, con- joined with serous effusion into the shut cavi- ties, particularly the pericardium, pleura, and peritoneum. 36. Diagnosis and Prognosis..—It has been very justly remarked by the writer to whom I have already referred, that, until numerous and diversified observations in clinical practice, illus- trated by the examination of fatal cases, shall have further enlarged our knowledge of this malady, any attempt to delineate the symptoms which are diagnostic of its presence must neces- sarily be somewhat imperfect. But it may gene- rally be inferred,—when the principal symptoms which have been enumerated appear—when the heat and pain attendant on this, as on other inflam- mations, are not concentrated in one part or organ, but are more or less generally diffused, particularly in the course of the arterial vessels__ when these sensations are accompanied with an audible or perceptible impetuosity of action, pro- pagated from the large trunks to the smaller and more superficial ramifications—and when, more- over, anasarcous injection of the surface or of the limbs, followed by wheals, vesications, or ecchy- mosed patches, supervene,—that the diseiise is inflammation of the arterial system, either in its partial or general form. 37. The Prognosis of arteritis may be said to be, upon the whole, unfavourable, even as respects its more immediate effects, in the acute states of the disease; but chiefly as regards its remote consequences in its chronic forms. The prognosis is more unfavourable when it is com- plicated with, or supervenes on other diseases (§ 33 — 35.). The morbid changes which it usually occasions are fully described in the next section of this article. Before proceeding to offer any observations on the treatment of arteritis, I will describe the various changes of structures which arteries pre- sent, as the greatest proportion of these changes are produced by inflammatory action in some one of its various grades or states. 38. IV. Morbid Structure of Arteries. 1st, Lesions of the individual coats of arteries.— A. Redness of the inner membrane of arteries is often observed in post mortem examinations. a. It seems to proceed from three causes: 1st, from the imbibition of the colouring particles of the blood remaining in the vessels, being entirely the consequence of death, and the result of in- cipient decomposition; 2d, from a change in the state of the blood occurring in the course of the disease which occasioned death, and existing some time before this event; and, 3d, From a morbid or injected state of the capillaries ramified in the coats of the vessel, or terminating in this mem- brane. In an epidemic amongst horses, which occurred at Paris in 1825, characterised by symptoms of disease of the thoracic viscera, no morbid appearances were found in the lungs, but the internal membrane of the large vessels was uniformly red, and the muscular structure of the heart remarkably softened. From the experi- ments of Gendrin (Hist. Anat. des Ivflam. t. ii. p. 9.), it is evident that the same varieties of colour, which we occasionally observe in arteries after death, may be produced by artificial irrita- tion. There is, however, this important differ- ence,—that when their redness is produced arti- ficially, it is accompanied by other alterations of tissue, such as softening, serous or purulent in- filtration, &c; whereas, in almost all the cases where the arteries have been found of a red co- lour throughout, the change was unattended by any other morbid appearance in them. I be- lieve that this coloration of the internal mem- brane of the arteries, as well as of the cavities of the heart, is more frequently owing to a morbid condition of the blood itself, than to any in- flammatory change in them. This opinion is confirmed by the circumstances and states of disease in which it commonly occurs; these chiefly consisting of depressed vital energies, deficient secreting power, and a consequent mor- bid condition of the blood itself. 39. b. The internal membrane of arteries some- times loses its tenuity and natural transparency, either in a few isolated points merely, or through a great extent of its surface. This state may amount to considerable thickening and opacity; but in many cases these appearances do not de- pend upon any remarkable change in this mem- ARTERIES — Morbid Structure of. 117 brane, but upon an albuminous exudation in its connecting cellular tissue. 40. c. Softening also takes place in this mem- brane, which is sometimes so friable as to be re- duced to a pulpy mass by the slightest scraping with the scalpel. Possibly, owing to this state of the inner membrane, its laceration may take place upon stretching the vessel by the more vio- lent motions ofthe body, or of a limb. 41. d. Rupture or laceration of the internal coat of an artery is sometimes met with ; it neces- sarily occasions an effusion of lymph from the lace- rated part, and the projection of the flaps of the divided coat into the canal of the vessel, either partially or entirely obstructing it. To this oc- currence is chiefly to be imputed the cases of spontaneous obstruction of arteries, which are sometimes met with. This subject has been well illustrated by Mr. Turner, in the third volume of the Transactions of the Medico-Chirurgical Society of Edinburgh. 42. e. Ulceration of the internal membrane of arteries -is not infrequent. The ulcers are gene- rally round ; occasionally one only is to be found. Sometimes the large arterial trunks, and particu- larly the aorta, are studded with them. But this is rarely observed, unless other alterations exist in the subjacent tissues, such as ossification, soften- ing, &c. M. Bouillaud is of opinion that the ulceration of the inner coat occasionally admits of cicatrisation. 43. B. The middle coat is more frequently diseased than the internal. It is often soft and friable, and deprived of its natural elasticity ; giving rise to serious modifications of the functions ofthe circulating system. M. Andral has found this coat remarkably hypertrophied ; the yellow fibrous tissue of which it is composed being as evident in the human subject as it is in the horse. This change may be confined to particular parts, occasioning irregularities in the diameters of the arterial canals, or it may extend throughout a whole artery. The fibrous coat may also become atrophied. In this state it approaches to the ap- pearance of cellular tissue, and is much thinner, resembling the tunic of veins ; and the artery loses its elasticity and collapses when divided. This coat may also acquire much rigidity, and be transformed into cartilaginous or even osseous rings, embracing the whole circumference of_ the vessel. This change is rarely met with in the aorta, but it not infrequently occurs in large ar- terial trunks, as the femoral artery, &c. Ulcera- tion may extend to and penetrate this coat, most frequently advancing from the internal mem- brane. 44. C. The external or cellular coat of arteries is liable to fewer alterations than the other coats ; it often remains sound when they axe extensively diseased, when it has alone to sustain the column of blood injected through it. But it also frequently participates in the changes of the other coats, becoming ruptured from the pressure of the stream of blood thrown into it, and more rarely ulcerated.—The foregoing chan- ges of the individual coats of an artery combine to affect its functions and condition, and give rise to important alterations of its structure and of its calibre, which may be increased, diminished, or entirely obliterated. Each of these requires a separate but brief consideration. 45. 2d, Changes of the structure and calibre of arteries.—A. Aneurism, a. True aneurism, or dilatation of arteries occurs ; 1st, in a part only of its circumference, and, 2d, in its entire circumference : the latter is the more frequent oc- currence of the two : it may embrace but a small extent of the vessel, or it may extend to a con.- siderable portion ; as, for instance, to nearly the whole ofthe aorta. Dilatation of a part only of the circumference of an artery is rare, but cer- tainly not so rare as to warrant some authors in disputing its existence. M. Andral states, that on more occasions than one he has traced distinct- ly the three arterial coats passing over the walls of a sac which seemed as if appended to the ar- tery, with the cavity of which it communicated. Dilatation either of a part, or the whole, of the circumference of an artery, constitutes the true aneurism of authors ; and according to its extent it may constitute simple dilatation, or true aneur- ism in its first stage, and sacculated aneurism, or the advanced state of this disease. 46. The coats of a dilated portion of artery, although not ruptured, may be otherwise altered. They are frequently thinner thap natural, and the middle coat is generally deprived of its elasticity. In this state the vessel yields like a vein to the distending impetus of the blood. In other cases, the coats of the dilated portion of artery are hypertrophied. M. Andral likens this state to the dilatations of the stomach and heart, which are often accompanied with an increased thick- ness of their parietes. 47. b. False Aneurism.—Mixed aneurism.— Dilatation with rupture of one or more of the coats, constituting the false aneurism of authors, is another frequent alteration. The internal and middle coats are those most frequently ruptured, the blood coming in contact with the external or cellular coat or sheath, dilating it in the form of a pouch, and thus forming the aneurismal sac. The parietes of this sac are generally much thick- er than the cellular sheath of the vessel was originally, owing to the gradual condensation of the surrounding cellular tissue from the pressure ofthe tumour, and the additional envelope it thus acquires. The interior of the sac is filled more or less with fibrinous coagula, arranged in concentric layers/the more exterior of which frequently be- come so dense as to be distinguished with dif- ficulty from the parietes of the sac. Around the exterior of the sac a degree of irritation is induced, giving rise to adhesions, wliich unite it more or less firmly to the surrounding parts. But these parts suffer other changes, particularly as the aneurismal tumour increases : they are mechani- cally compressed or displaced ; or they are worn away by absorption promoted by its pulsations, or by inflammatory irritation terminating in ulcera- tion and destruction of parts. This effect upon the adjoining structures has been shown under the article Aneurism of the Aorta, and it is therefore unnecessary to illustrate it further. Ac- cording to some authors, false aneurism consists of the ulceration or perforation of the internal coats, and of the dilatation of the external tunic only ; the changes above described constituting mixed aneurism. 48. c. Diffused aneurism, fyc.—In general the irritation created around the sac attacks, after a time, the sac itself, occasioning its ulceration and 118 ARTERIES—Morbid Structure of. perforation. Haemorrhage is then the result, which may be so great as at once to occasion death. It is frequently arrested by the anato- mical relations of the part: as when blood flows into the pericardium ; or when the blood passes into the parenchyma, or loose cellular tissue con- necting different organs or structures ; in which case it passes into the state of diffused aneurism. In some cases the hemorrhage is arrested by adhesions formed around the sac, constituting a second envelope to it, which confines the blood, and prevents it for a time from being further effused. Perforation of the sac, how- ever, may take place without haemorrhage, or even the production of diffused aneurism. This happens when a part in contact with the sac sup- plies the place of that portion of its parietes which has been destroyed, and affords sufficient resistance to the escape of the blood. Thus we have seen that the blood, in aneurism of the Aorta, may actually wash the partially destroy- ed vertebrae, no effusion taking place till still further destruction is occasioned ; and the tu- mour, in other cases, coining in contact with the periosteum, produces thickening of this structure, or the secretion of an osseous matter from it which partially surrounds the sac, forming an envelope to it, and preventing the escape of its contents until this also is destroyed. 49. In false and mixed aneurisms, the inner and middle coats are first perforated or ruptured, and the third coat either remains entire, or gives way at some remote period, and thus a secondary diffused aneurism is formed (§ 48.). But there is another form of diffused aneurism, in which all the coats of the vessel are ruptured or perforated at once, and the blood, passing entirely out of the vessel, forms no sac, but is diffused in the ad- joining parts ; or it impacts the cellular and pa- renchymatous structure in its vicinity into a spe- cies of sac or envelope ; or it is poured out into a shut cavity, or into some organ, whence it may be discharged externally, thus constituting pri- mary diffused aneurism. In the majority of cases, however, the aperture in the artery is the result of ulceration of one or more of the coats ofthe vessel, the remaining tunic giving way be- fore the impetus of the circulation ; the blood being either confined by the surrounding parts, or escaping into a cavity, according to the situation of the artery, and of the aperture in it. This per- foration and rupture of all the coats occur chiefly in the arteries of internal viscera, as in the splenic, hepatic, emulgent, iliac, and other arteries. 50. Aneurisms may terminate favourably, a spontaneous cure being sometimes effected by some one of the following processes :—1st, by a gradual contraction of the sac, and absorption of the coagula ; 2d, by the compression exerted by the sac upon the part of the artery immediately above it; 3d, by gangrene of the sac and ob- literation of the artery ; 4th, by inflammation or abscesses in the vicinity, and the coagulable lymph thrown out, obliterating the artery, as in the preceding case; and, 5th, by inflammation of the sac extending to the artery, and giving rise to adhesive inflammation of its interior, and ultimate- ly to its obliteration. 51. B. Narrowing of arteries is either con- genital or the effect of disease ; when the latter, it is very frequently associated with, or occasion- ed by, ossific deposits,—a change which will be considered in the sequel. It is chiefly in the aorta and large vessels departing from it that we meet with either congenital or morbid narrowing. Congenital contraction of the aorta is generally connected with extreme thinness of its parietes, and in some cases this defective developement has been so remarkable that the abdominal aorta has not equalled the usual size of the external iliac artery. 52. The contraction of the aorta, or of an ar- terial branch, may exist throughout its extent, or may be confined to a particular part. The ab- dominal portion of the aorta is more frequently contracted (see Aorta.) than the thoracic ; and when the former is narrowed, the latter is often dilated. Sometimes, however, the artery retains its natural calibre both above and below the con- stricted part: instances of this have been record- ed by M. Paris, in the second volume of De- sault's Journal, and by M. Reynaud (Journ. Hebd. de Med. t. i. p. 161.). In many cases of constriction such as I have now noticed, it is dif- ficult to determine whether this change has been congenital or the result of disease, inasmuch as the coats of the vessel have appeared unaltered from the healthy state. But there can be no dif- ficulty in determining in favour of the latter al- ternative, when the coats ofthe contrated portion are thickened, or contain ossific deposits, or are otherwise changed. When the contraction is the result of disease, it is sometimes very remarkable, the canal of the vessel being nearly obliterated. The narrowing found in the principal trunks or branches of arteries is almost always the result of inflammatory disease ; most commonly of ossific deposits, or of chronic inflammation. 53. C. Obliteration of arteries is frequent- ly observed. This lesion may occur in any part of the system, even in the aorta itself, but it is most commonly met with in the second or third order of arteries. The smaller branches may also be obliterated ; but they less frequently become the objects of examination than the larger trunks. The canal of an artery may be obliterated, 1st, by fibrinous coagula adheriug firmly to the pa- rietes of the vessel, or incorporated with them; 2d, by the conversion ofthe vessel to a ligament- ous chord ; 3d, by osseous concretions, or other morbid growths, filling entirely its cavity ; and, 4th, by the advanced progress of aneurism to a spontaneous cure. 54. a. The first species of obliteration has been found in the aorta by Professor Monro (Edin. Journ. of Med. Science, vol. ii. p. 351.); the part affected being somewhat contracted and filled up by a plug of fibrine, which adhered to the surface of the vessel by coagulable lymph. This form of disease is common in the arteries of the extremities, particularly the lower, and is sometimes owing to the rupture of the internal coat ofthe vessel. It occurs also in cases of gan- graena senilis, and, with the third species (§ 56.), is a frequent cause of the gangrene. It seems most probable that it is a more immediate con- sequence of inflammation than the second species. 55. b. The second form of obliteration is not uncommon in large branches of arteries, and has been found, in two cases, in the aorta : it is evi- dently a more remote cause of inflammation than the foregoing. The circulation being entirely ob- ARTERIES—Morbid Structure of. 119 structed, by the coagulable or fibrinous lymph poured out by the inflamed or ruptured internal membrane, and by the coagula thus formed, and being kept up by the enlargement of collateral branches, the obstructed part is deprived of its functions, and subsequently undergoes those changes which all vascular or other canals expe- rience when they no longer are pervious to the fluids which usually circulate through them,— they have the fibrinous coagula, which have been formed in their cavities, and the lymph effused between their coats, absorbed, and their coats be- come condensed into ligamentous chords. 56. c. The third species has been met with in the aorta by Dr. Goodison (Dub. Hosp. Rep. vol. ii. p. 193.), and M. Velpeau (Rev. Med. 1825, t. iii. p. 326.) In Dr. Goodison's case, an osseous deposit surrounded the canal of the vessel, which was completely filled at this part with a dense fleshy and fibrinous mass, resembling the structure of the heart. A similar obliteration also existed in the iliac arteries. In M. Vel- teau's case, the obliteration was owing to the formation of a scirrhous or carcinomatous tumour in the vessel, resembling similar tumours deve- loped in different parts of the body. Obliteration by polypous or other growths, by fibrinous coagula and coagulable lymph, by ossific depo- sits, &e. are also found in large arterial branches, especially in those supplying the lower extremi- ties. The obliteration of the arteries by ossifica- tion is one of the principal causes of the gangrene of aged persons. When a considerable artery, or even the aorta, becomes either, much obstructed, or entirely obliterated, hi any of the above ways, the circulation is generally carried on by enlarged collateral vessels. 57. d. The fourth species has been observed in several large arterial trunks. Dr. Monro's case of obliteration ofthe aorta may be partly ascribed to this cause; the coats of the vessel, although entire, being dilated below the constricted part. 58. D. Albuminous and purulent matter. — M. Gendrin (Hist. Anat. des Inflam. t. ii. p. 9.) has clearly proved, by his experiments, that, when an artery is artificially irritated, its parietes soon become injected, swollen, softened, and infiltrated by a serous fluid; its internal sur- face is coated by an albuminous exudation, and collections of pus form, either in the interior ofthe vessel, or between its coats. He has, moreover, demonstrated that, if the artery continues full of blood during the experiment, this fluid is coagu- lated, and altered in a variety of ways by the mor- bid secretion poured into it from the internal surface of the inflamed vessel. Similar appearances have been observed from disease, particularly in the aorta and large arterial trunks, where they are most obvious. Mr. Hodgson andM. Boijillaud found the internal surface of the aorta lined with a perfect false membrane; and when this was re- moved, the surface of the vessel was of a bright red colour. M. Andral has observed the inter- nal membrane of the artery raised by small ab- scesses, sometimes as large as the size of a nut, situated between the internal and middle coats. It is probably to the bursting of those into the vessel that ulceration of the internal tunics is owing. Pus is also sometimes found in the in- terior of arteries, either unmixed with the blood, or mixed with it and altering its appearance. 1 59. E. Atheromatous matter is frequently found between the inner and middle coats of ar- teries. It was first noticed in this situation by Monro and Haller. It is generally of the consistence of suet, of a cheesy opaque appear- ance, is greasy to the touch, with minute gritty particles thinly scattered through it. In some cases it resembles more nearly a semi-concrete pus, and seems to result from the changes which pus may have undergone subsequently to its secretion. In other cases the atheromatous mat- ter abounds in gritty particles, which occasionally even exceed the suety part; and the deposition thus passes into the form of a calcareous concre- tion. It is extremely probable that these varieties of morbid formation are connected with chronic inflammatory action of the coats of the vessel. 60. A variety ofthe atheromatous matter has been described by Morgagni, Scarpa, Stentzel, and Craigie, under the denomination of steato- matous deposition. The name, however, as Dr. Craigie has remarked, is not well chosen, inas- much as this formation is not adipose, but a firm cheesy or waxy matter, of a yellowish or fawn | colour. It seems merely a more concrete variety of the foregoing, and differing from it chiefly in the absence of gritty particles. It is more fre- quently found at the bifurcations of arteries, but it is not limited to those situations; and is gene- rally deposited between the inner and middle coats. When the quantity of this matter is con- siderable, it encroaches on the calibre of the ves- sel. This substance is met with either alone, or with patches of calcareous deposit. It probably derives its origin from a similar source to the atheromatous matter; and, according to Scarpa, always terminates in ulceration: but this is not invariably the case, as it has been observed, par- ticularly when unattended with calcareous form- ations, distending the coats ofthe vessel to a great extent without any ulceration. This change, however, takes place very generally, either when the deposition of this matter is considerable, or when associated with calcareous formations. When ulceration takes place, the coats of the vessel are soon destroyed to a greater or less ex- tent, and rapture follows; taking place, as shown by Mr. Hodgson, in a transverse direction to the axis of the vessel, and giving rise to extensive or fatal haemorrhage, or to circumscribed or diffused aneurism, according to the situation of the aper- ture in the vessel. 61. F. Calcareous or osseous concretions are the most frequent morbid appearances presented by arteries. These concretions, however, differ from healthy bone chiefly in wanting the fibrous struc- ture, in not being necessarily deposited in a car- tilaginous matrix, in consisting of a larger pro- portion of phosphate of lime, and less animal matter, and in presenting an irregular, homo- geneous, and unorganized appearance. Bichat and Bail lie considered that the larger proportion of persons above sixty years of age have some part of the arterial system affected by these form- ations. This change is very seldom observed in early life. Young found it, however, in an infant; Wilson in a young child; and Andral in the aorta of a child of eight years of age. M. Andral has met with ossific laminae in the aorta, in five or six persons of from eighteen to twenty-four years of age: and an extensive ossification of the Ossification of. 120 ARTERIES —( superior mesenteric artery of a person not quite thirty. This species of formation always is seated between the muscular coat and the internal mem- brane, which it often detaches from its connec- tions ; and it originates either in the atheromatous matter described (§ 59.), the place of which it sometimes takes; or in those whitish patches al- ready noticed, which apparently consist of an albuminous exudation formed between the inner and middle coats, and which pass from the albu- minous, first to the cartilaginous state, and sub- sequently to that of bone. 62. a. But this is not the only change which the vessel undergoes; for, whilst the calcareous deposits are going forward, the middle coat be- comes either hypertrophied, thus contributing to the thickened appearance which the vessel some- times presents, or atrophied, being apparently re- placed by the calcareous concretion, and leading to the mistaken opinion that this coat itself has been transformed into bone. The osseous con- cretions exist in various forms: sometimes they consist of minute grains; at other times of irregu- lar plates of different sizes; occasionally they in- crust the artery and convert it into an inflexible tube; and, more rarely, they give the sensation of a number of small bodies moving on each other, and as if jointed together. , 63. The ossific concretions may be very con- siderable, without in any way changing the calibre ofthe vessel, or even its form; or they may pro- ject into it so considerably as to obstruct, or even to obliterate its canal. They thus occa- sion gangrena senilis. It has even been supposed, — and the opinion is very probable, — that they may project through, or penetrate, the internal membrane, and fall into the cavity of the vessel; and, being conveyed onwards with the current of blood until they arrive at arteries of smaller ca- libre, may thus completely obstruct them. The calcareous concretions found in some rare instanc- es plugging up the canal of the vessel, evidently are produced in this way. 64. b. As to the comparative frequency of this lesion in various arteries, I may add a few re- marks, derived from the interesting materials supplied by M. Andhal (Anat. Path. t. ii. p. 395.). The aorta is the most liable of any to ossification in some part or another; but every one ofthe branches proceeding from it may like- wise be the seat of this change. The coronary arteries are frequently ossified, both in their trunks and in their subdivisions. The large ves- sels which arise from the arch of the aorta often present at their origin a bony ridge projecting into their interior. The cerebral arteries of old per- sons are frequently found studded with cartilagi- nous and osseous laminae; and M. Bouillaud has shown that this change disposes remarkably to apoplexy with sanguineous extravasation. Os- sification is very common in the splenic artery, but exceedingly rare in the hepatic, and coronary artery of the stomach. A bony ridge is often found at the origin of the common iliacs. The arteries of the lower extremities are not infre- quently the seat of these concretions; and they sometimes occur in the radial artery of aged per- sons. M. Andral has never met with this al- teration in the hypogastric artery. Haller met with it once in this vessel (Opusc. Path. Obs. 59.); and this is the only case of the kind on record. — All the morbid depositions described above have been found in the pulmonary artery, but much more rarely than in the aorta and vessels proceeding from it. 65. c. Origin of osseous formations in the arteries.—The ossification of arteries has been ascribed by many authors to slight chronic in- flammatory action. The experiments of M. Rayeu and M. Cruveilhier seem to confirm this infer- ence, as an occasional occurrence at least, parti- cularly in the fibrous and cartilaginous structures: increased vascular action of those structures, artificially excited, being generally followed by ossiform depositions; but, in a number of cases, particularly in those where the deposit takes place in the cellular tissues, no inflammatory ac- tion can be detected previously to this change: besides, increased vascular action frequently ex- ists, without being attended with ossiform depo- sitions. This lesion, therefore, cannot be alto- gether ascribed to this cause, although frequently resulting from it, in a certain order of tissues. It would be more correct to consider it merely as a consequence of disorder of the natural process of nutrition and secretion, frequently induced, in particular tissues, by a chronic state of inflam- matory action. But to what cause is this disorder of the nutritive function to be imputed, particu- larly when it occurs in parts which have not evinced any sign of inflammatory action, as in the cellular tissue connecting the internal coats of arteries ? The importance of this enquiry may appear from the very great proportion of persons, in advanced years, who are affected, in some organ or tissue, with this lesion, and from the remarkable part it performs in the production of a number of diseases of the most dangerous de- scription. 66. In answer to this, M. Andral very plau- sibly observes, that physicians have frequently noticed the existence or succession of three dif- ferent forms of calcareous productions in per- sons of a gouty diathesis: 1st, gravel and urinary calculi; 2d, hard concretions in the small joints; and, 3d, ossiform productions in the arterial sys- tem, and other parts. Is it not, therefore, probable that morbid ossification proceeds from a similar cause to those other calcareous formations ? We have seen that gout generally originates in an excessive use of animal food, conjoined with deficient assimilative and secreting powers of the frame. The highly azotised blood of a per- son thus circumstanced becomes surcharged with urea and phosphate of lime, as evinced by the state of the urinary secretion, which always, in such cases, abounds with uric acid and the earthy salts. The experiments of M. Magendie have proved, that by changing the diet of a per- son who has been living chiefly upon animal food, and by substituting substances containing no azote, the uric acid and phosphates disappear from the urine. May we not, therefore, infer that in consequence of the excessive use of animal food, conjoined with imperfect assimilative and secreting powers, these substances will accumu- late in the blood to a hurtful extent; the urinary organs being unable to eliminate them entirely from the circulating fluid ? The necessary result of this state of the blood will be, that these sub- stances will occasionally be deposited in other parts, giving origin to the uric acid concretions ARTERIES — Treatment of their Diseases. 121 found in the small joints, and to the phosphate of lime deposits found in the arterial system and some other parts. From this it will be apparent that the ossific formations met with in the arteries are derived from a similar origin to that which has been more fully explained under the articles, Gout, and Urinary Calculi. The increased vascularity, observed frequently to co-exist with the morbid secretion of calcareous matter, may proceed from the irritation produced in the capil- laries by the morbid matters circulating in them; or it may be a necessary attendant upon the se- cretory process, especially when this process is of a morbid description; or the accidental occur- rence of irritation and increased vascular action in the interior coats of the vessel may prove the determining cause of the ossiform deposit, to the formation of which a disposition had previously existed, owing to the excessive abundance of the phosphates in the blood. If this explanation of the origin of ossification in the arteries be correct, a rational method of preventing and combating this lesion is presented to us for adoption. 67. Treatment.—A. The more acute states of arteritis require the same general principles and details of treatment as inflammations of other parts. General and local depletions, calomel, and oleaginous purgatives, cathartic enemata, dia- phoretics consisting chiefly of camphor, antimony, and opium, &c. (F. 39. 184. 358. 460.); cool- ing diluents, and the rest of the antiphlogistic regimen, are indispensably requisite. After a copious depletion, practised so as not to occasion full syncope, the following will be found of ser- vice in preventing the re-accession of increased vascular action. No. 33. R Camphora rasae gr. iij.—v. •, Pulv. Jacobi Veri er. v. (vel Antimonii Tartar, gr. ss.); Calomel, gr. xii.; Opii Puri gr. ij.—iij-; Conserv. Rosar. q. s. ut fiat Bolus, statim post venaesectionem capiendus. 68. In the more acute states of arteritis, digi- talis, and emollient diluents, with nitrate of potash, or the vegetable acids, may be exhibited. After depletions have been carried as far as may be considered prudent, and when there exists no constitutional vice contra-indicating the practice, the mercurial preparations may be given to the extent of affecting the gums. The repetition of the bolus now prescribed will generally be suf- ficient for this purpose, the bowels having been well evacuated previously. In this form of ar- teritis, Hildenbrand recommends (Inslit. Med. t. iii. p. 26.) cold epithems over the seat of the inflamed vessels, the internal use of lemon ices, and the cautious exhibition of the superacetate of lead and opium (F. 206.), after depletions have been practised. Colchicum may also be given, or substituted for digitalis; but these medicines re- quire great caution in their exhibition, particu- larly after large depletions, and when antimonials precede or accompany them. The diet ought to be very low, cooling, and chiefly farinaceous; and, during recovery, the more heating kinds of animal food should be abstained from. During the disease, as well as during convalescence, per- fect tranquillity of body and mind should be in- sisted on. 69. In some states of acute arteritis, it may not be advisable to lower the powers of life too much; as we may thereby risk the occurrence of arterial throbbings, the extension of disease along 11 the internal membrane of the vessel, and the vitiation of the circulating mass by the secretion poured into it from the inflamed surface. The tendency also to limit the inflammation by the formation of coagulable lymph, when the period of resolution is past, may also be overcome by too great depression ofthe vital energies, which ought therefore to be supported in extreme cases, and not depressed too low in others. 70. B. The more chronic states of arteritis require cooling purgatives, occasional depletions, and a low refrigerant diet and regimen. A vege- table, particularly a farinaceous diet, is extremely serviceable in these states of the disease, chiefly by preventing the consequences to which they usually lead. The richer and more stimulating kinds of animal food, and particularly pork, should be constantly avoided, and all tendency to ple- thora suppressed or subdued. In the chronic as well as the acute diseases of arteries, physical and moral tranquillity is particularly required. The abdominal secretions and excretions ought to be duly examined and regulated, undue sinking of the vital energies prevented or counteracted, pure air prescribed, and due attention paid to the first indications of disorder of the digestive functions, 71. C. The consequences of inflammation of ar- teries, whether those more palpable changes which constitute the different kinds of aneurism, or those which are merely matters of more doubtful in- ference, can be treated only upon the above principles: above all, vascular plethora must be avoided, and tranquillity observed. There is, however, one fact, which, I consider, should not be lost sight of by the practitioner, and which is the result of attentive observation; namely, that, even in aneurism, more mischief than advantage will be derived from depressing the vital energies of the frame too low, than from observing a more moderate, or rather a less vigorous, mode of treat- ment. When carried too far, relatively to the circumstances ofthe case, those guards which the restorative powers of the frame set up against the extension of the disease are thrown down; the destruction of adjoining parts extends; the fibrous coagula which fortify the weakened parietes of the vessel, and tend even to a spontaneous cure of the disease (§ 50.), assume, as Mr. Guthrie has very justly remarked, a loose and spongy state, and allow the blood to pass through it, or between it and the coat or coats of the vessel; and the disease, consequently, makes rapid pro- gress. There can be no doubt, as hinted at by this eminent surgeon, that the extension, and ultimately the bursting, of aneurisms, are not altogether owing to the impetus of the blood in the vessel ; and that, therefore, the treatment which is solely directed to this point must be de- ficient. The suggestions now offered (§§ 69,70.), as well as those stated in the article on Aneurism ofthe Aorta, will be sufficient to guide the prac- titioner in this respect. 72. D. The complications of inflammations of arteries, and their consequences (§ 32. et seq.), require attention to the fact, that, when arteritis supervenes in the course of other diseases, it is generally during those stages which are charac- terised by depression ofthe constitutional powers, when the circulating fluid becomes materially changed from its healthy condition, and most probably loaded with an unusual quantity of 122 ARTS AND EMPLOYMENTS —as Causes of Disease. unassimilated, morbid, or irritating materials. Indeed, these are the circumstances which favour the occurrence of all inflammations affecting the different circulating systems—the lymphatic as well as the venous; and they account at the same time for the very frequent association of arteritis with phlebitis, particularly in the last stages of febrile and eruptive diseases. These considerations naturally suggest the propriety of having recourse to such measures as may be best suited to indi- vidual cases for the prevention of inordinate de- pression ofthe energies of life, during the advanced stages of diseases, when we fear the supervention or the existence of arteritis; or as may support those energies, whilst we excite the organs whose functions are chiefly to eliminate irritating and hurtful matters from the circulation. By thus opposing too great depression, further deterioration of the blood is more likely to be prevented than by any other indication of cure; whilst the re- moval of the cause,—the source of irritation of the internal surface of the vessels,—presents a probable chance of the disappearance of its effects. (See Aorta—Diseases of.) Bibliography. — A. Inflammation and its Consequen- c-U. —Langsvert, De Art. et Venar. Adfectibus. Prag. 1'64. —Morgagni, De Sed. et Caus. Morb. Epis. xxvi. art. 35, 36. — Oehme, De Morbis Recent. Natorum. Lips. 1773. — J. P, Frank, De Curandis Hominum Morbis, t. ii. Manh. 1792. — Schmuck, Observat. Med. de Vasor. Sanguif. Imlammatione. Heidelb. 1794.—Spangenberg, in Horn's Archiv fur Med. kc, b. v. 2. Heft., n. l. — Saase, Dissert. de Vasor. Sanguif. lnflammatione. Hal. 1797.—Portal, Anatomie Mtdicale, t. iii. p. 127. Paris, 1803.—Schwilgue, in Bibliothjque Mtdicale, t. xvi. — Treviranus, Biologie, h, v. p. 414. — J. Hodgson, Diseases of the Arteries and Veins. Lond. 1815.—Reiner, Dissert, de Plethora Sanguin. iielmst. 1797.— Kreysig, Herzkrankheiten, iii. theil. Ber. 1817. s. 2S9.—Dalbant, Observat, pour servir k l'Hist. de l'Arterite. Paris, 1819.— Bryant, in Lond. Med. Hepos.t. xviii. p. 6. — Vaidy, in Journ. Complement. Aolt, 1819. — Bach, in Rtvue Mtdicale, Mai, 1820. — Kennedy, in Johnson's Med. Chirurg. Review, vol. ii. p. 60. — Breschet, De l'Arttrite, Journ. de Progres de Scien. Med. t. xvii. p. 119. Par. 1829. — Bouillaud, Art. Arterite, in Diction, de Med. et Chirurg. Pratique, t. iii. Par. 1829. — Langanbeck, liosol. und Therapie d. Chir. Krankh. bd. i. p. 589. Gotting. 1822.—Naumunn, Arteritis, Medicin. Chirurg. En- cyclopadie, band. iii. Berlin, 1829. — V. N. Hildenbrand, Institutiones Practico-Medics, t. iii. p. 21. Wien, 1822. B. Morbid Structures, fyc. — Coxvper, Philosoph. Trans. No. 285. p. 1391. — Naish, Ibid. No. 389. p. 226. — Morg- agni, De Sed. et Caus. Morb. Epist. xxiii. ar. iv. 6., xlvi. ar. 20. — Faselius, Dissert, sistens Morbos Arteriarum, kc .fenn, 1757. — Gemma, in Haller's Biblioth. Med. Pract. ii. p. 198. — Walter, Observ. Anat. p. 44. — Stenstel, Haller's Disp. ad Morb. Historiam, &c. t. ii. p. 527. — Bichat, Anat- omie Gentrale, t. ii. p. 293. — Baillie, Trans, of Society for Imp. of Med. and Chir. Knowledge, vol. ii. p. 133. — Wenzel, in Hufeland's Journ. der Pract. Arzenevkunde, b. viii. st. 4. p. 160. — Scarpa. Sull' Aneurismo, cap. v. 6, 22. —Chaussier, in Journ. Gtntr. de Med. Mars, 1811. p. 318. — Maunoir, in Ibid. Mars, 1811, p. 323. — Hagstrom, in Hafeland u. Himly, Journ. der Pract. Heilk., Jul. 1811, p. 121.—Travers, in Med. and Chirurg. Trans, vol. iv. p. 438. —Yelloly, Ibid. vol. xii. p. 565. — Mondini, Archives Gtn. de Med. t. v. o 137. — Turner, Transac. of Med. and Chir- urg. Soc. of Edin. vol. iii. p. 105---Craigie, Elements of Gen. and Pathol. Anatomy, p. 87. —.4. Monro, in Edin. Journ. of Med. Sciences, vol. ii. p. 351. — Andral, On Pa- thological Anatomy, by Townsend, vol. ii. p. 367.—Guthrie The Diseases and Injuries of Arteries, kc. lond. I83o! (A work that should be in the hands of every practitioner.) ARTHRITIS. (See Gout.) ARTS and EMPLOYMENTS.__1. Pa- thology.— Etiology.—An inquiry into diseases caused by the prosecution of the various arts of civilised life is of the utmost importance to the scientific professor of medicine in all countries but particularly in this; for in no other country are the useful arts so extensively prosecuted as in Great Britain. The great importance of the sub- ject has been acknowledged by the success of the able works of Ramazzini, Merat, Patissier, and Thackrah, on the diseases of artisans. 2. As it would be foreign to my plan to take into consideration at this place the diseases occa- sioned by the numerous arts which furnish em- ployment and subsistence for a very large part of the population of this and many other countries; particularly as these diseases will be considered in their more important relations in other places, and many of them under distinct articles; I will here confine myself to a succinct account of the effects which the prosecution of the various useful arts directly or indirectly produce in the frame; interspersed with a few remarks as to their influ- ence in modifying the characters of various dis- eases, and as to the means by which their injurious effects may be partially prevented or counteracted. 3. In offering these observations, I will only, in some respects, observe the arrangement adopted by Ramazzini, and closely followed by Four- croy and Patissier. This arrangement is founded on the nature of the causes producing the diseases to which artisans are liable. The First Class of causes consists—1st, Of confinement, and insufficient ventilation ; 2d, Of undue exertion ; and, 3d, Of sedentary habits. The Second Class comprehends—1st, Undue exertion of particular parts, and insufficient exercise of other parts ; 2d, Unnatural or constrained positions in different employments ; and, 3d, Temperature and moisture. The TraRD Class embraces those causes which consist of materia] molecules, and which, coming directly or mediately in contact with the body, in the state either of vapour or of minute disintegration, penetrate the organs, and disorder their functions. These are—1st, Mineral molecules ; 2d, Vegetable molecules ; 3d, Animal molecules; and, 4th, Mineral and vegetable mole- cules acting mechanically. On the operation and effects of each of these, as being intimately con- nected with the nature, complication, and removal of diseases, I proceed to offer a few remarks. 4. I. Class first. 1st, The hurtful influence of confinement, and of insufficient ventilation, is great in proportion to the youth or early years of those who are thus circumstanced. In the ma- jority of factories, artisans are congregated in great numbers, necessarily confined during the greater part of the day in the same apartment, which, being usually warmed by artificial heat,—by pipes conducting heated air or steam,—have not the air renewed with that rapidity which necessarily ob- tains in apartments provided with the fire-places in common use. The consequences are, that those confined in them breathe an impurer air than under ordinary circumstances ; and expe- rience the debilitating influence occasioned by an atmosphere loaded with an increased quantity of carbonic acid gas and animal effluvia. 5. Persons who have already attained to their full growth, and those particularly who have nearly reached the meridian of life, seldom ex- perience the deleterious effects of confinement under such circumstances, to nearly the same extent as those in early life. When the subject was brought before parliament by Sir Robert Peel, Mr. Owen of New Lanark stated, respect- ing the children employed in his manufactory, that, although they were extremely well fed, clothed, ARTS AND EMPLOYMENT and lodged, looked fresh, and, to a superficial observer, were healthy in their countenances, yet their limbs were generally deformed, their growth stunted, and they were incapable of making much progress in the first rudiments of education. This statement, which appears to have been made as a result of large experience, agrees with the observ- ations of other able men. The evidence of Sir Astley Cooper is even still more decided, and is perfectly in accordance with the experience of every competent judge. The result of confine- ment, this eminent surgeon states, is not only to stunt the growth, but to produce deformity. Every traveller in countries, the population of which con- sists chiefly of those whose avocations bring them much in the open air, or in agricultural districts, must have remarked not only the much more fully developed frames, and larger lower extremities, of the inhabitants of those parts, but also the more phlogistic or inflammatory characters of their dis- orders, and their greater vital resistance and pow- ers of restoration when exposed to the causes, or suffering from attacks, of disease, than are mani- fested by the inhabitants of crowded manufacturing towns. 6. Not only is confinement in itself detrimental to the frame, particularly during the epochs of developement of the various structures of the body, when air and exercise are nearly as requi- site as food to their perfection, but the construc- tion of the apartments, the want of ventilation, the accumulation of animal effluvia, and the moral depravation consequent upon continued assem- blages of persons, little under physical or moral control, essentially increase its injurious effects, and co-operate with it in impressing an asthenic character on the frame; in disposing to the for- mation of tubercles, and to the strumous diathe- sis; in depressing the vital energies and mental manifestations; and, consequently, in disposing the body the more to the usual exciting causes of disease, and the mind to vicious habits and in- dulgences. 7. 2d, Over-exertion is a very frequent cause of disease among many artisans; and, like con- finement, it is the more injurious, the earlier in life it comes into operation. In the lower ani- mals, particularly in the horse, the consequences of over-exertion are fully manifested. This ani- mal seldom reaches one half of its natural life as employed in this and many other countries. As to effects of over-exertion on man, much will de- pend -ipou his habits and modes of living. When well fed, and of regular habits, its injurious conse- quences are neither so great, nor so soon appear, as when he is poorly fed or addicted to the use of spirituous liquors. 8. Over-exertion shortens life, 1st, by injuring the continuity, cohesion, or relative situation of various parts; 2d, by inducing that degree of ex- haustion which runs on to irremediable or fatal disease; and, 3d, by that gradual and insensible expenditure of vital influence, beyond the power of reinforcing it, whereby the mean duration of human life is shortened. The trades which chiefly illustrate the above positions are coal-heavers, na- vigators or ballast-dreggers, smiths, miners, &c. 9. It should not be overlooked, that in many trades the artisan is not only subjected to confine- ment in close and imperfectly ventilated apart- ments, but is at the same time obliged to over- — as Causes of Disease. J23 exert his physical powers. In such cases the ill effects are necessarily greatly augmented; more especially in children or very young persons, who are naturally impatient both of confinement and over-exertion; and in them particularly are the injurious effects, moral as well as physical, chiefly manifested. Many of those who become the most drunken, immoral, or feloniously depraved, have been initiated in vice from the associations formed in factories. 10. 3d, Sedentary habits are also adverse to health, but only in a negative manner, as respects persons living in well ventilated and wholesome situations. The simple neglect of due exercise, however, is after a time generally productive of disease, owing both to its effects upon the nervous and muscular energies — the manifestation of all our functions being improved by a moderate ex- ertion of them — and to its influence on the se- cretions and excretions, which require a certain degree of muscular exercise for their promotion. Literary men suffer in a particular manner from want of bodily exercise, chiefly owing to the over-exertion of the mental powers, the bent position ofthe trunk, and the stagnant air of close apartments. Clerks, and various artisans, suffer also from the same cause, particularly tailors, shoemakers, watchmakers, weavers, jewellers, &c. In some of these the pressure made upon the lower part of the sternum and stomach proves very injurious. 11. Mr. Dobson furnishes very instructive in- formation as to the effects of confinement to a particular posture and in a close atmosphere upon tailors. Of 334 men, employed by Stultz & Co., in London, six are above sixty years of age; fourteen about fifty; and the greater number of the remainder about forty. Three of the six above sixty have curvature of the spine. ' Their most common affections are dyspepsia, diarrhoea, headache, giddiness, and anal fistula, to which latter they are so subject that they have a " fistula club/' They attribute their complaints to the . bent posture of their bodies for thirteen hours a day, and the heat of the.workshop. Tailors are the most intemperate set of workmen in London. A large proportion of them die annually of phthi- sis. (Thackrah, &c. p. 17.) The diseases most commonly observed amongst shoemakers are chronic inflammations of the stomach, liver, and bowels, occasioned by the pressure of the last on the lower part of the sternum, where it occa- sions, in those who are long-lived, a considerable depression. 12. The sitting posture, when long or habit- ually continued, is very hurtful in persons of sedentary habits. M. Patissier remarks, that it causes the lymphatic to predominate over the nervous, sanguiferous, and muscular diathesis. Artisans and others who adopt it early in life, rarely acquire vigorous constitutions, or reach old age, although old age soon overtakes them. Persons with this habit soon become subject to dyspeptic disorders, to affections of the kidneys and urinary organs, to constipation, haemorrhoids, various cachectic affections, obesity, and, in fe- males, to fluor albus, and difficult or irregular menstruation. When, in addition to a long- continued sitting posture, the trunk is bent, and pressure frequently made over the epigastrium and sternum, as with shoemakers, weavers, at- 124 ARTS AND EMPLOYMENTS —as Causes of Disease. torneys' or bankers' clerks, kc, gastrodynia, nervous palpitations, chronic gastritis, pulmonary consumption, chronic pericarditis, and imperfect digestion, excretion, and assimilation, amounting even to complete asthenia, are the not infrequent results. The hurtful effects of the sitting posture and bent state of the trunk are much increased by deficiency of food on the one hand, or by too full living on the other; and by habitual excesses of any kind, but particularly in the use of ardent spirits. 13. Literary men who are of sedentary habits are liable both to the disorders which result there- from, and to those which depend upon over- exertion of the mental faculties. Amongst the latter, melancholy, hypochondriasis, cephalalgia, paralysis, apoplexy, palsy, inflammation of the brain or of its membranes, mania, and softening of the brain, hold a prominent place. All these evils are, however, in a great measure prevented by moderate diet and regimen, by avoiding ex- cesses of every description, by regular and mode- rate exercise in the open air, by early rising, by sufficient but not too much sleep, with attention to the digestive organs, and to the promotion of the abdominal secretions and excretions. 14. II. Class Second. 1st, The undue exer- tion of particular organs, with or without insuffi- cient exercise of other parts, is often productive of most injurious effects; but much of the evils im- puted to this cause by MM. Gosse, Merat, and Patissier, are either imaginary, or merely matter of occasional coincidence. A. The conseauences of undue muscular exertion are chiefly hernia, aneurisms of the large vessels, dilatation of the cavities of the heart, haemorrhages from the lungs or nose, injuries ofthe ligaments and intervertebral spaces, sprains and lacerations of muscles; and are chiefly met with among those occupations that are of a laborious kind, as porters, coal-heavers, draymen, &c. Of all these injurious consequences, hernia are very much the most frequent. Amongst all those persons who bring the back and superior extremities into frequent energetic exercise, it will be observed that the muscles of these parts are not infrequently developed either at the expense of those of the lower extremities, or to a degree far beyond them. This partly arises from the shuf- fling gait of those persons, and from not throwing i •• i • • ° the gastrocnemn muscles into action. 15. B. Over-exertion of the vocal organs is not infrequently productive of disease. The affections which proceed from this cause are haemoptysis, laryngeal phthisis, aphonia, oedema of the glottis; functional, and subsequently or- ganic, diseases of the heart and large vessels; nervous and cerebral affections. The persons most liable to be affected by this cause are public singers and orators; but I believe that the ill effects resulting from it, in any of the above states of disease, are not so great nor so frequent as some writers have stated. Much of the mischief imputed to this cause is referrible rather to the enthusiasm of singers and orators, to the passions which are called up during the exercise of their powers, and to the various dissipations and ex- posures into which their vocations lead them. The occurrence of musico-mania from excessive musical enthusiasm is known to all physicians. It is obvious that the first signs of the accession of the above diseases in the persons of singers and orators, require strict avoidance of the cause. 16. C. The continued or intense action of light on the eyes, and application of them to small objects, as amongst workers at iron forges and furnaces, engravers, watchmakers, embroiderers, painters, &c, are often followed by injury to, or entire loss of sight; persons thus employed being liable to amaurosis, cataract, inflammation of the retina, iris, or capsule of the lens, and to short- sightedness, owing to the more convex form the eye acquires from continued compression, by the muscles attached to the eye-balls. 17. 2d, Unnatural or constrained positions are extremely injurious in the prosecution of any art or employment. Occupations that require long- continued standing have been said to be produc- tive of varices in the lower extremities; but I am not aware that such affections are more common amongst printers, who usually stand at the frames, than in other persons. 1 here is no doubt of undue pressure made upon any particular part of the body hi the exercise of any art or trade, or even slight pressure when long continued, bein« most injurious. This is remarkably the case when the pressure is made upon the abdomen, paiticu- larly over the epigastrium, and still more so if it impede the actions of the respiratory muscles. Various occupations, which are injurious from this cause, might be pursued with great assiduity by attending to those circumstances, many of them trivial, which may remove or counteract it. rlhus clerks, and others, who are often injured by stoop- ing over a desk, and by pressing the chest against it, as well as by the sitting posture too long con- tinued, would be much benefited by frequently, or even occasionally, standing at a raised desk! Tailors and shoemakers are also very liable to suffer from this cause. The stooping posture is not infrequently productive of cerebral and nervous affections; hence the frequency of them in gardeners. Working in constrained positions shows its effects most decidedly in miners and colliers, who labour chiefly in the sitting or kneeling posture, frequently with the bodylbent in the greatest degree, in an unnatural atmos- phere, often containing hydrogen, or carburetted hydrogen, and carbonic acid gases, and with artificial light. They are, moreover, exposed to changes of air, and occasionally work with their feet in water. They are generally spare men, with slightly curved spine, and bowed legs. When the dirt with wliich their skin is usually loaded is removed, the complexion seems sallow and unhealthy. Their complaints are asthma, rheumatism, disorders ofthe head, intolerance of light, &c, evidently resulting from the circum- stances just stated, connected with their employ- ment, and their exclusion from the beneficial influence of sunshine, light, and air. They are not generally very intemperate, yet they seldom live beyond fifty. 18. 3d, Temperature and moisture, and par- ticularly rapid vicissitudes of them, are extremely productive of disease among artisans, but chiefly from negligence, and the want of caution in ex- posures to them. Forgers, glass-blowers, brass and iron founders, bakers, brewers, and various other classes of artisans, are liable to be affected by the high temperature in which they work, and by imprudent exposure to cold, when perspiring, ARTS AND EMPLOYMENTS —as Causes of Disease. 125 and often without any additional clothing. The most frequent consequences are checked perspir- ations, producing catarrhs, rheumatism, bronchi- tis, asthma, and inflammation of the lungs, or of some one of the abdominal viscera. 19. a. The bad effects of moisture only are pro- blematical, or at least not very remarkable. It is only from the circumstance of its being either the came of a greatly depressed temperature, or the very common vehicle in which other agents of disease are dissolved, and thereby diffused in the air, or applied in a more active state to the different organs, particularly the respiratory, that it becomes a very active agent of disease, as is demonstrated by the etiology of the intertropical and malignant diseases. When exposure of the external surface of the body to moisture is inju- rious, the mischief is caused chiefly by the de- pressing effects of the low temperature which it occasions. The animal heat is less rapidly car- ried off by entire submersion in water, than by aspersion merely. In the former case there is no evaporation, in the latter more or less evaporation takes place, and much cold is thereby generated. The histories of shipwrecks abound in proofs of this position. Dr. Currie, in his well known work, has adduced a striking example of it. It is owing to the evaporation which takes place from damp or moist clothes, and the consequent rapid reduction of their temperature, that disease is occasioned by them. 20. Artisans who, from the laborious nature of their occupations, perspire copiously, and thereby render their clothes damp, seldom suffer from this cause while they continue their labours; but when they relax, or desist altogether, then- wear- ing the moistened clothes, particularly in a state of exhaustion, is frequently productive of disease. Inattention to, or inability of, changing damp or wet clothes, are the most common causes of the disorders met with in milkmen, gardeners, fish- ermen, washerwomen, fullers, water carriers, and persons whose occupations are chiefly out of doors. In marshy or unhealthy localities the ef- fects of this cause are greatly increased. The sleepers and cleaners of hemp and flax are ex- tremely liable to intermittents, owing to the con- junction of vegetable effluvia with moisture. Even persons constantly employed in crowded factories, where the stagnant air becomes loaded with the foul vapours exhaled from the lungs of a number of persons, may have their clothes so saturated with moisture as thereby to occasion the usual consequences of cold, when exposed to a drier or opener air. It should be kept in recollection, that cold, when it continues to act for any time upon the frame, is sedative—it depresses the vital influ- ence; and, when acting partially, or directed to parts of the body only, that it is one of the most productive causes of altered energy and sensibility of the nervous system of such part, of irregular distributions of vital influence and of the blood, and consequently fruitful of inflammations, and of morbid discharges and actions. 21. b. The prevention of diseases resulting from the description of causes adduced under this head is important. Wearing flannel next the skin is amongst the most efficacious. For those who are exposed to moisture from out-of-door voca- tions, the use of external garments of dressed skins, or,of tanned leather, or of oil-skin, during 11* the time of exposure, is extremely serviceable, and is generally adopted by the "fishermen of northern countries. 22. III. Class Third. 1st. The mineral molecules, which, either in the form of vapour or of minute disintegration, come in contact directly or immediately with various parts of the body, am extremely frequent causes of disease in artisans, and some of the maladies they produce are pos- sessed of specific characters. 23. A. Mercury is one of the most common causes of the diseases of artificers, particularly workmen in quicksilver mines, glass-platers, gil- ders of buttons, toys, &c. Dr. Gosse has re- marked the greatly increased sensibility of those persons to cold, even to the slightest diminution of temperature, evidently owing to depression of the vital energy and organic actions, and conse- quently of the process of animal calorification. Persons long or habitually exposed to fumes of quicksilver are generally affected with ulcerations of the mouth and fauces ; painful or rheumatic affections of the periosteum, joints, limbs, and ligaments, particularly after exposure to cold ; eruptions on the surface of the body, and all the affections, to which the term pseudo-syphilis has been applied; as well as many of those which are usually denominated cachectic. The effects are altogether the same, although slower in their accession and progress, as those which result from a too long continued, but not violent mercurial course. 24. a. Amongst the most important ofthe affec- tions produced by the fumes or oxides of mercury in artisans is the mercurial palsy, the tremblement mercurial of the French pathologists. It is almost, but certainly not altogether, peculiar to these per- sons. Its approach is generally gradual, but oc- casionally sudden ; it usually commences with slight convulsive snatches, followed by agitations and tremors of the affected muscles, particularly those of the arms, which it first attacks, occurring as it commonly does amongst the workers in mer- cury. If the person continues his employment, the affection extends to the lower extremities and whole body. He becomes incapable of muscular exertion, and even of the avocations requiring the least precision of muscular action. Restlessness, falling out of the teeth, constipation or disorder of the bowels, a dry and brownish state of the skin, slight atonic convulsions, cephalalgia, delir- ium, great depression ofthe nervous powers, and of the general health, take place, in which state the patient may continue to live for many years. (Merat and Colson.) Although it is chiefly long-continued exposures to mercurial prepara- tions which produce this affection, a single ex- posure to then- fumes, even for a few hours, when they float in the air, may occasion it; the effects being both rapid and violent when their vapours are inhaled with the atmosphere, and act upon the extensive surface of the "bronchial tubes and air-cells. 25. b. The habits of the workmen exposed to the fumes or oxides of mercury, render the treat- ment of this affection extremely difficult, owing chiefly to the circumstances of their frequent re- course to spirituous liquors, for the temporary ad- vantage they afford, and to their deferring having recourse to medical aid until the disease becomes confirmed. In recent cases, leaving off the trade 126 ARTS AND EMPLOYMENTS—as Causes of Disease. that occasioned it will alone produce a cure. In long-continued or confirmed cases, benefit is ob- tained with much more difficulty; and, when pro- cured, the disorder is extremely apt to return after the slightest exposure to mercurial fumes. De Haen prescribed electricity in the cases which occurred to him. Lettsom recommended sul- phur; and I believe that its good effects are very considerable. In a case which lately came be- fore me, of violent cephalalgia, with muscular tremors, &c, after a severe mercurial course, large doses of sulphur merely, given every night in treacle, produced a cure in a few days. Mr. Pearson chiefly relied upon exposure to a dry and open air. Sementini states, that he obtain- ed uniform advantage from the internal use of the nitrate of silver, beginning with an eighth of a grain, and gradually increasing the dose to three grains in the day. I have lately employed the tincture of iodine in two cases of this affection with success; and in one case I lately prescribed strychnine, but lost sight of the patient before its effects were apparent. 26. c. It is obvious that it is of importance to be hi the possession of plans to prevent the injuri- ous effects of mercury on those employed in the arts in which it is used. These are sufficiently simple, and consist chiefly of common attention to cleanliness, and avoiding the fumes ofthe min- eral during the various parts of the processes of gilding. Workmen should avoid touching the amalgams that are used with the naked hand ; and ought to make frequent ablutions, particu- larly before taking a meal. During the process of volatilising the mercury by heat, the utmost caution should be exercised in performing the op- eration with a stove in which the current of air is very brisk, so that the fumes may be carried fully up the flue. In most of the manufactories in this country, the stoves are now sufficiently well con- structed for this purpose, the carelessness of the artisan being the chief cause of danger from his occupation. M. Jussieu states, that the free workmen in the large quicksilver mines at Alma- den, who took care to change their whole dress, and attended to cleanliness, were but little affect- ed by their occupation; but that the slaves, who could not afford a change of raiment, took their meals in the mine generally without ablutions, were subject to swellings of the parotids, aphthous sore throat, salivation, eruptions, and tremors. (Mim. de VAcad, des Sciences, 1719, p. 474.) 27. B. Lead. a. Injurious effects from lead, in the various states in which it is used, are very fre- quent and often fatal. Its oxides may be car- ried off in a state of vapour, dissolved in volatile substances,' as by turpentine in painting, and thus be inhaled into the lungs, and act most injuriously on the frame. It may also pass into the alimen- tary canal in various ways, or it may be absorbed from the skin, particularly of the hands, where it will both act locally, and be carried into the sys- tem, and produce its effects as when introduced by the two former channels. These effects are chiefly lead colic and paralysis. The workmen employ- ed in lead mines, those who are engaged in pro- curing it from its ores, who cast it or manufacture its various preparations, and who use them in the different arts, as plumbers, glaziers, painters in oils or water-colours, colour-grinders, type-foun- ders, printers, are the most liable to be affected bv lead; but all classes, under certain circumstan- ces, may also experience injurious effects from it. The deleterious nature of this mineral is certainly very great; but the fatal results are surely not one in three annually, as stated by Sir John Sin- clair. 28. b. M. Me rat has furnished some very in- teresting information respecting the frequency of colica pictonum in the various classes of artisans who come in contact with any of the different preparations of lead. It is derived from the list, kept at the hospital La Charite, in Paris, in the years 1776 and 1811. The total number in both years were 279. Of these 241 were artisans, whose trades exposed them to the poison of lead, viz. 148 painters, 28 plumbers, 16 potters, 15 porcelain makers, 12 lapidaries, 9 colour grinders, 3 glass blowers, 2 glaziers, 2 toymen, 2 shoe- makers, 1 printer, 1 lead miner, 1 shot manufac- turer. Of the remainder, 17 belonged to trades exposed to copper. Of the 279 cases, 24 were under twenty years of age, these being chiefly painter boys, not above fifteen; 113 were between nineteen and thirty; 66 between twenty-nine and forty; 38 between thirty-nine and fifty; 28 be- tween forty-nine and sixty; and 10 older than sixty. Among the 279 cases, 15 died, or 5.4 per cent. (See the article Colic, from Lead.) 29. c. The measures of prevention from the ac- tion of the preparations of lead differ in no respect from those which have been stated in relation to mercury ( § 26.). They chiefly consist of strict attention to personal cleanliness. The instructions given by M. Me rat are very complete, but ar« too particular to be followed by workmen. He recommends that the working clothes should be made of strong compact linen, be changed and washed once or twice a week, and be worn as little as possible out ofthe workshop; a light im- pervious cap ought always to be worn on the head. The artisan should never take his meals in the workshop, or without strict ablution of the hands, mouth, and face; and he ought to break- fast before leaving his home. 30. Derangements of the digestive organs ought to be watched with care. If colicky symptoms occur, he should leave off work, and take an aperient. He ought always to guard against con- stipation. The diet of those exposed to be affect- ed by the preparations of lead is of consequence. It should be light and digestible; and poor acid drinks ought to be avoided, particularly cider, as themselves often containing lead. "Various articles of diet have been recommended as cid- culated to impede the hurtful action of lead on the frame. Hoffmann mentions brandy — a somewhat dangerous recommendation. Fat food has been accounted preservative. Dr. Haen states, that the workers in a lead mine in Styria were much affected by colic and palsy, but, by- being told by a quack doctor to eat a good deal of fat, particularly at breakfast, they were exempt from these diseases for three years (Rat. Med. p. i. ch. ix.). Similar facts respecting the good effects of fat meat, as a preventive of the effects of lead, are recorded by Sir George Baker (Trans, of Lond. Coll. of Phys. vol. ii. p. 457.), and Mr. Wilson (Edin. Phys. and Lit. Essays, I. p. 521.). Those who work at furnaces in which lead is smelted, fused, or oxydised, should be pro- tected bv a strong draught through them. Mr. ARTS AND EMPLOYMENTS — as Causes of Disease. 127 Braid, of the extensive mines at Leadhills, in- formed Professor Christison (see his most valu- able work on Poisons, &c. p. 506.), that wherever furnaces of such a construction have been built, the colic has disappeared. 31. C. Copper, although extensively used in the arts, is seldom productive of much disease. Patissier states, that the workmen in copper become prematurely old, having a meagre and sickly appearance. This is, however, as much owing to confinement in ill-ventilated places, and intemperance, as to the metal. Me rat has ad- duced evidence of their being frequently subject to colica pictonum. They are likewise liable to diseases of the respiratory organs, — particularly those engaged in filing the metal; but this is en- tirely owing to the mechanical irritation occasion- ed by the finer particles when inhaled into the lungs. Asthma is frequent amongst brass-foun- ders, owing probably to this c;uise, and partly to the vaporisation of a portion of the zinc with which copper is amalgamated. 32. D. Zinc, arsenic, and antimony, are sel- dom productive of hurtful effects amongst artisans; owing probably to the first being chiefly employ- ed in the metallic state, in which it has no effect, although it is deleterious when oxydised; and to the circumstance of arsenic and antimony being generally used in small quantities. 33. E. The acrid vapours, which proceed from the mineral acids often produce violent effects when respired; chiefly asphyxia, and severe in- flammation ofthe air-passages; but they are eas- ily guarded against, and chiefly by operating in nearly open places. Persons who prepare arti- cles for gilding, by cleaning them in aquafortis, are equally liable to respire the vapours of these acids, but may avoid them with even a moderate share of caution. The inflammations of the re- spiratory organs occasioned by them, differ mere- ly in respect of their intensity, from the same diseases proceeding in an acute form from other causes. Chlorine gas, when respired in consider- able quantity, produces inflammation of the air- passages. The chief effects of habitual exposure to it are acidities and other complaints of the stomach. The trades in which workmen are ex- posed to chlorine do not seem to be unwholesome. Corpulent men are soon reduced by it to their natural size. During the epidemic fever that rag- ed all over Ireland from 1816 to 1819, the people tit the chemical manufactory at Belfast were en- tirely exempt from it. 34. 2d. Molecules of animal matter in a state of decay are frequently productive of disease, both in persons whose avocations expose them fre- quently to this cause, and in those who approach it only incidentally. Nightmen are chiefly ex- posed to this source of disease, particularly in Paris. The gases evolved when emptying the fosses d'aisances of that capital are frequently pro- ductive of serious and even fatal consequences. The exact nature of these varies with the vapours evolved. Ainmoniacal vapours usually occasion what the French term la mitte: sulphuretted hy- drogen, hydro-sulphuretted ammoniacal gases, and azote, produce le plomb. 35. A. The symptoms of la mitte are smarting ofthe eyes, with the sensation of sharp or pun- gent odour and uncomfortable feeling about the nose. To these succeed pain, extending to the forehead, and discharge from the eyes, occasion- ally with blindness enduring for two or three days. These effects, if not very intense, generally pass off by shading the eyes, and exposure to the open air: if they are more severe, the application of cold epithems to the eyes, and protecting them from the light, are usually efficacious. 36. JS. Le plomb is of two kinds: 1st. that oc- casioned by azote, and which is simply Asphyxy (which see) from the privation of respirable air, attended with coma or stupor; 2d, that caused by sulphuretted hydrogen and hydro-sulphuretted am- moniacal gases, which is the most dangerous and common, and is generally attended with convul- sions. (See Poisons.) The former is common- ly prevented by a free circulation of air; the latter is avoided by employing the chlorurets of lime or of soda, a solution of which is poured in the pri- vies, and reservoirs or drains, shortly before they are emptied. (See Treatment of Asphyxy and of Poisoning by deleterious Gases.) 37. C. The animal effluvia proceeding from slaughter-houses, dissecting-rooms, chandlery or adipocire manufactories, and other places where animal substances are manufactured or employed in the arts, are seldom so concentrated as to be productive of disease; but there can be no ration- al doubt of their unwholesome influence when con- centrated, or accumulated in a stagnant atmos- phere. The liability of butchers and cooks to be corpulent has been absurdly enough ascribed by some superficial writers to the absorption of nu- tritive particles from the air, without attending to the fact of a much larger quantity of animal food being ta_ken by them than by any other class of persons. 38. Dr. Withering had noticed (Letter to Dr. Beddoes, 1793.) the comparative exemp- tion of butchers and catgut-makers from phthisis. M. Patissier has made the same remark; and Dr. Beddoes has added to these employments soap-boilers, and the fishermen and fish-wives in the vicinity of Edinburgh. Glue and size boilers are exposed to putrid and ammoniacal exhalations from the decomposition of animal refuse. But these workmen are generally fresh-looking and robust. A similar observation is applicable to buckram manufacturers. Tanners are subject to animal vapours; but so combined with the odours of lime and tan as entirely to counteract any in- jurious effect which the former might produce. They are much exposed to wet and cold; yet they are generally healthy, robust, and tolerably ex- empt from pectoral diseases, particularly consump- tion. Mr. Thvckrah states, that he has care- fully enquired at several tan-yards, and could not hear of a single example of this disease. 39. 3d, Vegetable molecules. Corn-millers suf- fer remarkably from breathing an air loaded with the particles of flour. They are chiefly affected by indigestion, asthma, and morning coughs with expectoration, terminating either in consumption or in asthma; and are generally pale, sickly, and short-lived. This is the case only with those who work in the mills. Those amongst them who labour in the open air with the carts are not thus affected ; but, as other persons raising heavy weights, are subject to herniae. Maltsters are liable to the same diseases, arising from the same agents, and from the heated and sulphureous air of the kilns. Bakers are exposed to similar causes, 128 ASPHYXY. but to a much less extent, and suffer accordingly — chiefly from cough, asthma, affections of the stomach, rheumatism, and a peculiar chronic erup- tion on the skin. Snuff-makers are exposed to the dust of the tobacco; but they are not so much affected by it as may be expected. They chiefly complain of disorders of the head, stomach, and air-tubes: of the former, from the narcotic effect of this vegetable; and of the last, from its irrita- tion. The narcotic odour to which tobacco man- ufacturers are liable is not productive of any very appreciable mischief, owing to their having be- come insensible to its influence. 40. 4th, I shall here briefly notice those trades, the workmen in which experience the very injuri- ous effects of inhaling an atmosphere in which various vegetable, animal, or mineral molecules are floating, — causes which, although very dis- similar in themselves, generally act in nearly a sim- ilar manner—namely, by irritating the bronchial surface, and superinducing various modifications of disease, according to peculiarities of constitu- tion, temperament, and habits of life. a. The ar- tisans who suffer the most from these causes are dry grinders and needle-pointers; edge-tool, gun- barrel, and other grinders; flax-dressers, and pearl and horn button makers; iron, brass, and other metal filers; stone-cutters, miners, and quarriers, particularly in sand stone; wool-carders and feath- er-dressers; sawyers, turners, weavers, and starch- makers. All these suffer more or less, generally in the order here followed (needle-pointers and dry-grinders the most, and starch-makers the least), from chronic bronchitis, in one or other of its modifications: in some, from the spasm of the bronchi thereby occasioned, with the symp- toms of asthma predominating; in others, with those of chronic inflammation extending to the lungs; in a few, with pulmonary emphysema; and in many, with tubercular and cretaceous for- mations. The most inflammatory effects seem to result from needle-pointing, dry-grinding, and stone-cutting; whilst the more asthmatic affections proceed from the horn and pearl button manufac- turing. These workmen seldom live above forty years, and the greater number not beyond thirty or thirty-five. They often experience but little incon- venience till some time before the fatal disease takes place; but they are as often affected in early life, particularly pearl and horn button makers, the dis- ease subsequently assuming an asthmatic character. 41. b. Various means have been invented in order to prevent the molecules or dust arising in these trades from accumulating and being inhaled into the lungs of the workmen; but nearly every measure hitherto advised has been neglected by them. Amongst other contrivances, the muzzle of damp crape recommended by Dr. Johnstone, the sponge by Dr. Gosse, and M. D'Arcet's "fourneau d'appel," which is, however, not known in this country, may be named. The best means yet devised seems to be that invented by Mr. Abrahams of Sheffield, in which magnetic attraction is employed to arrest the floating metal- lic particles. This, as well as the use of the " damp bag " suspended over the stone, in grind- ing and pearl button turning, are most useful in- ventions. In mining, quarrying, or cutting stones, dry-grinding, &c, much good would probably re- sult from having moistened or wet woollen cur- tabs suspended over the heads of the workmen, and in such a way as to be agitated through the air of the place. The simpler the means, and the less trouble required in their use, the more likely are they to be adopted. 42. c. In respect of the treatment of the pulmo- nary diseases which result from these causes, very little difference from that employed under ordina- ry circumstances is required. The frequent use of emetics is adopted by the workmen themselves; and there can be no doubt of their utility in the most of the diseases of the air-passages. The other means of cure are fully noticed in their re- spective places. Bibliography. — Rammazini, Opera Omnia Medica. Gen. 1717. — Merat, in Diction, des Sciences Mt'dicales, t. vi. p. 32.—Patissier, Traite des Maladies des Artisans, et des celles que resultent des diverses Professions, kc, 8vo. Paris, 1822.—Merat, Traite de la Colioue Mitallique, 8vo. Paris, 1812. — Bertrand, Essai Mt'dical sur les Profes- sions et les M<"tiers. Paris, 1815.—Speer, in Dublin Hosp. Reports, vol. iii. p. 161.—C. T. Thackrah, The Effects of the principal Arts, Trades, and Professions, &c, on Health and Longevity, kc London, 8vo. 1831. — Colson, Sur le TremblementMi lallique, &c, in Archives Gener. de Mtd. t. xiv. p. 102., et t. xv. p. 338. ASCARIS. See Worms. ASCITES. See Dropsy of the Peritoneal Cavity. ASPHYXY. (From the privative a, and atpi'to*, I beat, I leap.) Syn. Aaifiv^ia, Hip. Asphyxia, Auct. Lat. Apoplexia Suffocata, Cullen. As- thenia Suffocatio, Young. Asphyxie, Le Pouts manquant, Fr. Der Scheintod, Pulsstillstand, Eine tbdtliche Ohnmacht, Ger. Mancamento di polso, Ital. Classif. 2. Class, Nervous Diseases; 1. Order, Comatose Affections (Cullen). 4. Class, Diseases ofthe Nervous Functions; 4. Order, Affecting the Sensorial Powers (Good). I. Class,III. Order (Author, see Preface). 1. Defin. Suspended animation proceeding from a primary arrest of the respiratory actions, the other functions being thereby abolished. 2. Asphyxy, according to its etymology, should be defined, the cessation of the action of the heart. In this case it would be synonymous with certain forms of syncope, from which, however, it most essentially differs. Yet even in syncope the most complete, the action of the heart never altogether ceases; it is only unusually weakened, and pre- viously to respiration being affected. Attention to the phenomena to which the term asphyxia has been so long applied, will inform us that the actions of respiration are primarily arrested; that the functions of circulation are subsequently abol- ished; and that death is the result of this succes- sion of events. It may, however, be stated, in justification of the change of signification which this term has undergone, that there is no state of the system from which recovery is possible, that is characterised by a more complete abolition of the action of the heart than this, although it takes place secondarily only from the arrest of the res- piratory functions. 3. Asphyxy has been very generally viewed as proceeding from causes which act in various ways; and the opinions respecting their nature and mode of operation have been extremely deficient in pre- cision and accuracy. According to the mean- ing which I have attached to the term, as stated above, asphyxy can only occur in a direct or primary form, from causes which either exclude ASPHYXY the air from the lungs, prevent its renewal, or abstract that constituent of it which is requisite to the respiratory functions. Authors have, how- ever, included, under the head of asphyxies, those states of suspended animation which proceed from the respiration of deleterious gases: and Dr. Good has comprised under it death or suspended animation from lightning and from intense cold. In every case of the action of deleterious gases, of lightning, and of intense cold upon the system, the respiratory organs, although one of the chan- nels for the action of the latter, are not the first to have their functions arrested. The action of all these agents is primarily exerted upon the ganglial and nervous systems; and, owing to their effects upon these systems, the function of the brain, of respiration, circulation, &c. are subse- quently abolished. As the action of the greater number of deleterious gases, when respired, is similar to that of other irritating and narcotic poisons, I shall consider them under the head of gaseous poisons (see Poisons). When, how- ever, they are of such a kind, or are present to such an extent, as to irritate violently the larynx, and, by exciting spasm of it, to exclude the air, or so as to displace, and to occupy the room of, the respirable atmosphere, their action is similar to other agents primarily occasioning simple as- phyxy: and they therefore require no further no- tice than by adducing them as causes of this state. In respect of the influence of cold and lightning upon the frame, it may be observed that, although exciting and concurrent causes of asphyxy, and producing this, with other changes in the vital functions, but in very different ways, they act directly upon the nervous system, and give rise to asphyxy only secondarily; and, like the more poisonous gases, chiefly through the medium of this system, particularly that part of it which presides over the functions of the brain and heart. Their action will therefore fall under dif- ferent heads. 4. I. Causes.—Asphyxy takes place in a pri- mary and simple form, from whatever excludes, or prevents the renewal of, air in the lungs of a healthy person, or consecutively upon other af- fections or diseases, especially those affecting the nervous system, and particularly the respiratory class of nerves. In the former state ofthe frame it is an idiopathic or essential affection; in which light it will be chiefly viewed in this place : in the latter it is symptomatic, or rather one of the modes in which disease terminates life. These states of asphyxy may proceed, first, from a pri- mary cessation of the mechanical phenomena of respiration, and, secondly, from a priniary default of the chemical changes which take place during tlie respiratory actions. 5. To the first of these is to be referred the asphyxy which depends upon inaction of the respiratory muscles (A.); and (B.) upon deficient expansion of the lungs, the inspiratory muscles performing their functions. A. Deficient or im- possible action of the inspiratory muscles pro- ceeds, 1st, from mechanical obstacles applied to them, as in the instances of death occasioned by earth falling upon the trunk of the body, and pressing it so strongly as to prevent them from expanding the thorax : 2d, from deficient or in- terrupted influence of the nerves supplying these muscles, as from injuries or division of the pneu- -Causes of. jog mogastric nerve; injury or pressure upon the me- dulla oblongata or spinal chord, either from frac- ture or dislocation of the spine, particularly of its cervical portion; and from the paralysis of the nervous system occasioned by a stroke of light- ning, or any other cause abolishing its energy: and, 3d, from want of activity, or deficient irrita- bility of the inspiratory muscles themselves, as from the benumbing influence of cold, and the suspended animation of new-born infants. 6. B. The asphyxy which proceeds from a deficient expansion of the lungs, is generally ow- ing, 1st, to mechanical impediments, as the pas- sage of some of the abdominal viscera through the diaphragm, the accumulation of fluids in the pleura, or similar causes : and, 2d, from paralysis of the nervous energy of the lungs, as in cases of death from cold, from lightning, from various poisonous gases, &c; whereby the vital expansi- bility of the organ is abolished, along with the other respiratory actions. 7. The second class of causes, or those which act by impeding or abolishing the chemical chan- ges effected by respiration, may be referred to two heads:—1st, Those which present a me- chanical obstacle to the entrance of air into the lungs, as strangulation; submersion; the introduc- tion of foreign bodies into the larynx, trachea, or even the large bronchi: and, 2d, Those which consist of a deficiency of respirable air, as a too rarified atmosphere, or the presence of azote, hy- drogen, carburetted hydrogen, protoxide of hy- drogen, or indeed of any of the deleterious gases. It is evident, however, that asphyxy is often oo casioned by the combined operation of more than one of its proximate causes. Thus it may pro- ceed from paralysis of the respiratory muscles, and of the nervous energy of the lungs them- selves; and hence be characterised by abolition of the respiratory efforts, by deficiency of the expansive power of the organ, and by arrest of the chemical changes which take place during respiration : and, on the other hand, several of the remote causes act by individually producing more than one of the pathological conditions now specified. 8. II. Characteristic phenomena of Asphyxy. —When asphyxy takes place slowly, especially from causes which interrupt the nervous influence actuating the respiratory muscles, it commences with greater or less difficulty of elevating the tho- rax; anxiety, with urgent desire to inspire, and constant attempts to fill the lungs, giving rise to continued gaspings, or quick, short, and imperfect respiratory efforts; pandiculation; vertigo; failing of consciousness and sensation; sometimes to convulsive movements both of the limbs and trunk, followed by immobility of the parietes of the thorax and abdominal muscles, weak and languid pulsation of the heart, and absence of pulse at the wrist; the face is coloured, livid, tu- mid, injected, and its veins distended; the hands and feet, as well as the face, present a reddish violet hue; and the cutaneous surface patches of a similar tint. At last the circulation is entirely arrested, and asphyxy is complete. The animal temperature, however, and the absence of rigidity of the muscles, continue for a long time after- wards, — almost always for a much longer period than from death under other circumstances, and from other proximate causes. 130 ASPHYXY —Pathology of. 9. These phenomena vary, particularly as re- spects the rapidity of their progress, according to the causes whence they proceed, and to the ex- tent to which air is excluded from the lungs. Where no obstacle to the action of the inspiratory muscles is present,—the obstruction to respiration existing in the air passages,—the efforts to renew the air in the lungs are much more convulsive and laborious. The anxiety is extreme, but of short duration, and rapidly followed by abolition of con- sciousness, voluntary motion, and ofthe functions of circulation. In this case the description of Shakspeare is physiologically accurate :— "But, see ! his face is black and full of blood; His eyeballs further out than when he lived, Staring full ghastly, like a strangled man; His ha r uprcared; his nostrils stretch'd with struggling; His hands abroad display'd, as one that graspM And tugg'd for life, and was by strength subdued." 10. In cases where asphyxy arises from a sud- den abolition of the nervous influence of the re- spiratory muscles, as from injuries inflicted on the medulla oblongata, &c, or when the trunk ofthe body is so compressed as to prevent all action of these muscles, but particularly when it proceeds from the former cause, the phenomena supervene and succeed each other with great rapidity ; but generally in the order in which I have enumerat- ed them, excepting that all respiratory efforts are instantly suppressed. In drowning, however, the progress of the symptoms are less rapid and somewhat different, as will be shown in the sequel. 11. III. The duration of life in cases of as- phyxy is very different, according as the causes which occasion it act with greater or less prompt- ness, or more or less perfectly, in preventing the renewal of air in the lungs. In general, the more slowly that abolition of the respiratory function takes place, as in cases of drowning, the longer does the action of the heart continue, although feebly and slowly, even after respiration has ceas- ed; and to this circumstance, as well as to the fluidity of the blood, which is long preserved, is owing the power we possess of recalling the as- phyxied to life; the more slowly the state of as- phyxy supervenes, the longer the person retains the ability of being reanimated, and vice versa. 12. The length of time, however, after which resuscitation cannot be accomplished is necessa- rily varied by different circumstances; and not only by the causes of asphyxy, and their modes of op- eration, but also the strength of constitution, age, and previous health ofthe person, and the man- ner in which abstraction of air has taken place. Much will also depend upon the changes which the asphyxy has produced in the brain,—the de- gree of congestion, or the occurrence of extrava- sation there,—circumstances which, when present to any very considerable extent, more particularly the latter, will generally preclude the possibility of reanimation. 13. IV. Appearances observed on dissection of asphyxied persons. — A reddish or violet red hue of the countenance and various parts of the surface of the body, which continues to retain its warmth an unusual length of time after death: this tint does not arise from the position of the body after death; and is chiefly seated in the mucous or vascular tissue of the skin, which, up- on incision, allows the blood to escape in a state of fluidity. The eyes are bright and prominent; the mouth sometimes natural, at other times ex- pressive of suffering; the limbs are rigid, and continue in this state unusually long, after having been late in assuming it. The veins and sinuses of the brain generally are filled with a dark fluid or semi-fluid blood; the substance and cavities of the brain are not otherwise materially altered. The base of the tongue is generally full or inject- ed, and even tumified, and its papillae developed; the mucous membrane of the larynx, trachea, and bronchi, is injected and red—the colour becoming darker as we descend from the larynx to the bronchial ramifications, where it assumes a violet or reddish brown tint. Their smaller branches often contain a little sanguineous frothy mucus. The lungs are distended, rise around the pericardium, and present a brown or blackish brown hue; their parenchyma, when divided, are of a redder tint, but give out, upon pressure, large drops of a thick, fluid, and very black blood. The liver, spleen, and kidneys are gorg- ed with blood, presenting a similar appearance. The veins of the heart are congested; and its right cavities, the vena cava, and other large veins, are engorged with black and seini-coagulated or fluid blood. 14. V. Theory of Asphyxy. — It is chiefly to Goodwin and Bichat that we are indebted for the near approaches which have recently been made to a satisfactory and consistent theory of as- phyxy, upon which a rational mode of treatment may be based. The venous blood sent by the right ventricle to the lungs, which contain a di- minished quantity of air calculated to convert it into arterial blood, is returned to the left side of the heart, but slightly changed from its venous state, from whence it is propelled through the ar- teries to the different organs. The consequence of the imperfect changes effected in the blood, owing to the interruption or cessation of the re- spiratory actions, is imperfect excitation of the most important organs of the body; and in pro- portion as the blood sent from the left side of the heart is possessed of more of the venous charac- ters, the absence of excitation is more manifest, until, as respects the brain, and lungs particularly, which are the first of all the organs to experience the effects resulting from the circulation of venous blood, a sedative or stupifying effect, but negative in respect of its nature, is produced upon them; as is frequently evinced on the brain in cases where asphyxy takes place slowly, and when the blood sent from the left side of the heart is com- pletely venous in its characters. 15. In tracing the phenomena it will be ob- served, that the capillary system of the lungs is the first to experience a loss of their vital tone and undergo congestion. This arises from the following causes :—1st, The absence of the usual stimulus of pure air in the air-cells : 2d, The circumstance of their being the first to receive the blood after being returned from other parts of the body fully charged with venous properties : 3d, The cessation of the mechanical actions of respi- ration; and, with them, of the expansive mo- tions ofthe lungs themselves : 4th, rlhe arrest of those changes which the blood undergoes from oxygenated air, and the influence of a darker blood than usual upon the pulmonary vessels: 5th, The loss of nervous influence, arising from the sedative effect of venous blood upon the ASPHYXY —Pathology of. 131 nervous centres, when circulating in arterial ves- sels: and, 6'th, The circumstance of the systemic capillary vessels retaining their tonicity and pow- er of reacting, for a longer time, upon their contents, when circulating venous blood, than the pulmonary capillaries ; consequently the blood is returned by them into the veins, and thence to the right side of the heart to be sent to the lungs, which are the first, from this and the foregoing causes, to experience congestion, and to lose the power of restoring it to the left auricle. Thus it will be seen, that the interruption to the circulation commences in the capillary system of the lungs, in consequence of the stop put to the mechanical and vital actions of this organ; and that the heart, which does not cease to contract until the functions of the lungs and brain have been abolished, no longer is supplied with blood from the lungs; the left side of" the heart being thus the ultimum moriens. 16. The early and manifest effects of asphyxy on the brain have been fully proved by the ex- periments of Bichat. This organ is deprived of its functions, and the comatose state is rapidly and profoundly expressed ; the venous blood conveyed to it, chiefly from its negative effects, grving rise to all the phenomena usually occa- sioned by a narcotic poison. Even the heart itself, although the last of the three organs to ex- perience the effect produced by the circulation of venous blood, is soon enfeebled in its action. This evidently arises partly from the abolition of the functions of the brain, and partly, or even in a greater degree, from the circulation of dark blood to the ganglia and nerves, whence the heart derives its action, and to its proper structure. But the experiments of Dr. Edwards and Dr. Kay evidently show that the circulation of dark blood does not destroy the irritability of muscles, but that it is a less powerful supporter of this property; and consequently that the irritability of the heart is not abolished, as Bichat supposed, but only insufficiently excited. Indeed, if this property were destroyed, resuscitation would be impossible. 17. The long continuance of the animal heat after the total cessation of the heart's action can only be explained by the integrity of the vital energies of the frame at the time ofthe event, by the continued fluidity of the blood, and the cir- culatory or oscillatory motion of this fluid in the systemic capillary system for a considerable time after the heart had ceased to contract,—phenom- ena, which have been satisfactorily observed in cases of asphyxy. The patches of lividity, and the dark colour of the surface, depend upon the injection of the capillaries of the surface with dark blood, and the engorgement of the veins. The slow accession of rigidity of the limbs after death is referrible to the longer duration of the animal temperature, and the fluidity of the blood, than in other cases; and to these causes also are to be imputed the possibility of resuscitation after a longer period from the cessation of respiration than in any other morbid condition of the frame. The marked rigidity of the limbs, after the body is quite cold, must be chiefly imputed to the perfect state of the vital energies when as- phyxia took place. 18. It has long been observed that the body of an asphyxied person appears to contain much ' more blood than that of an individual who has died in a different way. Bichat explains this by supposing that the organs receiving venous blood, which is devoid of the materials necessary to nutrition, yield all the fluids which they usually furnish without appropriating those which they usually do under other circumstances; so thai the quantity of blood is actually increased, par- ticularly in cases where the asphyxy takes place slowly. In proof of the accuracy of this view, it has been stated that, when asphyxy occurs suddenly, and the functions cease rapidly, less engorgement of the venous system and of the lungs is observed, than when death is caused more slowly, as in the case of asphyxy from burning charcoal. Perhaps the quantity of blood in the system seems greater from the circumstance of its fluidity, or rather the absence of coagula- tion; for when this takes place, the serum of the blood partly escapes into the shut cavities after death, and exudes through the vessels and tis- sues. 19. From the foregoing, therefore, it may be concluded that the cessation of the actions of respiration,—first the mechanical or muscular actions, next the vital or expansive mqtions of the lungs, — is soon followed by an arrest of the pulmonary circulation, afterwards by abo- lition of the nervous functions and influence, and lastly by cessation of the heart's action, in consequence of the blood not being restored to the left auricle and ventricle ; the latter of which, however, continues to contract as long as blood is sent to it. Hence, as respects the circulation, first, stagnation of the blood in the pulmonary capillaries upon the cessation of re- spiration takes place; next, a deficient supply of blood to the left side ofthe heart; and, lastly, an accumulation of it in the pulmonary arteries, and right auricle and ventricle, which are no longer able to overcome the resistance opposed to its pas- sage in the congested pulmonary vessels. Thus it will be seen that the left ventricle is actually the ultimum moriens, and not the right, as suppos- ed by many. Upon this view of the procession of phenomena in death from asphyxia, our endea- vours to restore animation are founded. 20. V. The varieties of Asphyxia, in a practi- cal as well as physiological point of view, deserve particular notice. The respiration of several gases is often followed by fatal consequences ; but as asphyxy is only one of the. deleterious effects they occasion, I have considered them in another place (see Poisons—Gaseous.). Of all gaseous bodies from which asphyxy may arise, azote and hydrogen alone act simply by produc- ing asphyxy; and they have this effect only when they are present in considerable quantity in the air, or when they are respired for some time. The effects which they produce differ in no respect, in the present state of our knowledge, from those described above. 21. A. Asphyxy from submersion.—a. There are various circumstances, both proper to the in- dividual, and connected with the submersion, which will modify the resulting asphyxy, and should be taken into account in our endeavours to restore animation. When a person is immersed in water he is seized with an urgent feeling of anx- iety at his breast; his pulse becomes weak and frequent. He struggles to relieve his distress, and 132 ASPHYXY—Treatment of. thereby rises to the surfiice of the water, and | throws out some air from his lungs. His anxiety j continues to increase, and his pulse becomes weaker; his straggles are renewed with more vio- lence; he rises to the surface again, throws out more air from the lungs, and makes hurried at- tempts to inspire, and in some of these attempts a | quantity of water goes down the throat with the . air, and excites cough and spasm of the glottis. These efforts tend to determine blood to the head, which, owing to the impeded state of respiration, partakes of the venous properties; and rapidly in- duces, from this circumstance as well as from the pressure it occasions, insensibility, loss of volun- tary motion, slight lividity of the surfiice of the body, particularly of the face, loss of pulse, re- laxation of the sphincters, and as the body sinks to the bottom, the expulsion of a portion of the air contained in the chest. 22. b. On dissection, nearly the same appear- ances as those already described are found. In addition to these, a frothy fluid is met with in the trachea, and ramifications of the bronchi, with some water, the quantity of which varies in dif- ferent cases. From Dr. Goodwin's very satis- factory experiments, confirmed by Mr. Coleman and Professor Meyer, it appears that this small quantity of water enters during the struggles to inspire, and, mixing with the mucous of the bron- chi, forms a frothy fluid, insufficient, however, to occasion the fatal changes in drowning. A con- siderable quantity of fluid is found in the stomach. According to Dr. Curry, the vessels of the brain are not particularly distended ; but there are exceptions to this. Dr. Berger, of Ge- neva, found that the air remaining in the lungs had lost nearly all its oxygen. Mr. Coleman states that the left ventricle of the heart is never entirely empty, it generally containing about half the quantity of that found in the right ventricle; and that a little blood is also found in the aorta. 23. c. In cases where a person, in falling into the water, has been struck on the head and stun- ned, or is intoxicated, or benumbed with the cold and fright, the efforts at preservation will scarcely be made, and the case will be more completely that of simple asphyxia. In cases of this descrip- tion the countenance is generally pale. The peri- od after which reanimation may be procured is extremely various—generally from five minutes to three quarters of an hour. Of twenty-three per- sons recovered from drowning, one had been three-quarters of an hour under water; four, half an hour ; three, a quarter of an hour ; and the rest for shorter periods. Dr. Edwards has very satisfactorily demonstrated that life is more rapid- ly extinguished by submersion in water of a very low temperature than in that of higher grades, evidently owing to the sedative effects of cold upon the nervous system. When submersion takes place during intoxication, there is greater risk of congestion or extravasation in the brain be- ing superinduced; and if syncope, by the fright attending submersion, occurs, fatal congestion and paralysis of the heart and lungs will chiefly su- pervene, but in a slower manner than under other circumstances; and, as M. Leroy (Archiv. Gin. de Mid. t. xvii. p. 469.) supposes, thus admit- ting of resuscitation at a longer period after sub- mersion. 24. B. Asphyxy%from strangulation.—When asphyxy is produced by hanging, and if the ex- clusion of air from the lungs is complete, the fol- lowing appearances are generally observed:—After loss of sensibility, epileptic convulsions, some- times slight, at other times marked ; and gener- ally attended with erections and emissions; turgid- ity, suffusion, and lividity of the face, extending to the shoulders, chest, arms, and hands : the eyes are open, projecting, and their vessels in- jected ; the features are distorted, and the tongue thrust out of the mouth ; the external muscles of respiration are firmly contracted ; the hands are clenched, and the sphincters relaxed. When the air is not perfectly excluded in hanging, the suf- ferings are prolonged, the engorgement of the head and face is greater, the lungs are less loaded with blood, and the vessels ofthe brain more con- gested, than when the air is completely excluded. In the majority of cases of asphyxy from hanging, the lungs contain more air than after death from natural causes, or from suffocation by a pillow when the air is only imperfectly excluded from the lungs. 25. There can be no doubt, that although death is caused by asphyxy in cases of strangula- tion, as proved by De Haen, Monro, and others, the interruption which the cord occasions to the return of blood from the head, and the consequent congestion of the encephalon, accelerate death In some instances, also, there is reason to believe that fracture, dislocation, or subluxation of the vertebrae ofthe neck is produced in the execution of criminals; but it very rarely, or perhaps never, occurs in cases of suicide by strangulation. To these additional effects upon the encephalon and medulla oblongata is to be partly imputed the want of success in our attempts to restore anima- tion after strangulation. 26. VI. General Treatment of Asphyx- ia.---The indications which naturally suggest themselves from the consideration of the causes of asphyxia, their mode of operation, and the ultimate results which they produce, are, 1st, to remove the patient as soon as possible from the causes which occasioned the asphyxied state ; and, 2d, to restore the function of respiration, and, through it, the circulation. The necessity of fulfilling the former of these is sufficiently obvious, and the means of doing so will necessarily vary with the nature ofthe cause, which should be instantly as- certained; but without delaying the employment of means to restore respiration. 27. The restoration of the function of respira- tion is to be attempted by various means, calcu- lated, in the first place, to dislodge the impure air contained in the lungs ; secondly, to replace it with pure air; thirdly, to excite the remaining vitality ofthe nerves and muscles; and,fourthly, to restore the circulation by measures calculated to return the blood from the lungs to the left side of the heart. The simultaneous attainment, as far as may be, of these objects, is to be attempt- ed by a judicious combination of means, a. The patient should be placed on his back, in an open air of a mild or somewhat high temperature, of from 65 to 70 deg. of Fahr., with the chest, shoulders, and head slightly elevated. He should be stripped of his clothing, and enveloped in a warm blanket. None but the assistants ought to be admitted into the room. The body should be ASPHYXY —Treatment of. 133 placed at a convenient height for the employment of the measures of reanimation. Pressure should then be made upon the breast and abdomen, al- ternating with relaxation, in such a manner as to simulate the actions of the chest in respiration. By this means the foul air will be thrown out of the lungs; and the restoration of the capacity of the thorax, upon the removal of the momentary pressure, by the elasticity of the costal cartilages, will draw fresh air into the lungs. It will some- tunes be of service to apply a har.d upon each side of the thorax below the arm-pits, and by gentle shocks endeavour to expel the vitiated air. Whilst this is being performed, bottles of warm water should be placed to the feet, under the knee- joints, between the thighs, and under the arm- pits. Dry warmth is particularly beneficial when applied to the epigastric region. Warm stimu- lating frictions over the surface should also be employed. 28. 6. After having used pressure so as to sim- ulate respiration for a few moments, insufflation of the lungs is next to be resorted to. This may be performed by the mouth, or by a bellows. When the latter is not at hand, the former must be adopted. The operator having closed the nos- trils, and applied his mouth to that of the patient, is to blow forcibly into it, pressing the chest after- wards, in order to expel the air, and again blow- ing forcibly into the chest. If the lungs cannot be inflated in this way, the operator should blow into one nostril, having closed the other and the mouth; and if a small wooden tube can be pro- cured, this may be used for the purpose, by in- serting one end of it into the nostril, and blowing into the other; or the pipe of a bellows may be inserted into it. 29. c. Insufflation of the lungs by the breath of the operator has been recommended by some in preference to the use of the bellows, on account of the higher temperature of the air thrown into the lungs by the former mode; whilst others pre- fer the latter method, on account of the purer air furnished by it. I believe that the advantage of the higher temperature of the former nearly coun- terbalances the disadvantage of less purity. If, therefore, insufflation by the bellows of a" warm air could be had recourse to, considerable benefit might be obtained. If the bellows are used, the pipe is to be introduced into one nostril; and, whilst the mouth and other nostril are closed, and the pomum adami pressed gently backwards and downwards by an assistant, the bellows are to be opened and immediately closed, so as to throw air into the lungs by a single stroke; after which, allowing the mouth and nostril to open, the chest is to be pressed so as to expel the air : thus air is to be forced in, and again expelled, about fifteen or sixteen times in a minute, so as to simulate respiration. 30. d. The external and internal use of stimu- lants has been recommended by J. P. Frank and Devergie. Of this class of means, galvanism holds the first place; but it is seldom that an ap- paratus can be procured. When it can be obtain- ed, slight shocks may be directed through the diaphragm or heart; or if an electric apparatus is at hand, as strong shocks of electricity as the ma- chine can furnish may be tried. Whilst we are proceeding with insufflation of the lungs, frictions of the surface of the bodv, particularly over the 12 " chest, on the insides of the thighs, &c, in order to promote the circulation and the animal heat, should be continued; and the nostrils may be irritated, or touched occasionally with a feather dipped in spirits of hartshorn or of aromatic vinegar. Sub- stances which are likely to increase the coldness of the surface by their evaporation should not be employed by friction. The introduction of warm stimulating fluids into the stomach, by means of a flexible tube and syringe, has been recommend- ed, and may be tried after insufflation ofthe lungs has been performed for a short time. More ad- vantage, however, will probably accrue from the administration of a clyster of warm spirits and water than from the injection of stimulants into the stomach, unless this can be done with an ap- paratus admitting of easy application. Tobacco- smoke has also been directed to be thrown up the rectum; but it is a more uncertain remedy than the clyster now mentioned. 31. e. Bleeding is one ofthe measures respect- ing which the greatest difference of opinion has existed. In certain circumstances it is often of great service, and in others detrimental. It is generally proper when the countenance is swollen, injected, or purplish ; the veins full or distinct; and the skin reddish, or approaching the violet tint. It is not always, however, possible to obtain blood; but even when we fail in procuring it, the opening which had been made should be carefully closed and bandaged, in order to prevent subse- quent haemorrhage, which may occur when least expected. Bleeding is also often required during the progress of recovery, particularly when the respiration is laborious, the brain loaded or op- pressed, and when delirium, the not infrequent attendant on restored animation, is present. 32. /. The means now recommended, partic- ularly frictions, inflations of the lungs, and the occasional use of stimulants, should be persisted in for several hours, unless stiffness of the limbs, and other indications of death, present themselves. Convulsive snatches of the respiratory muscles, with gaspings, followed by sighing, a more natural respiration, and slight palpitations, are the first signs of returning animation. When the circu- lation is restored, convulsions sometimes take place, and suddenly destroy the patient. Such seizures may occur even a considerable time after recovery has apparently been effected. The patient should therefore be watched for several days; and if an attack of this kind occur, blood- letting, and artificial respiration during its con- tinuance, may save the patient. Delirium, and all the forms of morbid reaction which occa- sionally appear on recovery from asphyxy, require depletions, with the means usually employed to restore the secretions and excretions, and to excite the emunctories to carry off the hurtful materials accumulated in the blood during the state of as- phyxy. 33. VII. Treatment of particular kinds of Asphyxy.—A. Of asphyxy from submersion. But little, in addition to what has been stated above, need be adduced under this head. The body should be carried from the place of sub- mersion to where means of restoration are to be used, in the recumbent posture, with the head and shoulders elevated; but neither of them bent, or hanging in an injurious posture. The wet clothes are to be immediately removed, the New-born Infants. 134 ASPHYXY —of] mouth and nostrils cleansed, and the body placed in warm blankets: this should be done as soon as the body is found, if the weather be cold, and the distance to the place where resuscitation is to be attempted be considerable. The directions given in preceding paragraphs (§ 27. et seq.), are now to be followed. Some advantage will be derived from placing the body in a warm sun, or before a fire, or surrounding it with dry warmth ; heated substances may likewise be applied to the epigastrium, the extremities, and insides of the thighs. Where a warm bath can be readily pro- cured, the body may be placed in it, and the tem- perature regulated to about 98° or 100°. Animal heat, proceeding from some of the domestic lower animals or from a healthy person placed by the side of the body, is, especially in the cases of chil- dren, a very efficacious mode of resuscitation. But all these means should not interrupt the per- formance of artificial respiration. The other mea- sures recommended in the foregoing section may also be resorted to, with the exception of bleeding, which is seldom beneficial until the circulation has been restored; when it will not infrequently be required, to subdue morbid reaction, in conjunc- tion with other remedies calculated to restore the secretions, &c. (§ 32.) 34. B. Asphyxy from strangulation requires the same measures which have been described under the head of general treatment (§ 26. &c), and particularly bleeding, which may generally be advantageously performed in the jugular vein. The head and shoulders ought to be raised as high as may be consistent with the means used for resuscitation; and, if a restoration of animation be effected, the usual means of guarding the brain from the ill effects of reaction or congestion, to which this organ is more liable after strangulation than after asphyxy from other causes, are to be put in practice. 35. In cases of asphyxy from obstruction of the glottis and larynx, or from substances having passed into this situation, or into the trachea, the operation of tracheotomy should be resorted to. Several instances of this description have been recorded, wherein it has been successfully per- formed. In all cases of recovery from asphyxy, the patient should be carefully watched for two or three days, and every appearance of reaction affecting any organ, more particularly the brain, instantly subdued by means appropriate to the circumstances of the case. Pure air, and the use of deobstruent purgatives and diuretics, are gen- erally necessary, in order to purify the circulating fluid, and change it from the unnatural state it had assumed during the asphyxy. Bibliography.—A. Ijouis, Sur la Certitude des Signes de la Mort, l2mo. Paris, 1752. — Pia, Detail des Succes de 1'Etablisscment que la Ville de Paris a fait en faveur des Noyts, 8vo. Lyon, 1768. — Gardanne, Sur les Moris apparentes dites Asphyxies, 8vo. Paris, 1777. —Cailleau, Mem. sur l'Asphyxie par Submersion, 8vo. Bord. 1799. —Portal, Sur le Traitement des Asphyxies, 12mo. Paris, 1811.-*-CuWen, in Edin. Med. Comment." vol. iii. p. 23.— J. Hunter, Observations on the Animal Economy, p. 136.; and Philos. Trans, for 1776, p. 412.— Good-Jyn, Ofthe Connexion of Life with Respiration, p. 82, kc Lond. 1788. — Bichat, Sur la Vie et la Mort. Paris, An 8. — Coleman, On Suspended Respiration, p. 248.—Berger, Sur la Cause de l'Asphyxie par Submersion. Gen. 1805. —■ Curry, Observ. on Apparent Death from Drowning, kc __Kite, in Duncan's Med. Comment, vol. xiv. p. 107. — Orfila, Secours & donner aux Person. Empois. ou As- phyxies, 12mo. Paris, 1818; et Archives Gi'n'r. de M d. t. xiv. p. 542. — Marini, Del Trattamehto degli Annegati, gvo. Pesaro, 1826. — Leroy, Recherchcs sur V Asphyxies, 8vo. Paris, 1829. — Edwards, De I'lnfluence des Ageni Phvsiqucs sur la Vie, part i. ch. 1., et part iv. ch. 4. Paris, 1824. — Piorry, in Journ. Hebdom. de Med. t. in. p. 556. — Devergie, art. Asphyxie, Diet, de Med. et Chir. Pratiq. t. iii. p. 542. — Kav, in Edin. Med. and Surg. Journ. vol. xxix. p. 42. — M. Bourgeois, in Archives G£ner. de M£d. t. xx. p. 220. — Meyer, Lond. Med. Repos. vol. iii. N. S. p. 436.—Humane Society's Fifty-seventh Annual Re- port, 1831, p. 62. 1. ASPHYXY of New-born Infants is fre- quently met with, particularly in those who are naturally feeble, or weakened by rupture of the cord or laceration of the placenta, in consequence of sudden delivery, or ofthe operation of turning, especially when required by uterine haemorrhage. It is also occasioned by compression of the cord, and a protracted parturition. 2. Besides the absence of respiration and of muscular motion upon delivery, the surface is pale; the flesh and limbs are soft and flaccid; the heat of the body is rapidly diminished, but the circulation still continues, at least for some time. Several cases which are viewed as asphyxy, more properly belong to syncope, or loss of blood, or participate in those states as well as in privation of the respiratory actions. This privation may depend upon imperfect circulation in the pulmo- nary arteries, and through the lungs; or upon in- activity of the respiratory muscles, and torpor of the nerves which supply them, owing to imperfect circulation in the brain; or upon these causes conjointly. Care should be taken to distinguish these cases from apoplexy; as the states of the vascular system, and of circulation in the brain, and consequently the treatment which is required in each, are very different. 3. The treatment of these cases consists of de- ferring the ligature of the cord for some time; of taking care that no blood is lost from dividing it; of enveloping the infant in warm flannel; of holding it near a warm fire, or plunging it in a warm bath, rendered exciting by means of salt or mustard; of removing all obstruction to the pas- sage of air into the lungs from about the throat and mouth; warm frictions of the surface of the chest, with gentle succussation with the palm of the hand on the shoulders; tickling or irritating the nostrils and arm-pits with a feather; dropping a little diluted aromatic, or ammoniated spirit upon the lips; and most particularly inflation of the lungs by the breath ofthe medical attendant, either blown directly into the mouth, the nostrils being closed, and the trachea gently pressed backwards; or through a curved tube introduced into the la- rynx, as recommended by Chaussier, and em- ployed by him at the " Maison d'Accouchemens " in Paris. This latter method is certainly prefera- ble. Insufflation is to be managed in the same manner, in other respects, as described in the foregoing article. But I think that the breath of the attendant is better suited to infants, than cold aii- thrown into the lungs by a bellows. 4. M. Desormeaux complains of his want of success from inflation of the lungs, even when carefully and assiduously employed, and places more dependence upon means calculated to ex- cite the respiratory muscles to contract. For this purpose, he recommends a species of spirit douche, and directs the practitioner to take a mouthful of brandy, and dash it forcibly against the anterioi parietes of the chest. He states that this is sel- dom required oftener than twice or thrice. Me- chanical irritation of the nostrils, or exciting ASTHMA — powders applied to the pituitary membrane, may be cautiously tried; a stimulating clyster may also be thrown up. Galvanism or electricity may likewise be resorted to when within our reach. We should not relinquish our endeavours at re- suscitation under two or three hours, or even longer; and, if we ultimately succeed, the state ofthe infant should be carefully watched for two or three days. Bibliography.—Burns, Principles of Midwifery, &c. 8th edit. p. 592. — Gardien, Traite Complet d'Accouc e- mens, kc t. iii. p. 135. —Desormeaux, art. Nouveaux-ncs, Diet, de Midi'cine, t. iii. p. 153. — Wilson, in Glasgow Med. Journ. vol. ii. p. 237. ASTHMA. Deriv. and Synon. ~Ao6ua, an- helatio: from «-<, I breathe; aaditutoj, I breathe with difficulty. Suspirium, Celsus, Seneca. Dyspnea Spastica, Auct. Var. Myspathica Spastica, Ploucquet. Asthma Chronicum, J. P. Frank. Asthma convul- sivum, Baglivi, Alberti, Hoffmann, Sauvages. Asthma Spasticum, Juncker. Pneusis Asthma, Young. Asma, Bolsaggine, Ital. Pousse, Asthme, Fr. Die Engbriistigheit, das Keu- chen, Ger. Classif. 54. G. Asthma; 3. Order, Spas- mi; 2. Class, Neuroses (Cullen). 4. G. Asthma; 2. Order; 2. Class(Good). 37. G. Asthme Convulsif; 4. Order; 4. Class (Pinel). II. Class, III. Order (Author, see Preface). 1. Defin. Great difficulty of breathing, recurring in paroxysms, accompanied with a wheezing sound, sense of constriction in the tho- rax, anxiety, and a difficult cough, terminating in mucous expectoration. 2. There are few diseases, the nature of which lias been a subject of greater doubt and difference of opinion than asthma. Until the writings of Floyer, Willis, Hoffman, Alberti, and Juncker, directed particular attention to its pa- thology, it was generally confounded with dysp- noea, being usually denominated intermittent or remittent dyspnoea. By these writers, and more recently by Sauvages, Cullen, Pinel, and Georget, asthma was considered as essentially nervous in its nature; and the lesions found upon the dissection of fatal cases viewed as its conse- quences, and not as its causes. More recently, and even at the present day, among many, it has been considered as a symptom of organic change of either the heart, large blood vessels, or of the lungs, air-tubes, &c. But this doctrine, although generally accurate in respect of Dyspnoea, is quite erroneous as applied to asthma. 3. Pathology of Asthma. — The depend- ence of dyspnoea, not only upon organic lesions of the organs seated within the chest, but upon the form of the thorax, upon diseases of adjoining vis- cera, and upon the state of the air-passages, is sufficiently obvious. The difficulty of breathing proceeding from these sources may be either con- tinued or remittent; but it never is, whilst the causes on which it depends are in existence, char- acterised by intervals of perfect ease. True asth- ma, however, presents intervals of healthy respira- tion; and although repeated returns of the attack will generally induce some change in the organ- ization of either the lungs or the principal organs of circulation, yet this is not uniformly the case; and moreover, an attentive examination of the athology of. 135 thoracic viscera, in recent attacks, fails of detect- ing in them any appreciable change, particularly during the intervals between the paroxysms. The disease has even proved rapidly fatal during the attack, and yet no alteration adequate to ac- count for the symptoms could be detected on dis- section. Instances of this description have been adduced by Wichmann (Hufeland's Journ. b. i. p. 18.), Parry, Georget, Andral, Laen- nec, and Guersent, and justify the opinions of those who have referred the disease chiefly to the nervous system. In some cases, after repeated returns of the attack, and when they have induc- ed organic change, the intervals are less distinctly marked, consist of remissions merely, and the disease may, at last, pass into confirmed dyspneca. 4. a. The structure of the air-passages and bronchi evidently shows that these parts are sus- ceptible of preternatural or spasmodic constriction. During 1821 and 1822, when engaged in some researches into the pathology of diseases affecting the trachea and bronchi, I was enabled distinctly to trace muscular fibres throughout those parts, both in man and in the lower animals. The dis- position of those fibres, in many of the lower an- imals, and the mode of their connection with the cartilaginous rings, are peculiar, and beautifully adapted to guard agiinst the contingencies to which they are liable from varying positions and habits of life. Upon those, however, I cannot here enter. About the same time that my at- tention was directed to this subject (Lond. Med. Repository, vol. xxii. p. 418.), the researches of Reisseissen of Berlin, and of Laennec and Cruveilhier of Paris, appeared; and the results, in respect ofthe structure ofthe bronchi and larg- er ramifications of the trachea, upon the whole, agree with what I had observed. It had been denied that the membraneous, or any other, part of the air-passages contain muscular fibres. But this was asserted chiefly by those who cannot be- lieve that a part is muscular, unless the fibres are the same in appearance as those which enter into the composition of the muscles of voluntary mo- tion. Other anatomists, who take a more com- prehensive view of the conformation and functions of the muscular system, consider, with greater justice, that the muscles which are acted upon by the will, form an order by themselves; and that there is another and a very important order of muscular parts, which are not directly influenced by volition, but which contract from stimuli acting on them, either immediately or mediately, and which present certain peculiarities in respect of the appearances of their fibres, of the mode of their distribution, and of the manner of their con- nection with internal tissues and organs. Now, the fibres which are discovered in the trachea, and traced to the smaller ramifications of the bron- chi, are in every respect similar to other involun- tary muscular fibres, in their organization; in their connection with a mucous surface, forming, in many respects, a tunic concentrically with the mucous coat; in being disposed in circular fibres, surrounding hollow tubes; and in being supplied entirely by ganglial or involuntary nerves. The disposition of the fibres, therefore, which are de- tected in the air-passages, being altogether similar to that which obtains in other canals, the mus- cular structure of which is not disputed, as in the alimentary tube and urinary bladder; the organ- 136 ASTHMA —Pathology of. ization of the fibres being also similar; their con- nection to a mucous surface, and the circumstance of their being supplied with the same order of nerves, being at the same time considered; are we therefore to be surprised that agents affecting either the mucous surfaces thus related to them, or the nerves supplying them, should be followed with analogous effects to those which we observe after the action of agents directed to the mucous surface or nerves of the alimentary canal ? 5. b. The lungs possess a vital power of expan- sion.— The structure ofthe air-passages, then, would lead us, independently of the results of observation, to infer that the circular fibres are lia- ble to experience, with all other involuntary mus- cular fibres, a spasmodic constriction; and it evinc- es, particularly in the conformation of the cartila- ginous rings with which the trachea and larger ramifications of the bronchi are provided, a mark- ed provision against an inordinate continuance or degree of this constriction; the rings, by their permanent elasticity, acting as antagonists to the circular fibres, preventing extreme constriction, and at last overcoming long-continued spasm, particularly in those larger branches, the inordin- ate constriction of which might have the effect of excluding the air from a very large portion of the lungs. In the larger ramifications of the bronchi, the muscular fibres connecting the extremities of the cartilaginous rings are thus antagonised by these rings; but, in the smaller ramifications, where the rings cease to be detected even in the imperfect forms in which they there exist, and where the fibres are perfectly circular, the only provision which can prevent an inordinate constriction of those fibres, is in the structure of the lungs themselves, which must necessarily un- dergo a change in bulk, and become more con- densed by tins constriction, in those parts, at least, to which the spasm extends; unless we be- lieve that the lungs, like various other organs, are endowed with an expansive power,—a power which physiologists and pathologists have too much overlooked in their exposition of the healthy and morbid actions of the animal econ- omy.* 6. The mechanism of the expansive power is so little understood, and generally so insufficient for the explanation of this phenomenon, that we must refer chiefly to the vital actions of the part, which must necessarily depend on the energies of the body generally. The expansile action of the penis, nipple, heart, uterus, &c. cannot be ex- plained by their organization only: it is manifest- ed to us only during life, and the perfection as well as imperfection of this action are always accordant with the degree of vital energy with which these organs are endowed. 7. I have long since had occasion to remark that the motions and functions of the lungs (Phy- siological Notes, 8,-c. to M. Richerand's Phy- siology, 2d ed. p. 62S.) have been too generally and exclusively referred to the mechanism of the * That the lungs, however, reallv possess this property may be inferred from the permanent elasticity of their structure, which continues for some time after death • and which is still more marked during life, as shown bv exposing the lungs of a living animal. This state may be'with pro- priety called the vital expansibility of the lungs, inasmuch as the degree of this state is chiefly dependent upon the vital energy ofthe system, and partly on the peculiar organiza- tion ol the lungs themselves. respiratory organs, and to chemical changes pro- duced in the lungs, to the neglect of a much higher influence, always controlling, modifying, or alto- gether changing, the subordinate powers to which their functions have been thus referred. That the vital energies of the frame are most power- fully exerted in the lungs, through the medium, especially of the organic nerves with which they are provided, must be evident to all who will contemplate the nature and extent of the changes constantly taking place in these organs upon the blood circulating through them; and the relation which subsists between their functions and the vital energies of the system generally. Now, it does appear to me that there exists a vital expan- sion of the lungs independent of that which they experience from atmospheric pressure, and from following the dilated parietes of the thorax dur- ing inspiration. In experiments upon living ani- mals, where the walls of the chest have been opened, the lungs are observed to swell and con- tract alternately. This fact, which was first in- sisted upon by M. Roux (Melanges de Chirurg. p. 87.), has since been duly appreciated by Prus, Laennec, and a few others. Even in cases where the portion of lung has protruded itself after a wound of the chest,—a circumstance which could only occur from active expansion of the lung itself, —this portion has been, although thus unnaturally placed and subjected to the pres- sure of the atmosphere, observed to dilate during inspiration. The not infrequent occurrence of ossification of the cartilages of the ribs in old persons, and consequent perfect immobility of the ribs, even without any evident dyspnoea, fur- nishes another proof of the inherent expansibility ofthe lungs: for without having recourse to. this vital property, we cannot explain the perform- ance of the actions of inspiration and expiration by the diaphragm alone. 8. This vital property, therefore, with which the lungs, in common with some other organs, seem to be endowed, together with the disposition and elasticity of the cartilaginous rings of the bronchi, furnishes an antagonising force to the unnatural constriction of the tubes from spasm of their circular fibres; and, while it serves to ex- plain the natural functions ofthe organ, with their modifications from the various influences to which this property is subjected, is one ofthe sources to which we are to impute some ofthe diseases, and more especially the one under consideration, to which the lungs are liable. 9. Having thus shown, from the structure of the air-passages that they, in common with all other hollow tubes ofthe body, admit of spasmo- dic constriction, and that they also present a pro- vision against the undue extent or continuance of this state, I should further remark, that a close observation of the phenomena of disordered res- piration is sufficient to convince us that they fre- quently experience this state, owing to the opera- tion of certain causes acting either directly on the mucous surface of the tubes, and impressing the nerves terminating in it, or originating in and irritating the nerves themselves, either at their origins or in their ramifications and connec- tions. 10. I. Symptoms and History of Asthma. — The premonitory symptoms of this disease are languor, sickness, flatulency, and other dyspeptic ASTHMA — Symptoms of. 137 disorders; heaviness over the eyes, and headach; uneiisiness and anxiety about the precordia, with a sense of fulness and straitness in this region and in the epigastrium. In some cases pain is complained of in the neck, with uncommon drow- siness and stupor. It is also often preceded by costiveness and inefficient calls to stool. 11. A. The invasion ofthe attack of spasmodic asthma is generally soon after midnight, or about one or two in the morning, and during the first sleep. The patient wakes suddenly from a sense of suffocation. He feels a most distressing tight- ness at his chest, with great anxiety, difficulty of breathing, and impediment to the free admission of air into the lungs. He assumes with eager- ness the erect posture, and cannot bear the least incumbrance about the chest. The breathing is wheezing, interrupted, and laborious. The shoulders are raised, the elbows directed back- wards, and every effort made to enlarge the thorax. Owing to the interrupted circulation through the lungs and heart, the countenance,. which was at first pale and anxious, becomes, particularly in plethoric habits, red or bloated, and covered with perspiration. The eyes are prominent, and the conjunctiva injected. A con- siderable quantity of pale urine is usually passed at the commencement, or previous to the acces- sion, of the paroxysm; and the lower extremities are usually cold. The pulse is generally acceler- ated, weak, irregular, and often intermittent. During the fit, the patient has commonly an in- stinctive desire for cool fresh air, which always revives him. A small or close room is offensive, and all warm substances given internally increase the flatulency of the stomach and bowels, and aggravate the symptoms. When the fit has con- tinued from half an hour to one, two, three, or even four hours, it leaves the patient; and his respiration, pulse, and feelings assume their nat- ural state. 12. This is the common course of a first and moderate attack of the disorder. Sometimes the patient has but one such fit; but more generally a slight constriction of the chest is felt through all the succeeding day, and the paroxysm returns at the usual period of the night; and this con- tinues for three, four, or even seven days; when the patient is at last altogether relieved from the attack. The disease may be suspended for a month, or several months; but it is liable to recur from changes of air, errors of diet, and from the operation of the other causes productive of it. 13. In some cases the attack is more severe from the commencement, and continues, with slight remissions for several days, accompanied with a harsh suffocative cough, great distension of the abdomen from flatus, and more or less of the symptoms which characterise the complaint in the severer states resulting from repeated at- tacks. 14. When asthma once seizes on the system, it seldom fails of recurring, though the intervals be- tween the paroxysms are of very uncertain dura- tion. In many cases it recurs periodically every ten days or a fortnight. Sometimes the attack returns at the full and change of the moon, or at one of those periods only. It has been observed to recur in females just after the menstrual discharge, or to precede this evacuation. Per- sons who have become subject to the disease | 12* seldom escape an attack in the spring and au- tumn. 15. After repeated seizures, the disease often assumes the most violent and distressing features; the difficulty of breathing in the fit amounts to the utmost degree, and is attended with the greatest tightness over the whole chest, the pa- tient feeling as if he were bound with cords. His anxiety at this period is inexpressible, and he labours in respiration as if every moment would be his last. Severe vomiting also fre- quently occurs. The matter discharged is slimy and frothy, or of a greenish yellow colour. He is subject to palpitations and faintness; and cool fresh air becomes absolutely necessary. About this period a loose stool sometimes takes place. The eyes are prominent, the face sometimes pale, sometimes high-coloured, bloated, or livid: the nose and ears are cold; the face, neck, and chest, covered with perspiration. The pulse is generally extremely weak, irregular, and even intermitting: there is often much difficulty of swallowing. The patient can scarcely speak, cough, or expectorate, and the stomach and bowels are much distended with flatus. As the paroxysm abates, the cough becomes freer, and is attended with the expec- toration of a little viscid mucus; and, in proportion as the cough and expectoration increase, the dis- tressing symptoms abate; this evacuation, which had been retained by the spasm of the air-vessels, indicating a solution of the spasm and a freer access of air to the cells of the lungs. An easy and free expectoration, particularly if it be ac- companied with softness and moisture ofthe skin, and a sediment in the urine, is a certain indica- tion of the subsidence of the attack. Sometimes when the paroxysm is unusually long, the patient experiences only a single occurrence of it during the attack. 16. B. The Humoral form of asthma is gene- rally gradual in its accession, and attended by extreme oppression, a suffocative cough, and a copious secretion and expectoration of mucus from the commencement of the seizure (§ 11.). It is sometimes the consequence of repeated at- tacks of the preceding variety; and is generally more severe and of longer duration than it, owing to the accumulation of viscid mucus in the air- vessels conspiring with the spasm it occasions to aggravate the symptoms. There are also less perfect intervals of ease in this form of the malady, than in the spasmodic. After the sub- sidence of the patient's sufferings during the first night of the attack, and while the expectoration is easy and copious, the lungs still continue irrita- ble through the day, and the respiratory function embarrassed from the slightest causes. At the approach of night, the fit recommences with the usual symptoms, and the night is passed nearly as the former. On the third day the remission is more complete, there is some additional expecto- ration, and bodily motion is performed with less distress, but still with great inconvenience. After the paroxysm has been renewed in this manner for three or four nights, or for a longer period, sometimes for several days or even weeks,'—for the duration of an attack varies much,—the ex- pectoration and cough are more easy and free, the daily remissions become more perfect, and the strength of pulse and vigour of action increase. 17. When the chest is examined by the ear or 138 ASTHMA—-Symptoms of. stethoscope, the sound of respiration is weaker during the fits, than in the intervals, but it is sel- dom altogether suspended in certain points of the chest; it is attended by a sonorous rattle, flat or sibilous, imitating the chirping of birds, the note of a violoncello, or the cooing ofthe wood-pigeon. With this there is frequently intermixed a mucous rattle; but this conveys the impression of being produced by a thinner fluid than the mucus of common catarrh. In the intervals of the attacks, these various species of rattle exist, but in a much less degree. The respiratory sound is louder than during the paroxysms : sometimes it is al- most puerile. If the complaint have occasioned dilatation of the bronchi, the respiration assumes more or less the character of the variety called bronchial; in all cases it varies in intensity at dif- ferent points of the chest, and these points change their situations from day to day (Laennec). The chest generally sounds well, throughout the attack, upon percussion. 18. I have stated (§16.), that the humoral form of asthma is often consequent upon re- peated attacks of the spasmodic; but this latter may also occur, although rarely, after the former; or the attacks in some persons present an evident complication of both forms of the disease. The stomach and bowels are extremely liable to dis- order in asthmatic persons, particularly in those subject to the spasmodic form of the disease. Colic pains, flatulence, loss of appetite, an irre- gular state of the bowels, and a disturbed, im- paired, and unrefreshing sleep, generally harass the asthmatic patient, even in the intervals be- tween the seizures. In females, the menses are generally impaired or irregular, and an attack often precedes the period of the menstrual dis- charge, the supervention of which generally acts as a crisis of the attack. 19. Symptoms of fever are not essential to the disease, though they often occur, especially when the humoral asthma, or an attack of catarrh, is complicated with the convulsive. Hectic fever, colliquative diarrhoea, faintings, palpitations, vo- mitings, coldness of the extremities, swelled legs, and other dropsical symptoms, are common in the last stage of the disease, and indicate organic changes in the substance of the lungs or heart, with obstruction to the circulation in these or- gans, and effusion of fluid in the chest,—results, however, which can only be ascertained with pre- cision by means of auscultation and percussion. 20. C. Terminations.—An attack of asthma generally terminates in one of three ways:—1st, By a return to the healthy function: 2d, By in- ducing further lesion; in which it either disap- pears, or becomes complicated: and, 3d, In death. On each of these I shall offer a few re- marks. 21. a. Although the paroxysms of asthma fre- quently terminate in a return to the healthy func- tions, a perfect immunity from future attacks can rarely be procured. Yet these attacks may be frequent, severe, and of long duration, recurrinc for a long series of years; the patient, notwith- standing, arriving at a very advanced age, before a fatal issue takes place. But they often produce the following organic lesions. 22. 6. The most common consequences ofthe disease to which I may now advert, are, chro- nic inflammation and dilatation of the bronchi, the different forms of emphysema and oedema; ofthe lungs; hremoptysis; tubercular formations, with which asthma may also be associated from its commencement; enlargement, and dilatation, &c. of the cavities of the heart; effusions of fluid in the pleura or pericardium; and wasting of the heart, or polypous concretions, within its cavities. As the reader will find all those lesions treated of under their distinctive heads, I shall here only re- mark respecting thein, that, when they supervene to asthma, many of the distinctive characters of this disorder entirely disappear in those of the superinduced disease, and the lesions of the re- spiratory functions assume the distinctive features of chronic, continued, or remittent dyspnoea Severe attacks of asthma may also terminate in congestions or effusions within the head, giving rise either to epilepsy, coma, or apoplexy. 23. It was already remarked, that auscultation and percussion furnished merely negative informa- tion in the different forms of asthma. But this in- formation is still important, inasmuch as it inti- mates the non-existence of any of the foregoing organic changes; and, when they do exist, those means of diagnosis enable us not only to recog- nise them, but also to ascertain with precision their nature, progress, and extent, and thus to form an accurate diagnosis and prognosis in re- spect both of the primary disease and of the con- secutive organic changes. 24. c. When the disease ends in death, this event is brought about generally by superinduc- ing some one of those changes already referred to as terminations of the disease, or of those lesions, with which it is frequently associated (§ 22.). Death may, however, occur, but much more rarely, from the severity of the attack; the requisite changes not being effected on the blood by respiration, owing to the obstructed state of the air-vessels, either from spasm or the accu- mulation of viscid mucus, or from both, whereby the nervous centres are supplied with blood un- suitable to their functions, and the heart ceases to contract with sufficient energy to preserve the circulation in a requisite state of activity through the lungs and brain. 25. D. The appearances after death may be in- ferred from what has already been stated. These appearances are rather the consequences of the disease, than the disease itself; for it is seldom that we have an opportunity of examining the body in recent and uncomplicated cases of asthma. Where, however, this has been done, the lesions, even when any have been detected, have been insufficient to account for the disease, Willis records a case of protracted asthma, in which no morbid appearance could be detected; and similar cases have occurred to Laennec, Andral, Cruveilhier, Bouillaud, Jolly, and others. Ferrus, after extensive experience, states that he has been unable to detect any lesions which can be attributed to uncomplicated asthma. The changes which have been noticed, therefore, by authors, are to be viewed chiefly as accidental occurrences, or associated maladies; and, perhaps, more frequently as the remote results of repeated or protracted attacks. The appearances usually observed in fatal cases are the same as have been described (§ 22.). 25. II. Varieties of Asthma, and of their Pathology.—Sauvages has enumerated no less ASTHMA —Varieties of. 139 than eighteen forms of this disease, many of them presenting no modification of the phenomena con- stituting the disease, but merely peculiarities as to cause, particularly as respects the occasional causes. Several of his varieties, also, strictly belong to the more generally symptomatic com- plaint to which the term Dyspncea is usually applied. The varieties of idiopathic asthma, ac- cording to Cullen, are the Spontaneous, Ex- anthematic, and Plethoric. Dr. Bree, who has given a comprehensive account of the disease, has divided it into forms which have reference chiefly to the doctrine which he has espoused re- specting its pathology. He assigns to it four species :—1st, Asthma produced by the irritation of effused serum in the lungs; being its most common form: 2d, That occasioned by the irrita- tion of aerial acrimony in the lungs: 3d, That dependent on irritation in the stomach, or some ofthe abdominal viscera: and, 4th, That depend- ent upon habit. Dr. Young has adopted a simi- lar arrangement. 26. M. Laennec has given a simpler view of the disease, and assigns it two forms, viz. asthma attended with puerile respiration, in which the vital expansibility of the lungs is increased, from a temporary augmentation of the want of the system for respiration, occasioned by some un- known modification ofthe nervous influence; and spasmodic asthma, from a spasmodic constriction of the air-tubes. Dr. Good has divided the dis- ease into the dry and humid ; but he has en- cumbered these two species with nearly as many varieties as have been assigned by Sauvages. The dry or nervous asthma he subdivides into the simple, metastatic, phlegmatic, vaporose, and organic,—a refinement which is neither founded in nature, nor can be available in practice; for a simple nervous asthma may be induced by injuri- ous vapours, or by repelled eruptions, and hence we have the first variety produced by either his second or fourth ; and the second, or the phleg- matic nervous asthma, may proceed from the same varieties. His fifth variety is certainly not admissible under asthma, unless as a consequence ofthe disease, but falls more properly under dys- pnoea, either in its continued or remittent forms. The Humid or common asthma he subdivides into the simple, plethoric, and atonic, — a division much more accurate than the foregoing, but still objectionable, inasmuch as it is impossible to draw any line of demarcation between them, and as the three varieties insensibly pass into one another. 27. By the great majority of authors who have written on the disease, it has been viewed simply in respect of its Idiopathic and Symptomatic forms ; both, however, presenting modifications resulting from peculiarity of causes, and the cir- cumstances ofthe patient, but insufficiently mark- ed to constitute distinct varieties. In the following observations I shall observe the same distinction, and divide the Idiopathic form of the disease into, 1st, The nervous asthma; 2dly, The prima- rily spasmodic asthma; and, 3dly, The pituitous or humid asthma. 28. 1st, Nervous Asthma. The asthma with puerile respiration, Laennec.—Char. Anhela- tion from a fee-ling of want of a more complete respiration than the patient enjoys, the pulmonary expansion distinctly taking place with prompti- tude, completeness, and uniformity, so as to furnish a general puerile sound on auscultation; usually accompanied with a slight cough, and with a free mucous expectoration. 29. This form ofthe disease was first accurate- ly described by Laennec, who pointed out the difference between it and the forms depending on spasm of the air-tubes. In this variety no spasm seems to exist in the smaller air-vessels and cells; for the whole tissue of the lungs is dilated to its full capacity, and with unusual promptitude and completeness, so that the puerile respiration is heard in every part of the chest; whereas in the other varieties the respiration is generally some- what more indistinct than in health. M. Laen- nec contends, and apparently with justice, that the wants ofthe system, in respect of respiration, may be exactly measured by the intensity of the respiratory sound; and that the intensity varies much, according to many circumstances, and par- ticularly according to the age of the individual, it being much greater in childhood than in adult life, There is no morbid affection, he observes, which can be more satisfactorily referred to sim- ple disorder of the nervous influence, than this dyspnoea accompanied with puerile respiration. In cases of this kind, the respiratory sound has resumed all the intensity which it possessed in early life. The pulmonary expansion evidently takes place completely and rapidly in all the air- cells, and yet the patient feels the want of a more extensive respiration than he enjoys ; and the lungs, although dilated to their utmost, have not, nevertheless, capacity enough to satisfy the wants of the system. This affection is common in per- sons affected with chronic mucous catarrhs, at- tended by a copious and easy expectoration; but even in them, during the severest attacks, the completeness with which respiration is performed is quite astonishing. Nevertheless the patient feels oppressed, and requires a more extensive respiration than his organization allows; the wants of the system in respect of this function being in- creased beyond the standard of health. 30. In this form of the disease it is not in the small air-tubes that we are to look for its proxi- mate cause, but in the trachea and large bronchial trunks, and particularly in the nervous influence itself ; and this will equally hold good even if we adopt the chemical theory of respiration, and refer the affection to an extraordinary want of oxygen in the blood, arising from impeded func- tion ofthe respiratory mucous surface, owing to the mucous secretion covering it. M. Laennec believes, as this species occurs only in persons affected with chronic mucous catarrh, that it can never amount to asthma, without the catarrhal complication. Adults and old persons, he re- marks, who have puerile respiration without ca- tarrh, are not, properly speaking, asthmatic ; but they are short-breathed, and dyspncea is induced by the slightest exertion, though when sitting still they frequently experience no oppression whatever. 31. This variety may be considered as depend- ing upon a temporary augmentation of the want of the system for respiration, occasioned most probably by some unknown modification of the nervous influence ; and apparently consisting in an expansile action of the lungs increased much beyond the healthy standard. But here a ques- 140 ASTHMA —Spasmodic. tion suggests itself, viz. can this augmented action of the lungs be owing solely to the state of this organ, or is it associated with, or partly depend- ing upon, increased activity of the respiratory muscles, particularly the diaphragm? M. Laen- nec states that it cannot be produced at will by a full inspiration; and, therefore, infers that this state of the lungs is a primary condition of them, and not depending on increased inspiratory efforts. 32. From this consideration I am led to infer that, although the vital expansile action of the lungs may be increased in this variety of asthma, it is accompanied with, and much assisted by, augmented activity of the diaphragm, which per- forms its office more promptly and completely in this variety of asthma than in any other; that instead of the disease being characterised by spasm of the smaller ramifications of the bronchi and air-cells, as in the second variety of asthma, the air penetrates more fully into them than usual; and that, if any spasm exists, it is limited to the trachea and large bronchial tubes ; the exalted state of expansion of the lungs, and of function of the diaphragm, being an effort to counteract this morbid condition of the large tubes, and to supply the wants of the system by a more forcible inspiration; the increased rapidi- ty with which the air is thereby made to pass through the strictured canals making more than amends for the diminished calibre of the passage. This form ofthe disease is frequently symptomatic of nervous affections, particularly of hysteria when the globus hystericus affects the state of the trachea, and of various diseases, in which the blood is imperfectly changed in its circulation through the lungs. But when thus symptomatic, it is often slight and evanescent. 33. 2d, Spasmodic Asthma. Syn. Periodic Asthma. Convulsive Asthma, Willis, Baglivi, Boerhaave. Asthma Siccum, Musgrave. Occult dry Asthma, Etmuller. Spasmodic Asthma, Laennec. Dry Asthma, Good.—Char. Parox- ysms sudden, violent, and of short duration, at- tended with hard spasmodic constriction in the chest; slight, dry, and difficult cough, and with a scanty expectoration, occurring only towards their close. 34. I stated that the vital expansive action of the lungs was increased in the foregoing variety. In this the ramifications ofthe air-tubes, and per- haps the air-cells themselves, seem to be unnat- urally constricted. The respiration, when exam- ined by the stethoscope, or by the ear merely, is heard either very imperfectly even on the most forcible respiration, or to a small extent only, or its sound may be but little impaired. The chest, during the paroxysm, sounds ill on percussion. These phenomena indicate that there is an im- perfect entrance of the air into the air-cells. M. Laennec states, that if the patient, after holdine his breath nearly as long as he can, breathes qui- etly, the spasm will often be overcome as it were by surprise, and the entry of the air into the cells will be heard in a clear or even puerile sound. This, and various other circumstances, independ- ently of the proof furnished by the structure of the air-tubes, indicate that the obstruction to the entrance of air into the cells is owing to spasm of the muscular fibres. 35. Dr. Williams believes that spasmodic asthma may be partial, affecting one lung only, or one more than the other ; but this is very sel- dom the case, unless when it is occasioned by, or complicated with, dry catarrh, which is some- times partial; or when the spasmodic constriction is excited by a collection of a pituitous fluid in some of the bronchi, — a complication of not infrequent occurrence, but falling more strictly under the next form of the disease. Although the paroxysms of the primarily spasmodic asthma are sudden, and generally of short duration, yet the disease is often of long continuance, and may, to a certain extent, become habitual, as shown by Dr. Bree and others. 36. During the spasm, the lungs seem, from an attentive examination of the thorax, somewhat drawn together, owing to the constriction of the air-tubes; and the parietes ofthe chest, being ne- cessarily pressed inwards at the same time, gen- erally yield a less clear sound on percussion. The serobiculus cordis is also drawn inwards and upwards, indicating the manner in which the diaphragm is affected during the paroxysm. This phenomenon, which was first pointed out by Scheidemantel (Frdnkische Betruge,No. 5.), arises either from the diaphragm being prevented from contracting to its full extent by the spastic constriction of the air-ves3els, or from a temporary paralysis of this muscle. That the latter state should take place, and be followed in a short space of time by a perfect restoration of actioB, and that repeated seizures of this description should be always succeeded by a similarly rapid return to the healthy state, cannot be admitted by any person who takes an intimate and com- prehensive view of the operation of the animal economy in health and disease. That retraction ofthe epigastrium, and even ofthe hypochondria, is owing to imperfect descent of tlie diaphragm from constriction of the air-cells, seems proved by the circumstance, that the pleural cavity is per- fectly closed, and forms nearly a vacuum, and consequently the capacity of the thorax cannot be enlarged by the action either of the diaphragm or of the other respiratory muscles, without the ex- pansion of the lungs. But this organ is only im- perfectly expanded, owing to the spasm of its air-vessels ; consequently the diaphragm either cannot assume its usual place, or does so imper- fectly, notwithstanding its efforts to accomplish this end; and the parietes of the thorax are every where pressed inwards, following the retracted state of the lungs themselves, and are only par- tially dilated after the most energetic action of the respiratory muscles, which at last overcomes the spasm of the air-tubes, as the want of respiration throws the former into spasmodic action, and tends to relax the spastic state of the latter. 37. This condition of the air-vessels, and the antagonising action of the respiratory muscles during the paroxysm, have a necessary tendeney to form a vacuum in the thoracic cavity; bat this can take place to a very small extent only, as the action of the respiratory muscles is insufficient to overcome both the pressure of the atmosphere surrounding the chest, and the spastic stricture of the air-tubes, as long as this stricture continues in full force. The consequence, however, of this antagonising action and tendency to form a va- cuum is, that a larger quantity of blood is drawn into the large veins within the thorax, and ASTHMA —Humid. 141 into the venous sinuses and auricles of the heart, occasioning congestion of those cavities, impeded circulation through the lungs, congestion within the head, and inordinate and irregular action of the heart, with various other injurious effects upon the central organs of circulation, as well as upon the cerebro-spinal centres. 38. In addition also to these effects, which take place during the antagonising struggle character- ising the paroxysm, rupture of one or more of the air-vessels or cells sometimes takes place, in con- sequence of the violent action of the inspiratory muscles on the one hand, and the unyielding state of constriction of the air-vessels on the other (§ 136.); and emphysema of the lungs is super- induced, forming one of the most common lesions found upon dissection of fatal cases, and in the opinion of some pathologists the proximate cause of the disease. (See Emphysema.) 39. 3d, Common or Humid Asthma. — Syn. Catarrhal Asthma; Continued Asthma; Humoral Asthma ; Pituitous Asthma. Spitting Asthma, Floyer. Asthma Humidum, Riverius and Mus- grave. A. Pneumaticum, Willis. A. Humidum, Baglivi. Pituitous Catarrh, Laennec. — Char. Gradual accession of the paroxysms, which in- crease in severity, are protracted, and attended with heavy and laborious constriction of the tho- rax, severe suffocative cough, and with expecto- ration, often commencing early, at first viscid and scanty, but becoming copious and affording relief. 40. This common form of asthma may present various pathological states and relations. It may, as stated by Cullen and Good, be characterised by plethora of the vascular system generally, and of the pulmonary tissue especially, particularly when it supervenes to the suppression of some ac- customed evacuation. It may also be associated with a relaxed or atonic state of the exhalants of the bronchial surface, particularly when it takes place after chronic catarrhs, and in aged or phlegm- atic subjects; and it may be attended with both these states, namely, with plethora of the san- guineous system, and atony of the exhalant pores of the respiratory mucous surface. Besides these states, it may vary in respect of the acuteness and chronicity of its symptoms and progress; it being either acute or chronic, or presenting grades inter- mediate between both. 41. The chief characteristic of tliis variety of asthma is the copious discharge of viscid mucus accompanying it. But the questions with several modern pathologists have been, whether the phe- nomena of the disease are to be imputed solely to the accumulation of this fluid in the air-passages, or in part only; and whether spasm of those pas- sages also exist in conjunction with an increased secretion of mucus, or not. I believe that an attentive observation of the phenomena of the dis- ease, with the assistance of auscultation and percus- sion t —which, however, occasionally furnish but little information, and that of a negative descrip- tion, in this disease, — will lead to the inference that it depends upon both those morbid states. The limits of our enquiry are now narrowed to the question of the priority of their existence, and the relation which the one holds to the other. As to these points it may be remarked, that the early occurrence of expectoration, as well as its abun- dance, forbid the inference that the production of viscid mucus is the consequence of relaxation of the spasm; whilst they favour the idea that the spasm is occasioned by this secretion in the irri- table and morbid air-tubes; the severity and dura- tion of the paroxysms being occasioned by these double states of disease, — an abundant secretion of viscid mucus in, and a spastic constriction of, the air-passages. 42. But it may be further enquired, are not those morbid changes the effect merely of a cer- tain condition of the air-passages still more inti- mately connected with the disease than they are? I do not deny the possibility of lesions antecedent to those now specified; but the difficulty of ascer- taining their exact nature must be conceded. It would certainly be advantageous to obtain this information, inasmuch as on it would be based the means of cure which might be employed early in the disease. That it is not inflammation is proved by concomitant and symptomatic phe- nomena, by the course of the paroxysms and of the disease, by the terminations usually charac- terising it, and by observation of the juvantia and ledantia during its progress. It seems, however, extremely probable that the morbidly increased secretion and spasm are preceded by a congestive state of the mucous respiratory surface; this state disposing to the spasm, and being, as well as the spasm itself, at last relieved by the copious effu- sion of mucus; the mucus first effused tending, however, for a time, to increase the spastic con- striction of the air-passages, and the consequent struggle of the respiratory muscles to overcome it (§36, 37.), and to procure a fresh supply of air in the lungs. This antecedent state of vascular turgescence of the mucous surface of the bronchi in asthma, is perhaps most marked in that form of this variety, in which little or no expectoration accompanies the cough, at least early in the attack, and which, from this circumstance, and the causes which induce it, has been called the dry catarrhal asthma. 43. If it be still further asked, to what cause are we to impute this congestive state of the respira- tory surfaces ? I can only answer, to a certain primary change of the vital energy of the organic nerves supplying the blood-vessels, and actuating the muscular fibres of the bronchi; and hence, as the morbid changes of the circulation, secre- tion, and calibre of the air-passages, are merely effects of one cause,—of a previous change of the vital manifestations of the nerves of the organ,— it becomes of the utmost importance to ascertain the nature of this primary change with as much accuracy as possible, in order that remedial agents may be directed with precision to its removal; but the prosecution of this very interesting topic falls under another division of my subject. In estimating, however, the nature of this, as well as the other varieties of asthma, the difficulties op- posed to expiration by the spasm of the air-tubes and the accumulation of viscid mucus in them, have been too generally overlooked in our eager- ness to ascribe all the morbid phenomena to im- peded inspiration. But I believe that the disease, particularly this variety of it, is as much occasion- ed by the obstacle these states of the air-passages present to free expiration; the air, by the greater power of the inspiratory over the expiratory muscles, being drawn in sufficient abundance into the lungs, from which it is imperfectly expelled. Diagnosis. 142 ASTHMA- From this circumstance the lungs are often kept in a state of inordinate dilatation, and the res- piratory muscles excited to convulsive actions, occasioning dilatation or rupture of the air-cells, and consequent emphysema of the lungs. In the more advanced stages of the disease, in old and debilitated subjects, this struggle to dilate the thorax still further, proceeding from the wants of the system for respiration, and to expel the air from the lungs through the obstacles placed in its way, generally terminates unfavour- ably to the latter part of the respiratory actions; consequently expectoration is impeded or sup- pressed, arid life is terminated, with the air- tubes and cells, and even the substance of the lungs, loaded and infiltrated with mucus, air, and serum. It is in this state that active stimulants and emetics, by rousing the energies of the frame, and by exciting the expiratory efforts during •the proeess of vomiting, prove so frequently ben-. eficiai 44. This form of asthma may be partial, af- fecting one lung only, or one more than another; hut it is more commonly general; and in some constitutions, particularly in aged persons, and ■when it has supervened to repeated attacks of catarrh, the quantity of viscid mucus expectorated is very great. 45. Its anatomical characters are, slight swell- ing, or thickening, and softening of, the mucous membrane, with a slight appearance of redness in parts, and with marked congestion, and purplish tint of portions of this surface in the more severe or protracted cases. Sometimes these lesions are accompanied with slight oedema of the membrane, «nd the developement of miliary tubercles in the lungs. 46, As the majority of cases of this disease is characterised from the commencement by copious expectoration, it becomes a question how far it deserves to be considered as a variety of asthma; but taking all its phenomena into consideration, particularly the spasm of the air-passages, and convulsive action of the respiratory muscles, as ■well as the circumstance of it having been usually considered as a species of asthma, and the dif- ficulty of arranging it otherwise, I was unwilling either to assign it a different place, or to make it a distinct disease, to which it scarcely can lay claim. M. Laennec has placed it amongst ca- tarrhal inflammatory affections of the bronchi: but I conceive that it is seldom inflammatory .o. 45. R Mist. Ammoniaci, Aquae Destil. Lauro-Cera- *''** S'jss- ! Tinct. Castorei 3 iij.; Tinct. Opii Co. (F. 729.) 3 ss. ; Syr. Tolutan. % j. Fiat Mist., cuius sumat cochleare unum amp]urn subinde. No. 46. R Balsam. Tolutan. 3 jss.—ij.; Mucilag. Aca- J;lae 3j • j tere bena et adde, miscendo, Tinct. Benzoini Comp., Tinct. Opii Camphoratae Prist.,aa 3 iij.; Olei Ani- si TT) xx.; Aquae Pulegii et Aq. Anethi aa g iij. ; Syrup. Simp. 3 ij. M. Capiat coch. ampla duo quater in die". 90. b. Emetics are amongst the most promptly beneficial remedies that can be resorted to during the paroxysm, with the intention of removing both phlegm and spasm ; and they have been justly recognised as such by G&lius Aurelia- nus, Horstius, Mayerne, Floyer, Aken- side, Bang, Kerbs, Hufeland, Wedel, Stoll, Bree, Loeffler, and Schmidtmann. Ipecacuan is, upon the whole, the best medicine that can be employed to produce this effect. The philosophical Akenside recommended a scruple of it to be given at the commencement of the paroxysm, and five grains every morning during the intervals, for some time, so as to occasion nau- sea. When the paroxysm is excited by an over- loaded or deranged state of the stomach, emetics are particularly indicated. It is in such eases that Schmidtmann, one ofthe most practical and ex- perienced of modern writers, recommends them ; whilst Stoll and Loeffler advise them prin- cipally in the humoral form of the disease. In the asthma to which several classes of artisans, par- ticularly pearl-turners, &c. (see Arts, and the Causes of Disease,) are liable, emetics have been found the most successful remedy in the paroxysm. But, besides this operation, ipecacuanha has an especially beneficial effect in asthma, as I have already particularly noticed. Next to it, and even superior to it in the very humid states of the dis- ease, are the preparations of zinc, particularly the sulphate, in suitable doses and forms of combina- tion (see F. 582—587.). 91. c. Nearly allied to emetics are nauseants and diaphoretics. These are sometimes of ser- vice, either at the commencement, or shortly be- fore the fit. The substances that may be employ- ed to produce this effect are ipecacuanha, and the different preparations of antimony, particularly the tartar emetic and kermes. These latter are prais- ed by Bang, Vicat, and Hufeland. Ipecacu- anha,^ from one to five grains, or the antimonials in full doses, may be combined with nitre, cam- phor, opium, or hyoscyamus, according to the circumstances of the case (see F. 393. 854.). 92. d. Refrigerants. Of this class of medi- cines the most useful is the nitrate of potash, in conjunction with camphor, ipecacuanha, and hyosciamus (F. 279. 431. 436.), particularly in the humoral variety of the disease ; in the state described as requiring blood-letting ; or when the attack has been induced by, or is compli- cated with, catarrh. Eeither of the followino- draughts may be taken at the commencement of the paroxysm, and repeated in two hours, if ne- cessary : — No. 47. R Potassae Nitratis gr. x.—xx. ; Spirit. JEther. Nit. 3 j. ; Vini Ipecacuanha; 3 j. ; Tinct. Hvosciami 3 i ; Mist. Camphora; % j. ; Syrup. Tolutan. 5" j. M. Flat Haustus statim sumendus. No. 48. R Potassae Nitratis sr. x.—xvj.; Vini Ipecacu- anha;, Tinct. Hyosciami, aa 3 j."; Liquor. Ammon. Acetat 3 iij. ; Mist. Camphorae 3yj.; Syr. Tolutan. 3 j. M. Fi- at Haustus statim capiendus. 93. Besides the internal use of refrigerants, Loeffler recommends cold epithems to be plac- ed on the chest, in the spasmodic form of the dis- ease : and several Continental writers advise clys- ters of cold water to be administered when asthma seems to be connected with hysteria. In such cases, clysters of assafcetida or of infusion of va- lerian are preferable. Refrigerants act both by diminishing inordinate secretion, and by allaying spasm ; and, when the disease is connected with active congestion, or excitement, are, with deple- tion, the safest measures that can be employed to remove, or to prevent the formation of phlegm. 94. D. To transfer irritation to other parts, or to recall-the disease to its original seat, when it has arisen from the metastasis of gout, rheumat- ism, or the suppression of discharges, is often an important indication. The usual means of revul- sion and derivation, or counter-irritation, partic- ularly those which produce this effect with the greatest celerity, as sinapisms, stimulating pedi- luvia, and the vapour bath, are the chief revul- sants that are admissible under such circumstances and at this period. They may be accompanied with diaphoretics, aperients, diuretics, or even emmenagogues, in particular cases. They have also occasionally been found successful in prevent- ing the accession of the fit ; particularly if em- ployed when the premonitory signs first appear ; and if internal derivatives, especially a purgative combined with antispasmodics and carminatives, have preceded them, and if they have been fol- lowed by gentle diaphoretics. 95. E. To remove flatulence, by means of gen- tle aperients combined with carminatives, is often necessary during the course of the paroxysm. I have observed much benefit derived from the ex- hibition of a purgative, combined with antispas- modics and carminatives, shortly before the ex- pected accession of the attack, particularly when the premonitory signs begin to appear, and the digestive organs evince disorder—such disorder often acting as the efficient cause of the seizure. (See F. 28. 181. 266. 379.) The combination of diuretics, also, with the medicines prescribed during the paroxysms, or of carminatives, in order to relieve the distressing flatulence with Which they are very generally accompanied or preceded, will be often found of service. 96. F. Besides the means noticed above, there are several which have been recommended in the fit—some of them most deservedly, others in a very ^discriminating, and hence not a very bene- ficial manner. Of the former of these, warm cof- fee is the most important. This dietetic remedy was used by Floyer in this disease, and more recently by Thilenius, Percival, and Bree. It generally affords much relief when made suffi- ciently strong ; and it seems to resemble the stim- ulating antispasmodics, particularly camphor, in its action. I have also observed the paroxysm checked by strong green tea. 97. My limits oblige me merely to enumerate the other medicines which may be resorted to in the paroxysms of asthma. The chief of these are, dry cupping between the shoulders, a weak solu- tion of phosphorus in asther, the oxides of bismuth and zinc, mix vomica, &c. by several Continental writers ; galvanism, as recommended by Dr. W. Philip ; electricity, by M. Sigaud Lafond ; the chenopodium ambrosioides, by Hufeland ; the infusion or spirits of juniper, by Bekker ; guaiacum, by Aaskow, particularly when the ASTHMA — attack occurs in the gouty or rheumatic diathesis; cajeput oil, in the spasmodic form of the disease, by Wickmann; the veratrum album, by Mul- ler; the muriate of ammonia, by Martius; and the external application of garlic, by Portal. 98. 2d. Treatment during the interval.—Our chief object during the interval is to prevent the accession of the attack, by avoiding the remote causes, and removing the morbid state of the digestive and respiratory organs which dispose to it, and whatever disorder of function or of struc- ture with which the disease may have become associated. We should, therefore, endeavour to form a correct opinion respecting the state of the bronchial mucous surface, the morbid associations ofthe affection, and the consecutive lesions which may have already supervened to it. The state of the digestive functions, of the alvine secretions and excretiohs, should receive the utmost atten- tion ; and the means which may be most appro- priately used for their promotion, in particular cases, ought to be assiduously employed. 99. A. Evacuations, tfc.—Under this head I will briefly consider blood-letting, emetics, pur- gatives, blisters, issues, and diaphoretics, a. Bleed- ing is seldom of service in the uncomplicated state of the disease. But when it is accompanied with vascular plethora, or pulmonary congestion; or when the attack seems to have been produced by the suppression of an accustomed discharge, whether sanguineous or of any other description; a moderate blood-letting, or cupping between the shoulders, will be of advantage. 100. b. Emetics during the intervals are only required when the disease is characterised by con- gestion of the mucous surface of the lungs, obstruc- tion ofthe bronchi by a viscid secretion, or torpid and loaded state ofthe liver and biliary apparatus. When prescribed shortly before the expected fit, they often succeed in preventing its accession. 101. c. Purgatives are often necessary; but they may also be detrimental. Those substances which irritate the digestive mucous surface, with- out producing a full feculent evacuation, are always prejudicial. Purgatives also are hurtful when they are employed so frequently as to lower the vital energies, and carry off a portion of the chyle which should be absorbed into the circula- tion. On the other hand, stomachic aperients and purgatives exhibited in combination with tonics and antispasmodics, and to the extent merely of promoting the digestive, assimilating, secreting, and excreting functions, are particularly beneficial. Either of Formulae 266. 450. to 456. 462., contained in the Appendix, or the following, may be prescribed:—■ No. 49. R AIoSs Socot. gr. iv.; tere ben? cum Gum. Mastich. gr. ij.; et adde Extr. Gentian* Comp. et Mass. Pilul. Galban. Comp. aa gr. iij.; Olei Anisi q. s. Fiant Pilula; iij. hora somni quotidife sumenda;. 102. d. Diaphoretics in small doses, in con- junction with anodynes, deobstruents, or anti- spasmodics, are of service merely in as far as they may preserve a regular state of an important function, and prevent the determinations to inter- nal organs which frequently follow any inter- ruption to it. But profuse perspirations and warm bathing are more generally prejudicial than otherwise. Indeed, whatever relaxes the cuta- neous surfaces beyond a certain degree has an injurious effect upon affections of the lungs which s Treatment. jcj| are not acutely inflammatory, and particularly in the pituito us chronic asthma. When the paroxysm is associated with the dry catarrh, diaphoretics may be carried further with advantage; and when combined with expectorants and antispasmodics (§ 91.), they are more generally applicable. 103. B. Expectorants, alterants, attenuants, and deobstruents, or substances supposed to have some one or more of these effects, have been very generally recommended in asthma. Several of these have little or no effect, and others may even be injurious, a. The expectorants most frequently employed are those already noticed; but I believe that they are seldom productive of much advan- tage, given in the interval. When the disease is complicated, as it not infrequently is, with dry catarrh, or irritation of the bronchial mucous sur- face, those substances which have the effect of soothing irritation, relaxing spasm, and softening the pulse, as James's powder, kermes, ipecacu- anha, camphor, antimonial wine, are in fact the best expectorants; inasmuch as they tend more to render the bronchial secretion less tenacious, where it is glutinous and obstructing the bronchi, and to diminish its quantity when too copious, than those which are of a heating or stimulating kind. 104. b. Amongst those medicines which are considered as attenuants, deobstruents, and alter- ants, there are none which possess greater claims to consideration in this disease than the pure alkalies and their carbonates, or their combina- tion with oils, and antispasmodic or narcotic sub- stances. However the propriety of applying the above terms to certain medicines in this disease may be cavilled at, there cannot be the smallest doubt, in the minds of those who closely observe the operation of remedies, that certain substances produce effects, on the respiratory surfaces and on their secretions, that justify the use of these terms. The alkalies in various forms of combina- tion, but particularly with oils, have been much praised by Wolff, Bache, Sarcone, Mas- cagni, and Laennec. Either in the pure state or in that of sub-carbonates, combined with the oils of aniseed or of almonds, with ipecacuanha, small doses of blue pill, and hyosciamus, the fixed alkalies are amongst the best remedies to which we can have recourse, particularly in the catarrhal or bronchial complications, and when the disease is connected, as it very often is, with irritability or other disorder of the digestive organs. I have experienced the greatest service, in practice, from the following, and from Formulas No. 348. 457. No. 50. R Sodae Sub-carbon, exsic. 9 ij.; Pulv. Ipe- cacuanha; gr. vj.; Pilul. Hydrarg. gr. vj.; Olei Anisi TTJ xij. vel q. s. ut fiant Pilulae xviij., quaruin sumantur bina; bis terve quotidie. No. 51. R Potassa; Sub-carbon. P) ij.; Pilul. Hvdrarg. gr. iv.; Extr. Hyosciami (vel Extr. Papaveris Albi) V) j.; Olei Amydal. Dulc. a. s. ut fiant Pilulae xviij., qu'arum capiat binas ter quotidia. 105. Under this head, I may make further mention of the balsams, combined with small doses of rhubarb, or with the addition of mag- nesia; of a combination of assafcetida, or myrrh, with galbanum, ipecacuanha, and soap, or the fixed alkalies (F. 503—510.); frictions with sti- mulating or antispasmodic liniments in the course ofthe spine (see the Liniments in the Appendix); the nitro-muriatic acid wash, in a tepid state, over the chest, night and morning, or either the one or other only; warm clothing, &c. rs Treatment. 152 ASTHMA — n 106. C. Blisters, issues, and artificial erup- tions are often extremely beneficial, particularly when asthma has supervened to suppressed dis- charges, to exanthematous diseases, or in the gouty and rheumatic diathesis. A large blister, applied between the shoulders or on the chest, a smaller one kept open, and issues and setons, have been recommended by the majority of wri- ters. Zacutus Lusitanus and Severinus ad- vise the actual or potential cautery to the nape of the neck. The production of artificial eruptions over the chest by the tartar emetic ointment ap- pears to me, from considerable experience of its effects for many years (see Lond. Med. Repo- sitory, vol. xvii. p. 302.), preferable to any other mode of counter-irritation in asthma, particularly when the use of the ointment is commenced during the interval. 107. D. Tonics and astringents.—a. The use of the preparations of bark during the intervals has the support ofthe best writers on the disease. Amongst these I may notice Floyer, Bang, Chapman, Heberden, Feldmann, Ranoe, Frank, Withers, Ryan, Bree and Laennec The states ofthe disease in which they recommend it, are, 1st, When the disease assumes a periodic type, or when it is connected with malaria; 2d, In the pituitous form of the disease, when the habit is relaxed and leucophlegmatic; and, 3d, When the stomach is much debilitated. There can be no doubt of the preparations of bark or the sulphate of quinine being indicated in such cases. Indeed, whenever the powers of the constitution require to be rallied, and where there exists no inflammatory irritation to contra-indicate it, bark and other tonics are frequently beneficial. In these cases, the decoction or the infusion may be given, with the liquor ammoniae acetatis, and vini ipecacuanhas, or with the subcarbonates of the alkalies. 108. 6. I have derived great service from the sulpfiate and oxide of zinc in the humoral form of asthma, particularly under the circumstances now described. Either of these preparations may be combined with ipecacuanha, camphor, myrrh, hyoscyamus, conium, opium, &c, according to the peculiarities of the case. Where it is de- sirable to produce a nauseating or emetic opera- tion during the fit, or in anticipation of it, the sulphate of zinc is the next best medicine to ipe- cacuanha that can be employed. 109. c. The preparations of iron have met with the approbation of Bree and Stanger, particu- larly the sulphate. It may be employed in similar cases to those for which bark and the sulphate of zinc are prescribed. I can only allude to the recommendation ofthe mineral acids with opium, by Floyer, &c; of the sulphate of barytes, by Keck and Hufeland; of arsenical fumes, by the Arabian physicians, and Ettmuller; of Fowler's solution, by Alexander; of the ni- trate of silver, by Zallony ; and of a solution of phosphorus in ether, by several German writ- ers. These very active medicines are admissible only in the most obstinate cases, particularly when occurring in relaxed or debilitated habits, and when other active tonics and antispasmodics are indicated. Saint Ignatius's bean, and the extract of nux vomica, have also been mentioned by Stein and Hahnemann. Strychnine, the active constituent of these substances, seems deservin» of a fair trial in asthmatic cases. 110. d. Sulphur, and its preparations, have been advised by Diemerbroeck, Gasser, Martins, and Bang; and from a few opportu- nities which have presented themselves of trying them, I consider them, particularly the balsamum sulphuris,—a combination of sulphur with the oils of aniseed, &c. (see F. 21. and 22.),—and the sulphurets of potash and soda, as medicines of no mean efficacy in several states of the disease. The sulphur precipitatum or sublimatum, taken in the form of an electuary (see F. 82. and 89.), is one of the best aperients to which we can re- sort in cases of asthma or continued dyspnoea. It may be also taken as follows:— No. 52. R Sulphur. Praecip. % ss.; Semin. Anisi con- tus. 3 ijss.; Confect. Senna; et Syr. Tolut. aa 3 Tj> M. Capiat coch. ij. minima pro dose. 111. There are various medicines which have been recommended in the paroxysm, which may also be occasionally employed in the interval, particularly shortly before the expected accession of attack, and upon the first intimation of its ap- proach. Of these, the most important are the antispasmodics and narcotics already mentioned (§ 75.), with the smoking of tobacco, stramonium, and aniseed, and the inhalation of the vapours of narcotic substances, and certain gases (§ 85. 88.).. 112. Flatulence is a very frequent attendant upon asthmatic cases, chiefly before the invasion of, and during, the attack. It seems connected with irritation of the digestive mucous surface, and deficient vital power. The relief of thisi symptom is often a matter of importance. For this purpose I have sometimes prescribed the following:— No. 53. R Olei Anisi TI, viij.—xij, r Sottas Sob-carbon, gr. xv.; Sacchari Albi, Magnesiae Ustaer aa 9 j-; tere et adde Tinct. Castorei 3 j- j Tinct. Sennae 3 ij- > Aquae- Menth. Virid. et Mist. Camphorae aa 3 v.; Syrup. Tolu- tan. 3 ss. M. Fiat Haustus, 3ti» vel 4iis- horis ad' tertians aut quartam vicem sumendus. 113. 3d. Ofthe treatment of the various symp- tomatic and complicated states of the disease.— But little is required from me on this subject, after the detailed account of the- treatment new given. When the disease is associated with either ©f the usual forms of eatarrh, diaphoretics, consisting chiefly of ipecacuanha, antimonials, &c, com- bined with narcotics or anodynes, are chiefly in- dicated; and, if inflammatory irritation seems to exist in the bronchial lining, local depletions, col- chicum, or digitalis, counter-irritants and revul- sants, gentle aperients, and the inhalation of the vapour of warm water, in which a little camphor has been thrown, may be added to the above. 114. In the frequent complications of inflam- matory irritation of the digestive mucous surface, and disorder of the biliary apparatus, or of de- rangement of the functions of the heart, it will generally be advisable to commence the treat- ment with five grains of blue pill on alternate nights, for three or four times, and with an aperient draught on the following morning. By these the secretions will be exeited, and the bowels evacuated. Afterwards the healthy state of action of the capillaries of the mucous surfaces generally will be promoted by exhibiting half a grain of blue pill, three or four times in the twenty- four hours, combined with two or three grains of the extract of hyosciamus, or of extract of hop; vegetable tonics, with the fixed alkalies, or ASTHMA —its Treatment. 153 other stomachic medicines, being taken through the day. If we have reason to suspect the existence of organic change within the chest, particularly inflammatory congestion in the lungs, enlarge- ment of tne structure of the heart, &c, the inser- tion of issues, or keeping up an abundant eruption on the external surface of the chest by the tartar emetic ointment, should be added to the above means. This treatment ought, with occasional variation according to the circumstances of the case, to be perseveringly continued for weeks, or even months ; and it will often succeed, even in the most unfavourable complications. The oxide of bismuth, combined with tonic or bitter extracts, will also be found of service in the gastric associ- ations ofthe disease. 115; When the disease is associated with affec- tion of the head, or curvature of the spinal col- umn, setons, issues, or moxas in the nape of the neck, or in the course ofthe spine, may be tried. If it be attended with disease ofthe liver, external irritation, the nitro-muriatic acid bath or lotion, small doses of mercury, and the plaster, Form. 117., may be prescribed. Organic lesions ofthe heart and large vessels, and dropsical effusions, require a combination of these measures with the use of alkalies, digitalis, opiates, &c. When hysteria, and generally increased sensibility and susceptibility, attend the asthmatic affection, ton- ics with antispasmodics are principally indicated. In the other complications of asthma, the treat- ment recommended in Dyspncea will be general- ly appropriate. 116. 4th. Ofthe regimental treatment.—Much advantage will be derived in asthma from strict attention to diet and regimen,—comprising bath- ing, exercise, air, and climate, the use of mineral waters, &c. A. Cold sponging the surface ofthe chest, and cold bathing, are amongst the most approved means that can be resorted to during the intervals of asthma. They tend both to diminish the sensibility and susceptibility of the patient to the impression of cold,—one of the most frequent exciting causes of the attack ; and to give a salutary tone to the respiratory mucous surfaces and vessels ramified in them; and hence they prove the best means which can be resorted to for the prevention not only of the asthmatic at- tacks, but of catarrhs, and all other affections and diseases of the respiratory organs. The patient should commence this practice with the following lotion, with which the whole of the chest and upper part ofthe abdomen should be sponged, or rubbed with a towel or piece of flannel wetted with it, and afterwards be dried, using smart fric- tion at the time :— No. 54. R Acidi Acelici Pyrolignei vel Vini Albi, Liq. Ammonia; Acetatis, aa 5 ijss. ; Aq. Rosarum 3v-> Spirit. Vini Tenuioris g ij. M. i iat Lotio. This should be used every morning upon getting out of bed; and if the patient commence with it during the winter, a fire may be kept in the dressing-room, and the chill taken off it for the first few days of using it. Instead of the above lotion, a solution of common salt in water, in the proportion of two table spoonsful to a pint, or one part of vinegar to two of water, may be em- ployed. After these have been continued for some time, or as long as the patient may please, and the system has been thus prepared for it, the shower bath may be substituted with advantage, > particularly if the patient be in that state of health which will allow him to bear the shock without risk. Sea or salt water bathing may also be re- sorted to all the summer and autumn; and the shower bath, or at least cold sponging the surface of the trunk of the body, all the" winter and spring; for it will generally be advisable not to discontinue this practice for any considerable time after it has been fully adopted and found of service. In ad- dition to the cold bath, the patient should have recourse to regular exercise in the open air; and attend to the state of his digestive organs, and the regular functions ofthe bowels. 117. If along with the asthmatic affection the patient have complained of palpitations, irregular- ity ofthe action ofthe heart, cedema ofthe ancles, severe dyspeptic symptoms, and disorder of the liver or bowels, these ought to be removed, before commencing with cold sponging and bathing, by local depletions when they are indicated; by very small doses of blue pill, or the hydrargyrum cuin creta, with the sub-carbonates of the fixed alka- lies, and hyosciamus given at bed-time, a gentle aperient draught the following morning, and bitter tonics, with the alkalies through the day. The recommendation of cold bathing in asthma may startle some; but when all associated disorder of an inflammatory kind has been removed by ap- propriate treatment, and the means now specified, and when the system has been duly prepared for it, cold bathing is actually one ofthe most saluta- ry measures, and the most permanently beneficial, that can be prescribed. It has, moreover, received the sanction of C^elius Aurelianujs, Floyer, Withers, Millar, Ryan, Bree, and Hufe- land,—names which should claim our respect for whatever they recommend, even if our own experience did not altogether confirm their opin- ions, which, however, is in accordance with theirs as to this practice. 118. B. Mineral watei-s.—The waters in this country, which are best suited to asthma, are those of Cheltenham and Leamington ; and of Buxton and Bath, to some of its complications, particularly the arthritic. Dr. J. Clark very justly remarks (The Influence of Climate, fyc. 2d ed. Lond. 1830, p. 371. et. seq.), that when asth- ma is accompanied with chronic irritation of the bronchial membrane, or with disorder of the di- gestive organs, and an unhealthy state of the skin, a course of warm mineral waters will often prove of benefit. The springs of Ems on the Rhine, of Carlsbad, of Bonnes and Cauterets in the Pyrenees, and of Mont d'Or in Auvergne, are those chiefly esteemed on the Continent. The great difficulty generally is, that the climate and degree of eleva- tion of these places will often not suit particular asthmatic cases. Where the climate of a valley is likely to suit the patient, Ems and Carlsbad will be preferred ; and where an elevated sit- uation is required, the Pyrenees and Mont d'Or will be chosen. The artificial waters of Ems and Carlsbad, prepared at Brighton, are but little inferior to the natural springs. In a case of this disease, where I directed those of Ems, great benefit was obtained from them. 119. C. Change of air and climate.—It is im- possible to point out the particular climate or locality which will best suit the asthmatic patient; for the state of air or climate which will suit one, will distress another, and without any very evi- 154 ATROPHY. dent cause to explain the different effect. In nearly all cases, however, changes of air are ben- eficial, chiefly as respects the general health of the patient, and the disorders with which asthma is associated. Upon the whole, a temperate, equable, and moderately moist state of the air is best borne: but even in this, there is much uncer- tainty. The physician must be guided in his choice by the kind of asthma with which the patient is afflicted, and by the ascertained ef- fects of certain seasons and localities in his particular case. In general, a moist and warm, or mild climate, as the south-west extremity of this island, will suit the spasmodic or dry form of the disease, and that most commonly associated with the dry eatarrh, much better than any other in this country; whilst the pituitous or humid variety, occurring in the debilitated or aged, and in those of a relaxed and leucophlegmatic habit, and attended with much expectoration, will require a dry and a somewhat bracing state of the air. 120. D. Diet.—Very little is required to be stated on this topic The food should be always light, digestible, in small quantity, and chiefly farinaceous ; particularly in those cases which indicate general or local plethora, inflammatory irritation, and disorder of the digestive organs. Floyer particularly insisted upon abstinence, as to both eating and drinking ; and later writers, and experience, have confirmed the justice of his injunction. When the disease is accompanied with lowered energies of the powers of life generally, the diet should not be so poor as to furnish insuf- ficient means whence the mischief may be repair- ed; hut it ought, notwithstanding, to be light or digestible, and not exceeding the powers ofthe digestive organs to manage with facility. Biblioo. and REFER.—Galen, De Difficult. Respirat. L i. ii. iii.; et De Locis Affectis, 1. iv. cap. 7.—Aretaus, De Morb. Diut., 1. i. cap. 9.—Celsus, 1. iv. c. 4.—Calius Aure- liunus, De Morbis Chron. 1. iii. ch. 1. p. 431.—Avicenna, Canon. 1. Ki. tr. 1. c. 7—42.—Fernelius, Consil. xxii. — Baglivi, Di- Pract. Med. 1. i. ch. 9. p. 64.—Severinus, De Efficac. Medicam. p. 220. — Zacutus Lusitanus, Prax. Histor. L viii. ob. 25. ; et Prax. Admir. 1. iii. obs. 126.— Mayerne, Praxis, &c. p. 184.—Willis, Pathologia Cerebri, cap. 12.; et De Morb. Convuls. cap. xii. p. 94.—Floyer, Gn the Asthma. Lond. 1698.—Diemerbroeck, Obscrv. et Curat. C. n. 63.—Panthot, Ergo Asthmaticis Tabellae de Sulphure. Monsp. 1653.—Dover, Legacy, kc p. 46.— Hoffmann, De Asthmate Convuls. Opera, vol. iii. p. 102. —Wagner, Diss, de Asthmate. Hain. 1706.—Ettmuller, Diss, de Asthmate. Lips. 1710.; et Opera, a Zwinguero, t. ii. p. 109.—AlbeHi, Diss, de Spirandi Difficultate. Hal. 1726. —Juncker, De Asthinatis Vera Pathol, et Therapia. Hal. 1752.—Ranoe, in Act. Reg. Soc. Med. Haun. vol. ii. p. 163., vot iii. p. 362., et vol. iv. p. 269.—Bang, in Ibid, vol. i. p. 10. 102. 110.—Aaskow, in Ibid., vol. i. p. 308.— Krebs, Medicin. Beobach. b. ii. h. iii. No. 7.—Akenside, Medical Transa^. of Coll. of Phys. vol. i. No. 7. p. 93.— Whytt, Works, p. 602.—Withers, Treatise on the Asthma. Lond. 1786.—Stoll, Rat. Medendi, p. iii. p. 36., et p. vii. p. 231.—Thilenius, Med. und Chirurg. Bemerk. i. p. 164. Millar, Observations on the Asthma, kc Lond. 1769.— Meyer, De Asthmate et ejus Spec. Got. 1779.—Ryan, On the History and Cure of Asthma. Lond. 1793.—Krelsch- mar, Horn Archiv. b. i. p. 227.—Chapman, in Medical Communications, &.c. vol. i. No. 22.—Heberden, Com- pient. de Morb. kc cap. 11.—Monro, in Edin. Med. Essays, vol. iii. p. 316.—Simson, in Ibid. vol. vi, p, 121,— Rusk, in Edin. Med. Comment, vol. iv, p. 198,—Fother- gill, Works, vol. ii. — Alexander, in Edin. Med. Com- ment, vol. xv.—Percival, Medical Essays, vol. i. p. 269. and vol. iii. p. 270.—Macbride, Med. Observ. and Inquiries, vi. No. 2.—Michaclis, in Richter Chir. Bib), b. v. p, 127. —Mascagni, Sull' Uso di Carbonato di Potassa, &.c. Mem. Dell. Soc. Itnl. Rom. xii. 1804.—Bree, Practical Inquiry into disordered Respiration. Lond, 1801.—Zal/ony, Traits de 1'Asthme, 8vo. Paris, 1809.—Stanger, in Med. and Chirurg. Trans, vol. i. — Schmidtmann, Anleitung zu Griindung einer Medicinalverfassung, th. i. p. 189.—Horn, Archiv fur Pract. Med. Jan. 1811, p. 87.—Henke, Ibid. b. vi. p. 271.—Loebel and Heinecken, in Ibid. July, 1810, p. 187., et May, 1812, p. 571. — Heinecker, Hufeland Journ. der Pract. Arzneyk. b. vi. p. 74.—Wichmann, in Ibid. b. i. p. 18.—Hahnemann, in Ibid. b. iv. p. 755.— Hufeland, in Ibid. b. W.—Reil, Fieberlehre, b. iv. p. 820. p. 62.—Wolff, Hufeland Journ. der Pract. Heilk. xviii. b. 1st, p. AS.—Loeffler, in Ibid. xxi. b. 1st, p. 60.—Tol- berg, in Ibid. xxvi. b. 3d, p. 26—Portal, Mem. sur la Nat. et le Traitement des Pleus. Maladies, t. ii. p. 70.— J. Frank, Praxeos Medicae Univ. Praecept. P. ii. vol. vii. p. 379.—Rostan, Journ. Gener.de Med. Sept. 1818; et Nouv. Journ. de Medecine, t. iii. p. 1.—Christie, in Edin. Med. and Surg. Journ. vol. vii. p. 158.—Schlesinger, Hufe- land und Himly Journ. der Pr. Heilk. Jan. 1810, p. 115. —Laennec, De l'Auscultation Mediate, 2 t. Paris, 1826. —W. Philip, Philos. Trans. 1817-22.—Reisseisscn, Ueber den Bau der Lungen-Fol. Berl. 1822.—Andral, Revue Med. t. iii. 1824, p. 330.; et Clinique Medicale, t. ii. p. 72. —J. Forbes, Med. and Phys. Journ. Oct. 1822.—Georget, Sur le Systeme Nerveux, t. ii. Paris, 8yo. 1822.—J. Be- gin, in Journ. Compl. t. v.—Ferrus, Diet, de Medecine, t. iii. art. Asthme, p. 101.'—Cruveilhier, Nouv. Biblioth. Med. t. v. p. 179.—Bricheleau, Archives Gener. de M£d. t. ix. p. 334.—Jolty, Diet, de Med. et Chir. Prat, t iii.— Parry, Elements of Pathology, ft 474., and Posthumous Works, &c. vol. ii. p. 19.—Andreius, in Glasgow Med. Journ. vol. i. p. 177.—Gannal, On the Inhalation of Chlo- rine. By Potter. Lond. 1830.—Kreyssig, Encyclop'adisches Wbrterb. der Med. Wissensch. b. iii. p. 575. ATROPHY.—(From the privative a,anArqo(filt nutrition, or rpoiplvo, I nourish.) Patholo- gy—Morbid Structure.—Syn. Atrophie, Con- somption, Fr. Ungedeiben, Schunndsuckt, Aus- zehrung, Ger. Voedeloosheit, Dut. Atrofia, Somma Magrezza, Ital. Wasting, Eng. 1. Defin. Deficient nutrition of a part or of the whole frame, owing to which its natural dimensions are necessarily reduced. 2. The healthy proportions of the various parts of the frame are preserved by their vital endow- ment, and are intimately dependent upon the conditions of this influence. When it preserves its due relations throughout the frame, a con- tinued vital attraction of molecules from the blood takes place, to an extent sufficient to supply the place of those particles, which, having lost their vital affinity, are removed by absorption. This slow process, by which animal particles are taken away, for a time, from the current of the circu- lation, assimilated in the various tissues, after- wards detached from them when they no longer are suited to the purposes of the structure, and carried back to the circulating current to be partly eliminated from the frame, and partly changed into different conditions, is not infre- quently liable to be disturbed in some one of its parts or steps. Thus, when the vital influence of an organ, or of the whole frame, is in a state of activity, the attraction of molecules from the blood, similar to those constituting the different tissues, is energetic, and extended to a greater number of such molecules, — they are held in closer affinity, and the bulk ofthe part is increas- ed. But when the state of the vital endowment is reversed, when it is weak or depressed, this at- traction proceeds slowly and languidly, and, the existing affinity being also weak, the molecules composing the tissues are sooner removed by the process of absorption than in health, and the part thus circumstanced is wasted, from a more rapid loss of its molecules than can be supplied by the low state of vital affinity. Thus, as in the former case, a double condition of the organi- zation, but of opposite natures, actually obtains; namely, the attraction is extended to fewer mole- cules, and the affinity between them is more lan- guidly exerted, they being more rapidly carried, ATROPHY. 155 by the process of absorption, back into the blood, from whence they came, in order to be partly changed and partly eliminated from it; and the part thus affected, instead of retaining its healthy proportions, becomes wasted, deficient in its con- stituent molecules, or atrophied. Thus we per- ceive that there is a continued circulation of nu- tritious particles in the very tissues which they compose; that this circulation, and the affinity which preserves them in their spheres, is vital, influenced by, and fluctuating with, the various conditions of the vital endowment of the frame, the nutrition and bulk of a part being intimately dependent upon it. 3. Nutrition being, then, the result of a vital attraction exerted between the molecules of mat- ter constituting the elementary tissues, and those which are similar to them in the blood, and being co-ordinate with the strength of that attraction, atrophy necessarily proceeds from a diminution of this affinity, and the more rapid transit, conse- quent upon this diminution, ofthe particles which have been attracted, back into the current of the circulation. The healthy proportion of the tissues is therefore continued by a due equilibrium being preserved between the attractive influence on the one hand, and the continuance of vital affinity on the other. When either the attraction is active, or its duration long, the bulk of the structures will be increased; but when the former is weak, or the latter of short continuance, atrophy will necessarily result. 4. The truth of these propositions is evident from a due consideration of the various pheno- mena of health and disease, and by the numerous contingent circumstances which influence the con- ditions of the different structures of the body. At this place I will briefly describe, first, the ap- pearances which atrophied structures assume; secondly, the various causes and circumstances which, influenced by the vitality of the frame, produce this change; and, thirdly, the treatment that may be employed to remove it. Thus I will confine myself, at this place, entirely to the con- sideration of atrophy, in its generic acceptation; the species being treated of under distinct and separate heads. 5. A. States or appearances of atrophied parts. —Atrophy may be confined to particular struc- tures; it may affect only a particular constituent tissue of an organ, whilst its associated tissues are hypertrophied, and it may extend to various con- tiguous structures or unconnected organs. A par- ticular constituent tissue may, however, be wast- ed, and yet its associated structures may be aug- mented in bulk, as I have shown occasionally to occur, when describing the morbid states of the liver. When this takes place, either no diminu- tion, or an actual increase of the whole organ, is observed. When a compound organ, or part formed of various elementary tissues, is atrophied in all its constituents, the diminution of volume is then very remarkable; although, in some cases, as when the atrophy consists chiefly of a rarefac- tion of the internal structure of an organ, as of the lungs and bones, the external surface presents little or no change. 6. The earliest and most essential change in an atrophied part is diminution of the quantity of blood sent to it; and next to this, and chiefly owing to it, is greater paleness of colour. Sub- sequently the organization is still more complete- ly changed; so much so, frequently, that all trac- es of its original conformation are lost, and the part is reduced to the state of cellular or fibro-cel- lular tissue, generally of small size. In some ca- ses, the part is not only extremely atrophied, bnt at last disappears altogether. When membran- ous structures are atrophied, they become much thinner and more diaphanous than natural, or even perforated. 7. The atrophy of certain organs or parts is a natural or healthy change, as respects the foetus in utero, and the newly-born infant. The parts which experience those changes are too well known to require notice. Several structures, especially muscular parts, sometimes have pre- ternatural quantities of fat deposited on their sur- faces during the progress of atrophy. This is of- ten observed in respect of the heart, and appears to result from the same causes; namely, diminish- ed vital energy, occasioning insufficient nutrition or assimilation (§ 2, 3.), and a morbid secretion of fat, which often is as much a consequence of diminished vital energy, as insufficient nutrition of the different structures is the result of this state; both changes being, in some cases, merely grades, in others modifications, of the same vital manifestation. 8. Various parts of the body naturally undergo marked atrophy during advanced age. Of these the most remarkable are the generative organs, particularly the ovaria, mammary glands, testes, the thyroid gland, the bulbs of the hair, adipose tissue, the lungs, and bones. Atrophy of these and other parts has received a more particular notice under their respective heads. I may, how- ever, remark, respecting the atrophy which re- sults from age, that it is very evidently the result of diminished vitality, especially as those parts which first experience a loss or diminution of their functions, either from age or exhaustion, are the first to be atrophied; and that it often differs from other forms of atrophy, in consisting merely of a deficiency of the fluid constituents of the struc- tures— in a condensation and dying ofthe organs, and not of a loss of the molecules constituting their solid parts. 9. B. The secondary causes which, under the influence of the vitality of frame, produce atro- phy, are, 1st, Original deficiency of developement, constituting congenital atrophy. This state of atrophy may exist in every grade, and may amount to a total absence of an organ or part. When it takes place to this extent, it has evident- ly arisen from an arrest of the formative process, or of the developement of the tissues, in conse- quence of disease of the embryo. If the disease affect the nervous centres, the parts supplied with nerves from them are sometimes either much atro- phied or altogether wanting, as MM. Rostan and Serres have shown. But this is only an occa- sional occurrence; for parts of the brain or of the spinal cord have merely consisted of a serous sac, and yet the organs of sense and the limbs have been fully developed; and there have occurred many cases in which both brain and spinal chord have been entirely wanting, and yet the nerves proceeding from them, and the organs which the nerves supply, have been fully formed; evincing the truth of the doctrine stated by the writer many years since (see London Med. Repos. vol. 156 AUSCULTATION. xvii. for May, 1S22; and Notes to Richerand's Elements of Physiology, 1st ed. 1824.), that the nerves are first formed, and the cerebro-spinal centres subsequently developed. 10. 2d. A diminution of the influence of those nerves which preside over the circulation of a part, and its assimilative and proper functions, rapidly reduces its volume. It is chiefly owing to this cause that the organs of generation waste in old persons. The ganglia which supply these organs, in both sexes, become, in old age, small and indistinct; and the nerves which issue from them to these parts can scarcely be traced. I have no doubt that a similar result follows injury or change of the ganglia or ganglial nerves in other parts of the body. The paralysis attend- ant upon painters' colic is generally accompanied with great wasting. In cases of unreduced dislo- cation, when the head of the bone presses upon the nerves, wasting is a frequent consequence, chiefly owing to the incapability of exerting the voluntary muscles, which are rapidly atrophied when they remain inactive. Injuries of nerves, of whatever description, that interfere with their functions, will, as shown by Bell, Lobstein, and several others, occasion atrophy. But I may add, that whilst injuries of ganglial nerves will produce it directly, by arresting the nutritive ac- tions, injuries of voluntary nerves occasion it in- directly only, and chiefly by depriving the mus- cles of their contractile powers, and reducing them to that state of inactivity which is more or less rapidly followed by atrophy. This is proved in the numerous instances which come before us of paralysis originating in the brain. The wast- ing of the paralysed limb in these cases is seldom great, and it is chiefly limited to the muscles; the other structures, particularly the cellular and adipose, being unaffected. 11. 3d. Diminished supply of blood is a very frequent cause of atrophy. This may be local, as in cases of obliteration of a large arterial trunk, and when the functions of an organ cease. In many such cases, however, the obliteration may be the consequence of injury of the ganglial nerves which supply the artery, or of the cessation of the functions of the part. The general state of atrophy which occurs after tubercular formations in the mesenteric glands, or in the lungs, is, gen- erally, partly owing to the diminution of the en- tire mass of blood, together with lowered vital influence; then utritious molecules, and the assimi- lating or attractive power being both deficient. A similar inference may also be extended to the wasting accompanying idiopathic anaemia. 12. 4th. When the functions of a part or or- gan are arrested, atrophy always results. This is remarkably the case in respect of the voluntary muscles (§ 10.). On the other hand, increased function of an organ contributes to augmented volume. The urinary and generative organs fur- nish well-known proofs of those positions, and illustrate those with which I commenced, namely, that nutrition, and consequently atrophy, most intimately depend upon the states of vital mani- festation of an organ or part. Other organs in- capacitated from acting also undergo a marked diminution of their size. Even the lungs, when the principal bronchial tube of one lobe is ob- structed, will experience atrophy of that lobe, as MM. Reynaud and Andral have shown. ' In cases of death from hunger, the stomach and large bowels appear wasted. 13. 5th. Atrophy will also present itself as a consequence of inflammation; and, in some cases, will amount to obliteration or disappearance of the part. Such changes are not infrequent in blood-vessels and excretory ducts. It is some- times observed in the spleen, liver, and gall-blad- der; the last of which has been observed to be wanting or entirely obliterated from this cause. In the majority of such cases, the atrophy has proceeded from obstruction to an artery or vein having occurred during the disease, probably from the extension of inflammation to them, or from the pressure of some ofthe usual products of the inflammatory state, 14. C. Treatment of atrophy. — In all these circumstances under which atrophy occurs, it will always be observed that the vital energies, in some one or other of its manifestations, are diminished or perverted — most frequently the former. This fact furnishes us with the most ra- tional indication as to the removal of the morbid state which it occasions. Having first ascertained the circumstances and pathological states of the atrophied organ, we are to direct our attention to remove them as far as may be possible. We are next to endeavour to restore the natural vital en- ergy of the.organ by exciting its functions, and promoting the constitutional powers. Knowing that, by increasing the natural actions of a part, we thereby increase its nutrition and bulk, we should endeavour to apply this principle to the removal of atrophy, but with a cautious avoid- ance of fatigue or exhaustion being occasioned by the means we use for this purpose. When the atrophy seems to depend upon the developement of tubercles, or upon engorgements of lacteal glands or tumours pressing upon nerves or large vessels, the preparations of iodine are indicated, on account both of their influence in removing these tumours, and of their excellent tonic pow- ers when judiciously administered. In many cases the functions ofthe digestive organs—stom- ach, liver, and bowels—are torpid, and conse- quently the nutritious fluids are not sufficiently prepared to be assimilated in the different tissues. Healthy chyle is not supplied in the requisite quantity, or, if supplied, is not converted into healthy blood for the nourishment of the struc- tures. In these cases, although the energy of the whole frame is deficient, yet our principal means of medication are to be directed to these organs. (See art. Consumption, Marasmus, Mesent- eric Disease, and Tabes Dorsalis.) Biblioo. and Refer. —Desmoulins, in Journ. de Phy- sique, t. xc. p. 442. — Ribes, in Bullet, de la Facnlte de Med. t. vi. p. 299. — Ferrus, Atrophie, in Diet, de Med. t. iii. p. 143. — Andral, Clinique Mtdicale, t. iv. p. 11.; et Precis d'Anatom. Pathol, t. i. sect. ii. ch. ii. — Bouillaud, Diet, de Mtd. et Chirurg. Prat. t. iii. p. 629. — Lobstein, Trait6 d'Anatomie Pathologique, t. i. p. 60. AUSCULTATION. — (From ausculto, I list- en). Pathology, Semeiology.— 1. This term is applied to the methods used to ascertain the seat and nature of disease, by the signs which may be recognised by the sense of hearing. It com- prises the study of all sounds indicative of disease, whether heard by the unassisted ear, or through the medium of instruments; and whether arising naturally, or produced artificially. The observ- ations I have to offer upon this mode of investi- AUSCULTATION —of Respiration. 157 gating disease may be arranged in the following manner ; but I shall confine myself at this place to the consideration of the first class of signs, and devote to the second class a distinct article. (See Percussion.) 2. I. Signs furnished by Sounds pro- duced naturally within the Body. A. Sounds having their seat in the chest.—a. Depending upon the passage of air during re- spiration. 6. Proceeding from the action of the vocal organs, c. Depending upon the action of the heart. B. Sounds having their origin in the arteries. C. Sounds seated within the abdomen.—a. Proceeding from air in the digestive tube. b. Depending upon the foetal circulation. II. Signs furnished by Sounds produced artificially. (See Percussion.) 3. Hippocrates remarked that the existence of fluids in the thoracic cavity might sometimes be ascertained by applying the ear for some time to the side of the chest ; and our countryman Hook (Posthumous Works, p. 39. &c), in sev- eral very pointed observations, not only stated the importance of attending to the sounds produced by the " internal motions and actions of bodies," but also of rendering them sensible so as to distinguish between them ; for the doing of both which, he thinks, "it is not impossible but that in many cases there may be helps found." M. Double, also, was in the habit of applying the ear closely to all parts of the chest, in order to examine the signs furnished by the action of the heart, and by respiration ; and published his recommendation to cultivate this means of diag- nosis, in his able work on Semeiology, two years before the appearance of M. Laennec's cele- brated production. Although, therefore, M. La- ennec may not have been the discoverer of the importance of auscultation in the investigation of disease, yet is he clearly entitled to the honour of discovering mediate auscultation—of inventing the stethoscope—and not only of bringing both these modes of examination into general use, but also of strongly recommending percussion, and of improving, in a very remarkable manner, our knowledge of the pathology of pectoral diseases. 4. It is unnecessary to occupy my limits with a description of the instrument termed the stetho- scope, as its construction, with the improvements of M. Piorry, and the acoustic principles on which it assists the sense of hearing, have been frequently described, and are so simple, as to be readily understood, even by those who are not already acquainted with it. I may remark at this place, that auscultation, like every other method of investigation, requires practice for its perfec- tion. The young practitioner should therefore early commence the study of the sounds of re- spiration and of circulation, at first with the un- aided ear upon the healthy subject, and preferably on children, from five to twelve years of age, as in them all these sounds are distinct, and seldom modified by organic disease. Having made him- self familiar with these sounds, by frequent re- course to this practice, he may provide himself with the cylindrical stethoscope in general use, and with the one called Piorry's ; and, with their aid, continue his study of the sounds produced within the living body. 5. Having limited myself at this place to the 14 consideration of the Signs furnished by Sounds produced naturally within the Body, whether heard by the unassisted ear, or by the aid of the stethoscope, I proceed, first, to notice the sounds having their seat in the chest and throat. These sounds are chiefly produced by the natural movements of the parietes of this cavity, and ofthe organs contained within it, and consist of, 1st, those of respiration ; 2d, those of the voice ; and, 3d, those of the heart. These will be successively considered. 6. I. Auscultation of Respiration.—A. Of the healthy and simple respiratory sounds. The passage of air into, and out of, the lungs occasions a somewhat different sound in various parts of the chest, owing to the difference of size of the tubes through which the air passes. Hence the respiratory sound has one character in the small bronchi and air-cells, another in the large bronchi, and another in the trachea. These sounds have been respectively denominated, by Laennec, Andral, and Williams—the best writers on auscultation—vesicular, bronchial, and tracheal. The tracheal sound is heard in the an- terior and lateral parts of the neck, the upper portion ofthe sternum, and the sternal part ofthe subclavian regions. The bronchial respiration is heard in the middle portion of the sternum, and parts of the mammary regions contiguous to it, and in the axillary and interscapular regions. Vesicular respiration is perceptible over the re- maining parts of the cbest in health. These sounds are double ; the one being that of inspira- tion, the other of expiration. The former is much stronger than the latter, which is often scarcely to be heard by the unpractised ear, unless assisted by the stethoscope. 7. It is difficult to describe these sounds with accuracy. The vesicular sound is a dull and dif- fused murmur, or a feeble breathing, resembling that proceeding from the passage of the air through the nostrils in a healthy and quiet sleep. The bronchial respiration is more tubular and blowing, and is chiefly confined in health to the situation of the largest bronchi. The tracheal sound merely conveys the idea of air passing through a tube of larger calibre, and is more hollow and blowing. 8. The respiratory sounds vary in their inten- sity, not only in different persons, but also in the same person, at different epochs of life, and at va- rious times. The thickness of the parietes of the chest does not materially diminish their intensity; but the activity of the respiratory function affects them most materially ; this function presenting different grades of activity in different persons. Dr. Williams has remarked that they are more distinct after meals and moderate exercise. After excessive exertion they are diminished. Fear, and the depressing passions, have a similar effect. 9. The respiratory sounds are greatly modified by age. From birth to the period of puberty, they are much louder and shriller than in after life, and the whole respiratory function more active. This state of the respiration has been called puerile by Laennec; and occurs sometimes in adults, either generally or partially, from momentary excitation, or the presence of disease in a part or parts ofthe lungs. At puberty the respiration is less noisy; and in a few years becomes much deeper, and assumes the adult character. 158 AUSCULTATION—of Respiration. 10. The vesicular sound being the result ofthe perfect penetration of the air into the lungs, its equal and simple presence is a sign of the healthy performance of the function. But this sound may vary in degree. It may be feeble in all parts, owing to constitutional peculiarity, or only in particular parts, when we should suspect dis- ease ; but it is no proof of disease, unless it be associated with certain peculiarities of sound here- after to be noticed. The total absence of re- spiratory sound in a part indicates either the ex- clusion ofthe air from the part of the pulmonary tissue underneath, or effusion of fluids, or the in- troduction of air into the pleura. Here we must have recourse to percussion, in order to give pre- cision to the information. (See Percussion.) In some cases the natural vesicular sound is ab- sent, and a bronchial respiration is heard. In these we must infer that the vesicular murmur is suppressed by a condensation of the pulmonary structure, which, owing to this change, becomes so good a conductor of sound, that the bronchial respiration either becomes louder or is heard in unusual places. In other cases, a sound re- sembling the tracheal is heard in situations where vesicular respiration alone exists in health. This is caused by the passage of air into an ulcerated cavity or cavern communicating with the bronchi, and from this circumstance is called cavernous raspiration. 11. B. Of the morbid respiratory sounds.— The respiratory sounds are not only varied in de- gree, but also in kind, or they are mixed with different adventitious sounds. These variations of kind are produced, 1st, by changes in the parie- tes and vicinity of the tubes, and in their secre- tions; and, 2d, by morbid states exterior to the pulmonary tissue. Under the first of these are ranked the different varieties of sound produced by the presence of morbid secretions within the air-tubes, and the lesions producing these secre- tions. This class of morbid sounds have been variously denominated. By the French they have been named rale ; by some of our own writers the word rattle, and by Dr. Johnson the word wheeze, have been used. As we have no Eng- lish term which so fully expresses the idea, to which this morbid sound gives rise, as the word rhonchus, adopted by Dr. Williams, and some French pathologists, I shall use it here. 12. a. Moist crepitous rhonchus, the rale crepi- tant of Laennec ; the crepitant rhonchus of Dr. Williams, has its seat in the air-cells and minute bronchi. It resembles the sound from nibbing a lock of hair between the finger and thumb, when held close to the ear; or the crepit- ation of a piece of lung distended with air when compressed. It is generally uniform, and con- tinues to the end of inspiration, and seems to arise from diminished calibre of the minute bron- chi, owing to interstitial effusion, and the admixture of the respired air with the secreted or effused fluids in the air-cells and tubes. It is charac- teristic of incipient hepatisation of the lungs from pneumonia, and of its resolution ; of oedema and apoplexy of the organ ; sometimes of early phthisis, of pulmonary catarrh, and bronchitis. But it is only pathognomonic of the first stage of pneumonia ; and the more viscid the mucus that is secreted, the more distinct is the crepitant character of the rhonchus. In the other diseases in which it occurs, the crepitation is less perfect. 13. b. Dry crepitous rhonchus, the craquement of Laennec, resembles the sound produced by blowing into a dried bladder, and conveys the impression of air distending lungs that have been more or less dried, and whose cells have been unequally, but much dilated. It is only heard during inspiration, and occurs only in pulmonary emphysema. 14. c. Dry bronchial rhonchus.—This is either sibilous, rale sibilant sec; or sonorous, rale sonore sec, of Laennec The former is a low or loud, shrill or bass, and prolonged whistle, such as may be produced by air passing through a small circular aperture, and is owing to some contrac- tion or constriction of the bronchi. The latter is a dull, prolonged, snoring sound; sometimes very loud. It occasionally resembles the bass note of a violoncello, or bassoon, or the buzzing of an insect. It seems to be produced by a flattened contraction in a bronchus of considerable size, leaving very little aperture ; and arising from external pressure of the bronchial tube, from local thickening of its mucous lining, or from tenacious mucus within its canal. In a modifi- cation of the rhonchus, which Dr. Williams calls the dry mucous rhonchus, the sound re- sembles that of a click-wheel, and is produced by a portion of very adhesive mucus attached to the bronchial lining, which, yielding with a jerk- ing resistance to the air forcing its passage, there- by occasions a ticking sound. 15. d. The mucous rhonchus, the rale muqueux of Laennec, the humid rhonchus of Dr. Wil- liams, takes place in the bronchial tubes, and is produced by the passage of air through a thick- ish fluid, giving rise to a kind of bubbling within the air-tubes. It is most frequent in bronchitis and pulmonary catarrh, accompanied with mu- cous secretiona; in haemoptysis, in phthisis, in pneumonia, and in other diseases which are at- tended at any period with expectoration. This rhonchus is more gurgling, loud, irregular, and coarse, the larger the bronchi in which it is seat- ed, the bubbles being there larger and more un- equal. In the trachea, these characters are par- ticularly marked, and have been denominated tracheal from this circumstance, by M. Laen- nec In the smaller bronchi, on the other hand, this rhonchus is more equal, and its characters less remarkable, the bubbles being of much smaller size. The bubbles producing the mu- cous rhonchus must necessarily vary in their cha- racters with the varying fluidity of the secretion, and thus the rhonchi will differ accordingly. If the fluid be very thin, the bubbles will be nu- merous, readily formed, and rapidly break : but if it be viscid, they will be fewer in number, and will often pass along the tubes for some way be- fore they break, the sound being diffused, more regular, and rare. Also the continuance of the rhonchus will be an indication of the quantity of liquid present in the bronchi, as justly remarked by Dr. Williams. If this rhonchus accompany only the first part of inspiration and the end of expiration, the secretion must be scanty. Eut if the whole of the respiratory act be attended with this sound, then we may conclude that the quan- tity of fluid is considerable, and extends to the smaller bronchi. 16. e. The cavernous rhonchus, or gargouille- AUSCULTATION — of the Voice. 159 ment, the mucous rhonchus of men-bid excavations in the lungs, occurs when these cavities contain a fluid, and communicate with the bronchi. It gen- erally exists in the advanced stage of tubercular fihlhisis, in abscess, and partial gangrene of the ungs. This rhonchus is characterised by a strongly marked mucous gurgling or bubbling sound, con- fined to a small spot and determinate situation, and is particularly marked upon the patient taking a full inspiration, or after coughing. 17. It may be remarked that this class of mor- bid respiratory sounds—proceeding from changes in the parietes of the tubes, and in their secretions —will sometimes be more or less obscurely heard through effusions in the pleura, when not very large. I proceed to consider the second class of morbid sounds, or those arising from lesions ex- terior to the pulmonary tissue. 18. a. Metallic resonance, tintement metallique of Laknnec, is observed only when a quantity of air is accumulated in the pleural cavity, as in pneumothorax; or rarely in cases where very large tuberculous excavations are formed in the lungs. It is most commonly heard when both air and fluid are effused in the pleural cavity, and when there is a communication between this cavity and the bronchi. It is most distinctly heard upon coughing. Laennec has distinguished two vari- eties of this sound, namely, metallic tinkling, and amphoric buzzing or resonance. These sounds are occasioned by the impulse given to the air accumulated in the pleura, by the vibrations of air rushing through a fistulous opening in the pul- menary pleura, or striking against a condensed part of the pulmonary tissue, or of the pleura itself. 19. b. Rubbing sound, the sound of fnclion, the bruit de frottement ascendant et descendant of Laknnec This sound has been particularly in- vestigated by MM. Honore and Reynaud. It is an obscure, dull sound, perfectly distinct from the respiratory sounds, but synchronous with the motions of the parietes of the chest during inspir- ation and expiration, and resembling that produced by the rubbing of two soft and somewhat rough bodies on each other. It is loudest, or only heard, during inspiration. It is sometimes present in in- terlobular emphysema, but is more frequently and sensibly heard in pleuritis, with partial albu- minous exudation, and with little or no effusion of serum. 20. II. Auscultation of the Voice.—The voice, although produced chiefly in the larynx, has its sound partially propagated inwards by the air in the trachea and bronchi, occasioning, in the smaller ramifications of the latter, a vibratory sensation or fremitus, rather than a distinct sound to the ear through the stethoscope; but, in per- sons with a large chest and strong voice, a more distinct vocal resonance. When the instrument is applied in the situation of the larger bronchi, as between the scapula? and under the axilla?, the voice is heard much more distinctly, and the arti- culation may even be distinguished; but the sound does not seem to enter the cylinder, or to traverse its tube. If we place the stethoscope on the trachea or larynx, when the patient is speaking, we hear the whole ofthe words, loudly and arti- culately, and as if passing through the instrument to the ear. These sounds have been called, from their site, bronchophony and laryngophony; and arise from the vibrations propagated through the air contained in the trachea and bronchi, and which become weaker as they extend in the direc- tion ofthe air-cells. 21. The degree of vocal resonance in the chest differs in different persons. It is loudest and most extensive in those who are thin, and have a strong, sharp, treble voice; so that natural bron- chophony will extend further in young subjects and in females, particularly through the upper regions of the chest. In fat persons with a deep voice, the natural bronchophony is confined and obscure, especially during the deeper notes. In all the lower parts of the thorax, particularly during the deep tones of the voice, there is either no resonance, or merely a slight thrill or vibratory fremitus, which may likewise be felt upon apply- ing the hand to its parietes. Such are the healthv sounds of the voice in different parts ofthe chest; but in certain states of disease they are very mate- rially altered, and both the bronchial and laryn- geal sounds are developed in places where they never exist in health. Of the various manifesta- tions of these sounds in disease, I now proceed to take a brief notice. 22. a. Bronchophony is developed in disease by the same causes that render the bronchial respir- ation audible, viz. condensation of the substance of the lungs in the vicinity of large bronchial tubes, without diminishing their calibres, as in hepatization or induration, from the formation of tubercular matter. From this circumstance bronchophony is an important symptom in pneu- monia and phthisis. When the condensation is seated near the surface of the upper portions of the lung, and near a large bronchus, the sound may nearly approach laryngophony. The bron- chial respiration is generally present with bron- chophony, excepting when the hepatisation is ex- tensive. 23. b. JEgophony (from aTc, a'yoc, a goat, the sound resembling the cry of this animal,) is merely a modification of bronchophony; and oc- curs when, with the circumstances which produce it, there are superadded the existence of a thin layer of fluid between the surface of the lungs and the pleura costalis. The bleating sound of the voice to which the term aegophony has been applied is variously modified in different persons, according to the natural tone of their voice, and the different modifications of the dis- eases which produce it : thus it will resemble the squeaking of Punch ; or possess a shriller or sharper key, and sound more like the echo ofthe patient's voice than the voice itself. ^Egophony only exists in pleurisy or slight hydrothorax, when the quantity of fluid efiused is no more than forms a thin layer between the lungs and parietes of the chest. Laennec states that he has found this symptom present in almost every case of pleurisy; and considers it to be owing to the natural resonance ofthe voice in the bronchial tubes, rendered more distinct by the compression of the pulmonary texture, and modified by its transmission through a thin layer of fluid in a state of vibration. Dr. Williams ascribes it to " the successive undulations of the liquid, the result of an irregular transmission of the so- norous vibrations." yEgophony often co-exists with bronchophony, and the one passes into the other. 160 AUSCULTATION —of the Heart. 24. c. Pectorilogy.—The existence, in disease, of vocal resonance in any part of the chest, to the extent of laryngophony, has been termed pectorilogy by Laennec It may be either im- perfect or perfect. It is the result of a morbid cavity, formed in the substance of the lungs, and communicating with the bronchi; to which cavity the sound of the voice, or vibrations of the air in the tubes, is propagated. When the stethoscope is applied to a part of the chest, under which one of these cavities is situated, the words which the patient utters seem to proceed from that spot; and hence the term pectorilogy. " The distinction between perfect and imperfect pectorilogy is, as in the case of natural resonance, whether the voice seems to traverse the tube, or remain at the end; and the physical difference producing the two modifications consists in the size and situa- tion of the cavity. The most perfect pectorilogy is produced in cavities of moderate size, which are situated near the surface of the lung, and freely communicate with a large bronchial tube. If the cavity be deep-seated, or if its communication with the bronchi be imperfect, the resonance of the voice will not amount to perfect pectorilogy. True pectorilogy produced by a cavity, is gener- ally abruptly circumscribed, so that its limits can be distinctly traced." — (Williams's Rational Exposition, fyc. p. 43.). Andral appears to be correct in considering perfect pectorilogy as not common, and that the imperfect state of this sound, or bronchophony, is very frequently mistaken for it. When present in any part of the chest where there is naturally no bronchial resonance, it may be considered as a certain indication of the exist- ence of a morbid cavity, generally tubercular; and when heard in situations of natural bronchial re- sonance, although more doubtful, yet if it be per- fect, distinctly circumscribed, and heard on one side only, the same conclusion must be come to. It may be further added, that an empty state of the cavity, its rounded and regular shape, and natural sharpness of the voice, particularly in women and children, tend to render pectorilogy perfect. 25. III. Auscultation of the Heart.—A. In its healthy state. I have always viewed Laen- nec's explanation ofthe sounds proceeding from the heart's contractions as the most defective part of the exposition of his system; and a similar opinion seems to have been entertained by Mr. Turner, Dr. Williams, and several others. The observations of Mr. Turner, and of Drs. Stokes and Corrigan, first shook the stability ofthe views of Laennec on this subject; and the recently published researches of Dr. Hope have almost altogether overthrown them. As I consider the exposition of the actions and sounds of the heart, given in Dr. Hope's work, to be the most accurate, I shall follow it on this occasion. 26. 1st. Of the contractions of the heart in the order of their occurrence, 8rc.—The first motion of the heart following the interval of repose, is the systole of the auricle. It is a very brief and slight contractile movement, most considerable in the auricular appendix, and propagated toward the ventricle, in the systole of which it termin- ates, by a nearly continuous action. The sys- tole of the ventricle commences suddenly, and diminishes considerably the volume of the or°-an. "Synchronous with the systole are the first sound, the impulse of the apex against the ribs, and the pulse ofthe vessels near the heart;" the pulse at the radial arteries following at a barely appre- ciable interval. The diastole of the ventricles follows their systole; and these compartments return, by an instantaneous expansive movement, to the same state as during the previous interval of repose. The diastole is accompanied with the second sound, with a rush of blood from the au- ricle, by a contractile motion of this cavity most observable at its sinus, and by a retrocession of the apex of the heart from the ribs. " Next succeeds the interval of repose, during which the ventricles remain at rest in a state of fulness, though not of distension, through the whole period intervening between the second and the first sounds ; but the auricle remains at rest during the first portion only of that period, the remainder being occupied by its next contraction, with which recommences the series of actions described." •— (Hope on the Dis. of the Heart, Sfc. p. 40.) 27. The rhythm of the heart, or the duration of the several parts of this series of actions, con- stituting what may be called a beat, is the same as described by Laennec : — 1st, The ventricular systole occupies half the time of a whole beat; 2d, The ventricular diastole occupies a fourth, or at most a third; 3d, The interval of ventricular repose occupies a fourth, or rather less, during the latter half of which the auricular systole takes place. 28. 2d. Causes and mechanism ofthe motion.— The auricles, being always in a state of fulness, arrive, during the first half of the period of repose of the ventricles, at a state of distension, on which they react and propel a small additional quantity of blood into the full but not yet dis- tended ventricles, in order to bring them to this state, and to cause them to react, and thus expel a greater or less portion of their contents. Dur- ing the expulsion ofthe contents ofthe ventricles, Dr. Hope considers that the apex of the heart is tilted upwards and forwards, and occasions the impulse against the ribs, in consequence of the retraction of the ventricles upon their base, and on the auricles, which, being hi a stt.te of extreme distension, serve as a fulcrum beneath them. The diastole of the ventricles appears to be oc- casioned, 1st, by the relaxation of the principal part of their muscular structure, assisted by an elastic property; 2d, by the distension of the auricles, which has arrived at its height, and brings into action certain layers of ventricular fibres having a powerful influence in distending these cavities; 3d, by the width of the auriculo- ventricular opening, which allows the blood to rush instantaneously, and with facility, from the auricles into the ventricles. The blood expelled from the former cavities into the latter being in- stantly replaced from the venae cavae, distension of the auricles immediately recurs, and the same series of actions is continued. 29. 3d. Causes of the sounds.—There can be no doubt that the sounds of the heart's actions are not produced by the mere contraction of its muscular structure. To what other cause can we impute them ? I conceive that they can only be referred to the action of the parietes of the cavities on the fluid circulating through them, and to the motions of this fluid. According to this view, which has been very diligently investi- AUSCULTATION — of the Heart's Sounds. 161 gated by Dr. Hope, the systole of the ventricle is the cause of the first sound, by the impulse it communicates to the blood, and the diastole of the ventricle is the cause of the second sound; owing, in the opinion of this writer, to the rush of blood from the auricles, produced as already explained (§ 26.), and the succussion of the stream against the walls of the ventricle, when abruptly arrested by the completion of the dias- tole. 30. I consider that it is clearly made out, 1st, That the impulse, the pulse, and the first sound, coincide; 2d, That the ventricle is concerned in the production of the second sound, although the exact manner, in which the motions of the ven- tricle and this sound are connected, has not yet been conclusively ascertained; and, 3d, That the actions of the auricles are insufficient to produce either impulse or sound, and that neither the one nor the other result from them. With respect to the production of the second sound, I think that the opinions of Mr. Turner, Dr. Corrigan, and Dr. Williams, are untenable, and therefore may not be stated; and that the explanation of Dr. Hope requires further confirmation. From the third of these facts I believe that it may be legitimately inferred, that the physical signs of disease of the auricles are very imperfect, and therefore uncertain. 31. B. Auscultation ofthe morbid sounds and impulse of the heart.—1st, Of the impulse of the heart. Although, strictly speaking, the sounds of this organ are the only objects of auscultation, yet, as the impulse or shock it communicates to a part of the chest is usually made a matter of enquiry, although by a different sense, during the time that auscultation is being performed, I will briefly notice it at this place. The impulse necessarily varies, even in health, in different persons, with the state of the heart's action, and the habit of body. It is also greatly modified by mental emotions, and by various affections of the digestive and other organs. It is always synchronous with the first sound of the heart; but, in rare cases, a slight second impulse also accompanies the second sound; but this is felt deeper in the chest; is more of an obscure tremor, much slight- er in degree than the chief impulse or shock, and is only met with in cases of hypertrophy with dilatation. 32. When the impulse is prolonged, strong, and characterised by an extensive heaving move- ment, thickening of the walls of the ventricles may be inferred. It should, however, be recol- lected, that whatever excites the feelings of the mind, or hurries the circulation, will occasion a strong impulse; but, in such cases, the actions of the heart are also unusually frequent. Morbid im- pulse of the heart is present in the states of both mental and corporeal repose; and is often uncon- nected with increased frequency, as in hypertro- phy of the ventricles. 33. The impulse may be diminished, even in health, as by the depressing passions. It is often constitutionally so small in amount as scarcely to be felt. It is also lowered by diseases of remote organs, as diarrhoea, &c, and by abstinence and blood-letting, and whatever depresses the energies ofthe system. It is generally weak in congestion ofthe cavities ofthe heart, in cases of thinning of their parietes, in the asthmatic paroxysm, in con- 14* gestion ofthe lungs, in some cases of pneumonia, and in the advanced states of various diseases; and it may even, although very rarely, accom- pany certain states of hypertrophy of the heart, particularly during the operation of debilitating causes. 34. In health, the impulse is usually limited to the immediate region of the heart, and chiefly in the situation of the cartilages of the fourth, fifth, sixth, and seventh ribs. Its sphere is extended by increased action ofthe organ, whether the re- sult of mental or corporeal excitement or of dis- ease; by hypertrophy, and by certain organic changes of organs in the immediate vicinity. When the muscular parietes of the heart are in- creased without any dilatation of the cavities, the sphere of impulse is not extended far beyond its healthy site; but when dilatation is combined with hypertrophy, the impulse may often be felt on the right side of the sternum, below the clavi- cles, and even on the back. Diseases of adjoining organs, as hepatisation of parts ofthe lungs in the vicinity, effusions of fluids in the pleural or peri- cardic cavities, tumours in the mediastinum, close adhesions of the lungs to the costal pleura, adhe- sion ofthe pericardium to the heart, displacement ofthe heart, and even an enlarged liver or spleen —when rising into the thoracic cavity, and press- ing the diaphragm upon the pericardium — will extend, often to a considerable distance, the im- pulse of the heart, owing to the increased density of parts which receive the shock. Much discus- sion has arisen as to the manner in which the heart's shock is produced. Further than that it is occasioned by the muscular actions of the organ, I believe that the phenomenon has not been satis- fiictorily explained, at least in such a way as ac- cords with the various conditions it presents in health and disease. The explanation given by Dr. Hope has been already stated (§28.). 35. 2d. Of the changes produced in the natu- ral sounds of the heart by disease.—The sounds of the heart vary in different persons, even in health. In some they are louu and distinct; in others, the reverse: they may also be dull or clear, in respect of their key. They are generally dis- tinctly heard by the unaided ear; but more accu- rately with the stethoscope. The impulse and sound are never both present in health, to a great degree, as they depend upon opposite conditions of the ventricles; the impulse being great in pro- portion to the thickness of the parietes of the ventricles, the sound to their thinness. The sounds of the left side of the heart are strongest at the junction of the cartilages of the left fourth, fifth, sixth, and seventh ribs, with the sternum: those of the right side, under the sternum and towards its right edge. The sphere ofthe heart's sounds is, in a very few persons, nearly limited to the sphere of impulse; but it is generally far more extended, even in health. It should not be overlooked, that the sphere of sound is much larger in children and young persons, in females, in the lean, and in those who have narrow or small chests; whereas, in persons whose thoracic cavity is large, and its parietes thick, muscular, or fat, the sound is heard much less exten- sively. 36. The sphere and loudness of the heart's sounds are increased by the same moral, physi- cal, and morbid causes, which have been stated 162 AUSCULTATION —of the Heart's Sounds. to augment its impulse (§ 31.). Therefore, when frequency of pulse accompanies increase of sound, no actual disease may exist; but when a natural or slow state ofthe pulse is attended with an aug- mented range of sound, disease may be much more certainly anticipated. The circumstance of the sphere of sound being extended by the organic stead of those natural motions which contribute to the healthy sounds of the organ. Hence, what- ever produces the morbid change of the motions ofthe fluid, will occasion the adventitious sounds; and we have reason to infer that such change is produced either by a permanent alteration of the apertures and canals through which the blood is lesions already noticed as conveying the impulse propelled, or by a spasmodic or nervous state of of the heart (§34.), and by tuberculous excava- the same parts, tions in the lungs, should not be overlooked. In taking account of the heart's sounds, we should also be aware that the sounds of respiration will occasionally mask them, as the heaving of the chest during inspiration will, in a slight degree, mask some ofthe shocks of the heart. General- ly, the sounds of the heart are strongest in the left anterior part of the chest; and progressively weaker in the sternal, in the right anterior, the left posterior, and in the right posterior parts suc- cessively. If this succession be deviated from, or in any way altered, disease exists; and the de- gree, state, and order of deviation, become signs of some importance. It has been remarked by Laennec, that, when the sounds are heard be- yond the healthy sphere, in persons with the chest well formed, and presenting none of the causes alluded to as giving rise to such extensive range, these persons will be found to be subject to pal- pitations, to shortness of breath upon the slightest exertion, to attacks of asthma, and to congestions ofthe internal viscera. 37. 3d. Ofthe adventitious sounds ofthe heart. — The sounds of the heart may not only be changed in degree, in extent of sphere, and in the succession of intensity, but entirely new sounds may be superadded. The most common of these are the bellows sound (bruit de soufflet), the saw sound (bruit de scie), and the rasp sound (bruit de rape). These may either take the place of the natural sounds, or may be conjoined or super- added to them; and they may be present with either the first or second sound, or with both. The bellows sordid resembles the puffing of a pair of bellows, and conveys the idea of smooth- ness. The saw and rasp sounds are so named from their similarity to the sounds occasioned by the sawing or rasping of wood, and convey the idea of roughness. But the bellows sound may insensibly pass into the others; and they all vary greatly in loudness. They may occupy the place of the first or the second of the heart's natural sounds, but more frequently that of the first than of the second. The saw and rasp sounds are generally louder, and present a wider range of intensity, than the bellows sound, which is more closely limited to the part which occasions it. They may all be heard in arteries at a distance from the heart, more particularly the bellows sound; and often when they do not exist in the region of the heart. When the saw-sound pro- ceeds from the heart, it may generally be traced along the arch of the aorta to the subclavian and carotid arteries. 38. The causes of these sounds, and the exact site of the changes which produce them, are ob- viously the important considerations attached to them. They have been accounted for in various ways, even by their eminent discoverer; and, in general terms, they may be said to arise from unnatural or morbid motions induced in the cur- rent of blood circulating through the heart, in- 39. The simple bellows sound is more com- mon, and arises from slighter changes than the saw or rasp sounds, and is less to be depended upon in diagnosis. Pressure on an artery will occasion it; and when present in the heart, it will sometimes be removed by blood-letting. When even existing permanently, although it is a very strong indication of organic change in the heart, it cannot be implicitly relied on; but when only occasionally present, although such change may be its cause, yet it deserves no reliance. The saw or rasp sounds are much less frequent than the other; are much more constantly found in connection with contracted orifices of the heart; and are very frequently indications of an increased degree of the same cause that produces the bel- lows sound. It may, however, be generally in- ferred, 1st. That these sounds arise from some change in the orifices of the heart's cavities, pro- duced by nervous or temporary causes, or by al- teration of structure; more frequently the latter. 2d, That these sounds, therefore, although they indicate the existence of organic disease, are not conclusive evidence of it, as they sometimes arise from other causes. 3d, That in proportion as these sounds possess more of the rasping charac- ter, the greater is the probability of organic change. 4th, If the sounds disappear after deple- tions, upon repose, or without sufficient reason, their dependence upon functional disturbance may be inferred, although not implicitly relied on; their continued absence, however, strengthening the conclusion. 5th, The continuance of these sounds, notwithstanding the means now mention- ed, or their diminution merely, is nearly conclu- sive of organic change. 6th, Intensity of the sounds is no indication of the degree of valvular disease, or extent of the contraction of an orifice; as they may be weak, when these organic chan- ges are extreme. A moderate contraction and size of current seem to be requisite to their full production. The relation of these sounds to the particular changes which occasion them is con- sidered in connection with these changes. (See H r. a r t—Diseases of.) 40. The rasp and saw sounds are often accom- panied with a phenomenon resembling a species of impulse, and which can be estimated by the sense of touch only. This is the thrill or purring tremor, termed " bruissement " by Corvisart, and " frimissement cataire " by Laennec, which is felt when the fingers are placed upon the heart, or on an artery. When existing in the heart, the feeling excited upon applying the hand to the region of this organ, is analogous to the sensation occasioned by the saw or rasp sounds. The fact is, that the same pathological condition gives rise merely to modified sensations as perceived by the medium of different organs, the object exciting the sensations being one and " same; the only difference beino-, that a the stronger current is required to produce the pur- BARBIERS —Sym ring tremor, than is necessary to the production of the >sounds. It is owing to this circumstance that it is strongest in hypertrophy of the ventri- cle, or when the circulation is hurried. A firm pressure of the hand on the region of the heart is necessary to feel it well ; and a moderate pres- sure to feel it in the arteries. 41. The last adventitious sound that I have to notice is that which Laennec has termed the " cri du cut'r," and which resembles the creaking of the leather of a new saddle. It seems to be chiefly observed in cases of pericarditis, when the opposing surfaces of the pericardium lose their lubricity, and when they are rendered rough by the exudation of coagulable albumen, or are in an unusual state of dryness ; and to be occasion- ed either by their friction whilst in this state, or by the motions produced in that part of the pericar- dium reflected over the heart during the systoles and diastoles of the ventricles. It is unnecessary to add any thing at this place, to what has been stated respecting the ausculta- tory signs in diseases of arteries, and particularly of the aorta. The employment of auscultation ofthe abdomen, in order to ascertain the existence of pregnaney, is comprised in the article Preg- nancy. Bidliog. and Refer.—Double, Semeiologie Generale, L ii. p. 31. Paris, 1817.—Laennec, De 1'Auscultation Medi- ate, t. ii. Ire edit. Paris, 1819. ; 3d edit. Paris, 1830.—Bertin et Bouillaud, Sur les Maladies du Coeur, &.c. Paris, 1824. — Andral, Clinique Mtdicale, t. ii. et iii. Paris, 1824, passim.—Turner, in Trans, of Med. and Chirurg. Soc. of rZdin. vol. ii.—P. Colin, Sur 1'Exploration de la Poitrine, &c. 2d edit. Paris, 1830.—C.J.B. Williams, Rational Expos, of the Physical .Signs of Diseases of the Lungs and Pleura, &c. Svo. Lond. 1828.—Reynaud, Journ. Hebdomad. No. 65. t. v. p. 576.—Stokes, in Transactions of Irish College of Physicians, vol. v. p. 305.—Townsend, Ibid. p. 137.—Cor- rigan, in Duh, Med. Trans. New Series, vol. i. pp. 1.151.— Ferguson, in Ibid. p. 11.— Hope, in Lond. Med. Gaz. 1829, passim ; and Diseases of the Heart and Great Vessels, 8vo. 1831, p. 28. et seq. BARBIERS. Classif. 4. Class, Nervous Diseases ; 3. Or- der, Affecting the Muscles (Good). I. Class, IV". Order (Author). 1. Defin. Tremor, withpricking, formicating pain; numbness ofthe extremities, principally of the lower, followed by contractions and paralysis of the limbs, inarticulation or hoarseness of voice, emaciation, and sinking of all the vital powers. 2. This disease has been described by various authors since the appearance of the work of Bontius. But we have had no satisfactory ac- count of it until Mr. Marshall furnished it in his interesting work on the diseases of Ceylon, and distinguished it from Beriberi, with which it had been confounded by Bontius, and recently bv Dr. Good. Dr. J. Clark had, however, no- ticed it briefly as a distinct disease, many years previously ; and the definitions of it given by Sauvages, Linnaeus, Sagar, and Aikin, seem to indicate that they were not altogether unac- quainted with its nature. I shall here follow the accounts of it by Dr. Clark and Mr. Mar- shall, as they seem to be the most precise, and to have been the result of much experience. 3. Symptoms.—The disease generally com- mences with a formicative pricking pain in the muscles of the lower extremities, with numbness, tremors, and an imperfect command of the powers of locomotion. Both lower limbs are always equally affected. In some cases the forearms oms— Treatment. \q$ and hands, and the powers of articulation, are subsequently similarly seized. As the disease ad- vances, the patient is unable to walk steadily. Standing or walking aggravates the uneasiness of the limbs, and either is impossible without sup- port. The superior extremities become incapa- ble of performing their usual offices ; and want of sound sleep, great sluggisliness, and inactivity, are complained of. The limbs afterwards are de- prived of all feeling, and lose their natural tem- perature ; the extensor muscles become quite paralytic, and the limbs contracted. Loss of ap- petite, indigestion, emaciation, &c. soon follow ; and the pulse gradually sinks to a frequent, thready, or fluttering state ; all the vital powers become depressed, and death supervenes. As respects its duration, it may be protracted for many months, and it may present various grades of severity. Its forms are frequently more mild, the above description applying to the severer cases. The diagnosis of barbiers is described in the article Beriberi, with which disease it has often been confounded. 4. Mr. Marshall observed many cases of this disease, in 1812, amongst the Caffres compos- ing the 4th Ceylon Regiment. He never noticed it amongst the indigenous inhabitants of this isl- and ; and, from every information he could col- lect, it was only known amongst Africans who had arrived in the island ; and he believed that late comers were more disposed to it than accli- mated residenters. Mr. Marshall also met with it in Europeans in Ceylon : and he has ob- served an analogous affection in horses and dogs ; from which, however, he never knew them to recover. 5. Dr. Lind states that barbiers is a species of palsy frequent in India, affecting chiefly the lower classes of Europeans, who frequently sleep, when intoxicated, in the open air, exposed to the land winds ; and that its attack is sudden, depriving the limbs of motion, &c. It appears also to pre- vail in Java. Dr. Bo stock has described a case which seems to be nearly allied to this affection : and I have, for several years, been occasionally consulted by a patient, whose complaints are very nearly the same as those now described ; and who had been previously seen by several medical men, and by some since he was under my care. 6. The remote Causes of this affection are cold and moisture applied to the body ; intox- ication, irregularities, and excessess consequent upon inebriety ; violent exercise in the sun ; lying down in the open air during the heat of the day; exposure to the cold chilling dews of the night, or sleeping when thus exposed ; suddenly ob- structed perspiration, by currents of air ; long fasting, and whatever exhausts the energies of life. The translator of Bontius's work states that barbiers is frequent on the Malabar coast, where it attacks those who unwarily sleep ex- posed to the land winds, particularly in the months of January, February, and March ; and that it is seldom cured till after the shifting of the monsoon, unless the patient changes the climate. 7. Treatment.—This affection appears to originate in depressing and debilitating causes ; to be characterised by a gradual and chronic sinking of the nervous energy ; and therefore to require a tonic, restorative, and stimulating treatment. 164 BERIBERI—Symptoms— Causes. Frictions, with stimulating liniments along the course of the spine, and on the limbs ; attention to the due performance of the secreting and ex- creting functions ; tonics, combined with warm cardiacs, gentle aperients, and antispasmodics ; vesication ; stinging with nettles ; electricity ; the internal use of the extract of nux vomica, or of strychnine ; the application of external warmth, and the use of warm clothing ; a nourishing and digestible diet ; regular habits, and change to a healthy ah- or locality ; are the chief means of cure. Dr. John Clark states, that the few Eu- ropeans whom he saw ill with this disease were cured by a change of climate, and a sea voyage. In other respects, the treatment is the same as that recommended in the article Palsy, particu- larly palsy from lead. (See Colic—from Lead, and Palsy.) Bibliog. and Refer.—Bowriiw, DeMedicinalndorum, c- '•—Lind, On the Diseases incidental to Europeans in Hot Climates, kc 4th ed. Lond. 1788.—John Clark, On the Dis- eases which prevail in long Voyages to Hot Countries, and on those in the East Indies, kc vol. i. p. 99. Lond. 1792, 8vo. —Marshall, Notes on the Medical Topographv of Ceylon, &.C. 8vo. J222, p. 161.— Bostock, Trans, of the Med! and Chirurg. Society, vol. ix. art. i. p. 1.—Good, Study of Med- icine, vol. iv. p. 493. BERIBERI. Syn. Beriberia, Synclonus Beri- b-eria, Good. Hydrops Asthmaticus, Rogers. Classif. 4. Class, Diseases of the Ner- vous Function ; 3. Order, Affecting the Muscles (Good). I. Class, V. Order (Author). 1. Defin. Oppressed breathing ; paralytic weakness, numbness, and stiffness of the lower extremities ; general edema, with a swollen and bloated countenance. 2. Symptoms.—The attack is in some cases gradual ; in others sudden and severe. When it is the former, which is more commonly the case, the patient complains for several days of weak- ness, and inability or unwillingness to exert him- self. To these feelings, pain, numbness, and stiff- ness of the lower extremities, accompanied with oedema ; muscular weakness, and dyspnoea, par- ticularly upon motion ; a feeling of numbness, fulness, oppression, and weight at the scrobiculus cordis ; extension of the oedema over the body, and leucophlegmatic tumescence of the counte- nance, supervene. As the disease advances, the dyspnoea increases, and the face is more swollen and bloated. The lips, which were at first pale, become bluish and livid ; and the lower extremi- ties more numb and feeble, or even paralytic. The stomach is often irritable, especially in the advanced stages of the disease, when it often re- jects all ingesta ; the bowels constipated ; the urine scanty, high-coloured, and sometimes almost suppressed : the pulse is at first either more or less quick, small, and hard, or but little affected ; subsequently irregular or intermittent ; and the dyspnoea at last becomes distressing and attended with great anxiety, and sometimes with a peculiar fluttering about the heart, and sinking or leipo- thymia, succeeded by palpitations. In the more advanced stages of the disease the patient can- not lie down ; his sleep is uneasy, interrupted, and always unsound ; and the recumbent posture induces violent palpitations, sense of suffocation and anxiety. The oppression at the prtecordia and weight at the scrobiculus cordis increase and are attended with spasms of the muscles of the thorax and abdomen ; the countenance becomes livid, and the extremities cold ; vomit- ing is either frequent or nearly incessant ; the pulse sinks, and the patient dies nearly in a state of suffocation. 3. In this, the most common form of the dis- ease, it usually runs its course in about three weeks or a month ; but sometunes, in slighter cases, the patient experiences several relapses, and is at last carried off unexpectedly, when the anasarcous symptoms have nearly disappeared, and he has been judged convalescent. In some of the mild- er attacks, several of the above symptoms are extremely slight, and the disease is altogether of much longer duration, or consists apparently of several distinct seizures. Such seem to have been the form of the majority of cases which Mr. Marshall has given in his work. In the most sudden and severe attacks, however, the pain, numbness, stiffness, and cedema of the lower ex- tremities ; the dyspnoea and anxiety, and all the more urgent symptoms, are either present from nearly the commencement, or they rapidly su- pervene to each other, and the patient dies in a few hours, or in a day or two. Such cases ap- pear to be not so frequent as those which are more mild. 4. Remote Causes.—This disease is nearly peculiar to India, and is most prevalent hi va- rious parts of Ceylon, on the Malabar coast, and in that tract of country which extends from Mad- ras to Ganjam ; being, according to Mr. Hamil- ton, confined to these parts, and extending no further inland than forty miles. It is most preva- lent during the decline of one monsoon and the setting in of another, when the air is damp, cold, and loaded with vapours, and the vicissitudes of temperature greatest. Captain Percival, in his " History of Ceylon," ascribes it to low diet and bad water, and partly to the dampness of the cli- mate. Mr. Ridley, however, states that the worst cases he had of it at Trincomalee, where it was remarkably prevalent, occurred during the change from wet to dry weather, when a strong and hot land wind prevailed ; and that its sever- est prevalence at Fulitoopane was during dry weather. In the Indian peninsula it seldom ex- tends further inland than sixty miles ; but in Cey- lon, particularly at Kandy, it has prevailed under very different circumstances, as respects season, states of atmosphere, and topography. It seems to have been much more prevalent in particular districts, where it may be said to be endemic, in one year than in another ; and to have assumed, at distant periods, a nearly epidemic form. Dr. Christie states, that a residence of several montlis in the district where it prevails is necessa- ry to its production ; and Dr. Rogers never ob- served it in any person who had not resided six months or upwards in Ceylon. Dr. Hunter has met with it also in Indian seamen, particularly Lascars, after exposure to a moist and variable at- mosphere and privations of food. 5. Opinions respecting both the remote and proximate causes of the disease differ very mate- rially among those who have had opportunities of observing it. Mr. Dick found it most prevalent amongst soldiers who had taken much mercury for venereal complaints, and who were addicted to spirituous liquors. He never met with it in the officers. Mr. Ridley, on the other hand, states, BERIBERI — Diagnosis — Treatment. 165 that, in 1804, " both officers and privates fell vic- tims to it." Drs. Christie and Rogers view it as a consequence of deficient and poor diet, im- pure and moist air, and of prolonged exposure to marsh exhalations; and consequently as a disease of debility,'—an opinion which is in accordance with that of Mr. Dick and Mr. Ridley. Mr. Colquhoun found it to prevail notwithstanding prophylactic measures founded on these views; and Mr. Marshall did not observe it to occur amongst the troops in Ceylon, when exposed to the causes to which Drs. Christie and Rogers impute it; and from that circumstance, as well as from the effects of medicines, thinks it a disease of increased vascular action; in which opinion Mr. Hamilton agrees with him. 6. Appearances on dissection. — There is al- ways a leucophlegmatic appearance of the surface, with oedematous effusion to a greater or less ex- tent in the sub-cutaneous cellular tissue, and pale- ness of the muscles; sometimes with a watery obesity and deposition of fat in the abdominal re- gions. Occasionally there is fluid effused between the membranes ofthe brain, and in the ventricles; with vascularity ofthe encephalon, and slight ap- pearances of congestion in the spinal canal. Se- rum is always found effused in the pleural cavity, and very frequently in the pericardium. The lungs are gorged with dark blood, and their struc- ture more or less cedematous. Old cellular adhe- sions are sometimes found connecting the oppo- site surfaces of the pleurae. The heart is general- ly soft, enlarged, and flabby. The peritoneal sac often contains much serum; and the liver is al- ways found engorged with dark blood, is unusual- ly large, and of a very deep colour. The spleen is generally very soft, large, and is, as well as the large veins, loaded with black blood. Sometimes inflammatory appearances are observed in the diaphragm and serous surfaces; but these are on- ly occasionally and very loosely noticed. (Chris- tie, Rogers, Marshall, and Hamilton.) 7. Nature of the disease. — It is evident that the nature of this disease can be inferred only from what is known of its exciting causes, and the appearances presented after death. Of the for- mer we have very imperfect, loose, and conflict- ing information : of the latter no precise and mi- nute account. It is difficult to explain the early occurrence of the paralytic symptoms. The spin- al cord, brain, and nerves supplying the lower extremities, have not been sufficiently investigat- ed to warrant a positive opinion as to the particu- lar state of these parts, to which these symptoms may be referred. They may, however, depend upon congestion of the veins and effusion of fluid within the spinal canal. The dyspncea is evi- dently owing to congestion of the lungs, and cedema of their structure; and the feeble and ir- regular action of the heart may be imputed to the weakened vital energy and structure of the organ, in connection with effusion of serum in some cases into the pericardium. The effusion of fluid within the serous cavities may, like other effu- sions, depend upon very different states of the vessels and serous membranes. By Mr. Mar- shall and Mr. Hamilton it has been viewed as the result of inflammatory action. But where there is merely an effusion of a limpid serum, without either albuminous flocculi or adhesions, there evidently can exist no actual inflammation. Viewing the antecedent symptoms in relation to the post mortem appearances, as far as both have been described, it may be inferred that the dis- ease is more dependent upon active congestion of the lungs, liver, and spinal cord, than upon any of the usual states of inflammatory action; and that this congestion is intimately connected with weakened power of the nervous and circu- lating systems; manifested chiefly in the heart and extreme capillaries of the cellular and serous structures, with imperfect function of the liver and lungs, and with effusion of serum to a great- er or less extent into the shut cavities and cellu- lar structures of the body; giving rise to a nearly universal acute dropsy, and complicated with more or less of paralysis of the lower extremi- ties. 8. Diagnosis.—The paralytie symptoms, constant dyspncea, universal cedema, and leuco- phlegmatic intumescence of the countenance, characterise this disease sufficiently, and distin- guish it from the cachexia Africana, with which it has been considered as being allied (see Ca- chexy — African.). It has been, however, more commonly confounded with barbiers; but the history of both diseases show a very obvious difference between them. Barbiers is a very chronic disease, in which the paralytic symptoms, tremors, spasms, and contractions of the limbs, and emaciation, are the most remarkable symp- toms; whilst the present malady is extremely acute, often of very short duration, and is charac- terised by general cedema, dyspnoea, the sudden- ness of its fatal termination, and the frequency of its occurrence. The former is, in fact, a species of paralysis; whilst the latter is a form of acute dropsy, very generally diffused throughout the body, and complicated with slight paralytic symp- toms. 9. Treatment.—According to this view of the disease, the discordant accounts given of the success of treatment will be readily accounted for. When the disease prevailed very generally in the carnatic, during 1782 and 1783, Mr. Dick, who appears to have treated a very great number of cases, found most advantage, during the former of these two seasons, from a pill, containing a quarter of a grain of extract of elaterium com- bined with extract of gentian, given every hour, until copious watery evacuations were procured; and this plan was repeated every third or fourth day, till a cure was accomplished. In the fol- lowing season this treatment was not so success- ful. He found most advantage from large doses of spirit of nitre, antimonial wine, frictions with warm camphorated oil, aperient medicines, and wine to support the strength. Bleeding and mer- cury were tried without benefit. Dr. Christie recommended mercury, to excite ptyalism, com- bined with squills; cordial liquors, consisting chiefly of gin punch; stimulating pediluvia, with warm liniments; and when the patient was con- valescent, tonics, composed of bark, wine, and porter. In more urgent cases, he prescribed blisters to the chest, and brandy, aether, and laud- anum, to relieve the vomiting, dyspnoea, and spasms. He found digitalis of no service. Mr. Hamilton's first cases terminated fatally under the plan recommended by Dr. Christie; and Mr. Colquhoun trusted to mercury, but found 1 that many of the patients who died in hospital of 166 BLOOD — Healthy Relations of. the disease were in a state of salivation from this medicine. 10. This want of success led later writers on the disease to have recourse to other means. Dr. Hunter had tried blood-letting hi one case, without any apparent effect either one way or another. Dr. Rogers stated, in his thesis on the disease, that blood-letting hastened the fatal termination: but, according to Mr. Hamilton, he has since prescribed it successfully. Mr. Mar- shall appears to have been the first to employ blood-letting in a decided and successful manner in the treatment of beriberi; and the same prac- tice was adopted by Dr. Paterson (Marshall, on Ceylon, Src. p. 161.), and by Mr. Hamilton. The bleeding was large, and repeated; and fol- lowed with the internal and external use of mer- cury, laudanum, and the vapour bath. To these were added purgatives of calomel and camboge. 11. The practice of Mr. Ridley, who expe- rienced, himself, two very severe attacks; and who, excepting only Mr. Dick, has had the most extensive experience as respects this disease, having treated almost a hundred cases in one year (1814); recommends a nearly similar treat- ment to that advised by Mr. Dick. In the early stage, he directs purgatives of calomel, jalap, and crystals of tartar; the lower extremities to be well bathed, afterwards rubbed with camphor and oil of turpentine, or with the mercurial lini- ment, and then rolled in flannel bandages. He subsequently prescribes a pill, composed of one or two grains of calomel and two or three of powdered squills, every third hour; and a solu- tion of crystals of tartar, as common drink, or made into punch with geneva or arrack. In the more advanced stages, he advises blisters to the back of the neck, or to the seat of pain and tight- ness; the warm-bath; frequent fomentations of the legs and abdomen, followed by frictions with mercurial ointment, camphor, and oil of turpen- tine; and clysters with asther, and purgatives. When the dyspncea, spasms, and vomiting are urgent, he states, that he has given large doses of opium, aether, and brandy, with stimulating diuretics. When they could be retained on the stomach, small and repeated doses of camboge were also exhibited. 12. From the above statements, as well as from the varying character of the disease in Euro- peans and natives, in different seasons, as observ- ed by Mr. Dick, and in various localities; — judg- ing also from the nature and combination of the remote causes, and from the post mortem appear- ances;— I should infer, that a depletory treat- ment may sometimes be required amongst Euro- peans; and that the means of cure should be modified according to the characters ofthe mala- dy and the state of the vital energies; that, on some occasions, general blood-letting — in others, cupping in the course of the spine; blisters; free purging with calomel, camboge, jalap, elaterium, &c.; antispasmodics, consisting of opium, aethers, brandy in some cases, camphor, &c; diuretics, such as squills, cream of tartar, juniper, tere- binthinate preparations, &c; the vapour bath, or fomentations, followed by frictions with stimu- lating liniments, mercurial or camphorated lini- ments, with oil of turpentine, camphorated oils, along the spine and lower extremities ; expect- orants, consisting of ammoniacum, ipecacuanha, camphor, &c; constitute the chief means that are likely to remove the internal congestions, to reduce the circulating fluid to a nearer equality with the vital power, to restrain effusion, and to restore the various secretions and excretions of the body. After these means have been judi- ciously administered according to the peculiarities of the case, or when circumstances seem to re- quire it earlier in the treatment, stimulating and restorative medicines may either be conjoined with the above, or be exhibited on such occasions as may require them. BlBLIOG. AND Refer.—Bontius, De Medicina Indo- rum, kc—Dick, in Duncan's Edinb. Medical Commenta- ries, vol. x. p. 207. —W. Hunter, Diseases incident to In- dian Seamen on Long Voyages. Calc. 1804. — Rogers, Diss. de Hydrope Asthmaiico. Edin. 1808. — Ridley, Dublin IIos. Reports, vol. ii. p. 227. — Marshall, Notes on the Medical Topography and Diseases of Cevlon, p. 161. 8vo. Lond. 1822. — H'amilton, in Transac of the Medical and Chir. Society of Edin. vol. ii. p. 12. — Good, Study of Medi- cine, vol. iv. p. 493. (The papers of Mr. Dick and Mr. Ridley are very able and instructive.) BLOOD. Syn. yJlua, Gr. Sanguis, Lat. Sang, Fr. Das Blut, Geblut, Ger. Sangue, Ital. Classif. General Pathology — Etiol- ogy, Semeiology. — General Ther- apeutics. I. States of the Blood in health. — 1. A. Of the states of the chyle. In order to ac- quire accurate ideas respecting the blood in dis- ease, it is necessary to be acquainted with the varying conditions and appearances of the chyle, according to the food, from which it is chiefly elaborated. To these, however, I can only brief- ly refer. This fluid, when removed from the thoracic duct, is usually of an opaque while or opalescent appearance, and separates into a ser- ous portion, and more or less firm clot. The for- mer resembles the serum of the blood, the latter consists chiefly of fibrine. If the animal have been fed with fat animal food, the chyle at the time of coagulation assumes a rose colour, and, in addition to the separation of the clot, which falls to the bottom ofthe vessel, a thin liquid oily layer forms on the surface of the serum. In ani- mals fed on vegetable food, the chyle is generally opaline and nearly transparent, and separates in- to a serous fluid and a small fibrinous clot only. According to MM. Prevost and Dumas the chyle contains globules, similar to those contained in the blood, but of a smaller size. The fibrinous coagulum seems to be formed from their aggre- gation. The serum ofthe chyle also contains al- bumen, and the saline ingredients found in the seram of the blood. 2. B. The globules of the blood, particularly in respect of their relation to the other constituents of this fluid, and the changes they experience when removed from the blood-vessels, excite the utmost interest in the mind of the pathologist. It is evident that they are suspended in the serum by means of the vital influence which the blood derives from the vessels and organs in which it circulates. According to the microscopic re- searches of Sir E. Home, Mr. Bauer, and of MM. Prevost and Dumas, they consist of a central colourless spheroid; and of a species of membranous sac of a red colour, surrounding this spheroid, from which it readily separates after death. The central bodies are transparent and spherical in the mammalia; and, when deprived of their coloured envelopes, are generally disposed BLOOD — Healthy Relations of. 167 to assume ranges or fibrous meshes. The col- oured portion appears to be a kind of jelly, easily divisible ; but insoluble in water, from which it may be separated by repose. It is likewise transparent; but much less so than the central corpuscle: and the fragments arising from its division are not susceptible of regular aggrega- tion. 3. C. State ofthe blood in the vessels.—Accor- ding to the observations of Kolk, Treviranus, and others, the globules of the blood possess a rotatory motion during life, independently of the motion arising from the impulse of the heart; and this motion continues till coagulation takes place. More recently, this subject has been investigated by Professor Schultz, of Berlin, who has con- firmed the fact respecting the intestine motion of the globules, by virtue of which they move on by themselves, surrounded by envelopes of colour- ing matter, and keeping at a distance from one another. This force, with which the globules of the blood are endowed whilst circulating in the vessels, I have, in my physiological notes, im- puted to the influence exerted by the ganglial nerves on the interior of the vessels, which they every where so abundantly supply, as stated in the article on the pathology of the Arteries. But, besides this force of mutual repulsion, to which the fluidity of the blood is evidently owing, under the vital influence exerted by the organic nerves on the vessels, there is evidently another force also in action, by which the globules are at- tracted by the tissues, when they are brought more intimately in contact with them during their cir- culation in the minute vessels. Whilst, then, the former force keeps the globules in a state of con- stant motion and repulsion, and is exerted in the stream ofthe circulation, the latter tends to bring the globules to a state of repose, and is exerted in the organic structures themselves, at the point of contact of the solids and the globules. This lat- ter force, which was first very minutely examined by Professor Schultz, and briefly stated by M. Andral, in his Pathological Anatomy, without acknowledgment, may be compared to a vortex, whence globules constantly p;iss from the arterial or terminal capillaries, and are lost in the differ- ent tissues. So that, although the vital endow- ment of the blood is manifested by its fluidity in the vessels, it assumes an opposite manifestation in the capillaries, where this fluid is brought within the sphere of the vitality of the different struc- tures; each one attracting from it those constitu- ents of which itself is formed, and which are always present in healthy blood. 4. Thus we see organization commencing in the chyle, advancing further in the blood, and reaching its acme in the vital attraction of the constituents of the tissues from the blood circula- ting in the capillaries which supply them. At this part of the circle, where the arterial capil- laries, with the fluid circulating through them, become, as it were, confounded with the tissues in which they are distributed, there appears, ac- cording to Professor Schultz, to be not only a constant attraction of particles by the tissues from the blood, but also an equal extrication of other particles from them into the blood received by the radicles of the veins. Thus it appears, that as the proximate constituents of the different tissues exist in the blood, as was first shown by Dr. Prout, and subsequently insisted on by Majf.n- die and Andral ; and as these become iden- tified for a time with them, are afterwards de- tached, and flow back into the current of the circulation; the intimate connection and mutual dependence of the blood and the different solids, both in health and disease, ought not to be over- looked. But it is at the same time manifest that these constituents are kept in solution during cir- culation, and attracted during nutrition, by the vital influence; that the various parts into which the blood separates on removal from the vessels are only indications of its condition when circu- lating through the frame; that no such separation occurs in the healthy body, and never, excepting very partially, in disease ; that this change pro- ceeds from the loss of vitality sustained by the blood when removed from the frame, and that the phenomena connected with it have an intimate relation to the vital endowment of this fluid, de- rived from the vessels and the nerves supplying them. 5. D. Coagulation of the blood.—This process is modified by numerous circumstances, and by various diseases. Generally, however, the blood soon separates into two portions—the serum, and the coagulum or clot; and in this separation the red globules are principally concerned ; it being chiefly the result of the loss of the vital motion which these globules possess in the vessels, and of the attraction existing between the colouring envelopes and central bodies. As the vital at- traction, which keeps the red substance fixed around the whitish corpuscles, ceases soon after the removal of the blood from the vein, these bodies can then obey the force which tends to unite them, and they then form a net-work, in whose meshes the liberated red particles are en- tangled, and thus produce the phenomena of co- agulation. If the coagulum be exposed to a stream of water, the colouring matter is washed away, while the aggregates formed by the colour- less corpuscles remain in the form of filaments, in which may be recognised an analogous struct- ure to muscular fibre, and constitute the fibrine of the blood. 6. It seems extremely probable, that the col- ourless globules observed in the chyle form the central corpuscles, and, when they have acquired their coloured envelopes in the progress of san- guifaction, constitute the red globules. And it appears equally reasonable to infer, that both the suspension of the globules in the serum, and the attraction between their coloured envelopes and colourless corpuscles, are entirely vital, inasmuch as both phenomena cease soon after the blood is removed from its source of vital endowment: and th-.t vital manifestations become first apparent in the chyle, and still more so in the blood; coagu- lation being the result of the loss of this endow- ment, and taking place with a celerity in proportion to the rapidity of its departure. In cases where the vital energy, or that manifestation of it exert- ed by the organic nerves on the vascular system, is unexhausted, or is in a state of healthy excite- ment, coagulation is perfect and somewhat slow; but where it is depressed or exhausted, this pro- cess is quicker, but much less complete. Besides these, it presents various other phenomena, which are intimately connected with the nature of mor- bid actions, and which I shall notice immediately. 163 BLOOD—Excess of—Plethora. 7. E. Chemical relations of the blood in health. —The analysis of the blood given by M. Le Canu, who obtained the prize given by the Aca- demie Royalede Medicine of Paris, is extremely minute; and, as respects the principal ingredients, agrees very closely with the results stated by Berzelius and Marcet. The oily matter first detected in the blood by Dr. Trail, and subse- quently found by Drs. Christison and Babing- ton, has likewise been recognised by him as con- stantly present in the serum. The results of the analysis ofthe serum by Le Canu, Berzelius, and Marcet, are as follows :— LeC ANU. Berz. Mar. 1st Anal. 2d Anal. 90S Water 906-00 901-00 900-00 Albumen - 78-00 81-20 80 86-80 ' Animal matter sol. in water and alco. 1-69 2-05 — — Albumen, combined *. with soda Crystallisable fatty 2-10 2-55 ~ ~ matter 1-20 2-10 — — Oilv matter 1-00 1-30 — — * Muco-extractive mat. — — — 4-00 * Extractive mat. sol. in alcoh. and acetate of soda — — 4 — Hydrochlorate of soda and potash - 6-00 5-32 6 6-60 Sub-carh. and phosph. of soda and sulph. potassae - 2-10 2-00 S 2-00 Phosph. of lime, uiagn., and iron, with sub- carb. of lime, and mag. 0-91 0-87 — 0-60 Loss 1-00 1-61 1 ^- 1000-00 10 0-00 1000 1000-00 8. The blood, according to M. Le Canu, con sists of the following constituents :— Water ... - 780-145 Fibrine - - 2-100 Albumen - 65-090 Colouring matter ... 133000 786-590 3-565 69-415 119-626 4-300 2-270 Crystallisable fatty matter - - 2-430 Oily matter ... - 1-310 Extractive mat. soluble in alcohol and water ... - 1-790 1-920 Albumen combined with soda - 1-265 2-010 Chloruret of sodium and potassium, alka- line phosphate, sulphate, and subcar- honates - - - - 8-370 7-304 Buhcarbonate of lime and marnesia, phosphates of lime, magnesia, and iron, peroxide of iron - 2-100 1-414 Loss - - 2-400 2-586 1000-000 1000-000 According to some chemists the blood also con- tains carbonic acid (Vog el and others); a yellow colouring matter, resembling that of the bile and the urine (Chevreul, Lassaigne, &c.) ; and a substance analogous to urea (Prevost, Du- mas, Vacquelin, and Segalas). Vauque- lin and Chevreul consider the fatty matter to be similar to that of the brain and nerves. 9. a. The quantity of water in the blood of a healthy person varies, according to M. Le Canu, in 1000 parts, from 853-135, the maximum, to 778-625, the minimum. He found the medium quantity in males to be 791-944, and of females 821-764. The quantity also appears to vary with the temperament; as the lymphatic temper- ament in the male furnished 830-566, of the fe- male 803-716 ; and the sanguineous in the male 786-584, in the female 793-007. * Probably the same constituents, differently named, and more minutely examined, by M. Le Canu. 10. b. The albumen contained in 1000 parts of blood varies from 78-270, the maximum, to 57-890, the minimum. It is nearly the same in the male as in the female, being only about one part more in the former. The difierence in the quantity appears to have no relation to the tem- perament, nor to the age of the subject, from twenty to sixty years. 11. c. The quantity of fibrine contained in the coagulum varies extremely. According to Ber- zelius it is only -75 for 1000 ofthe blood. M. Lassaigne states, that the fibrine of the blood of a young vigorous man is only 5^5 of its weight In the researches of M. Le Canu, who has in- vestigated the subject more closely than his pre- decessors, the quantity of dry fibrine contained in 1000 parts of blood varies from 1-360 to 7-236— the medium of twenty-two experiments being 4-298. It appeared to be greatest in the young or middle-aged of the sanguine temperament, and in the inflammatory state ; and least in the lymphatic constitution, the aged, and those suffer- ing under congestion or haemorrhage. 12. d. The proportion of globules varies much more remarkably in the blood of a healthy per- son, than that of the albumen ; the maximum being 148-450, the minimum 68-349., and the medium 108-399, in 1000 parts of blood. The medium quantity in males was 132-150, and in females 99-169. The periods of life intervening between twenty and sixty years had no influence on its quantity; but it was found to vary with the temperament. The medium quantity in the lym- phatic temperament was 117-300 among females, and 116-667 among males; and in the sanguine- ous temperament, 126-174 in females, and 136-- 497 in males; giving 19-830 more globules to the sanguine temperament in 1000 parts of blood. M. Le Canu found the globules of blood greatly di- minished in females subject to a copious flow of the menses. The quantity of globules is also, rel- atively to the other constituents ofthe blood, great- ly diminished by blood-letting, whilst the albumen is not sensibly affected. Thus, a first bleeding furnished in 1000 parts of blood 792-897 of water, 70-210 of albumen, 9-163 soluble salts and animal extractive matters, and 127-73 of globules; but a third bleeding a few days afterwards in the same patient (a female), gave 834-053 of water, 71-111 of albumen, 7-329 of soluble salts and extractive matters, and 87-510 of globules. 15IBLIOG. AND REFER.—Marcet, in Transact, of Medico- Chir. Society of Lond. vol. ii. p. 365.—Berzelius and Mar- cet, in Ibid. "vol. iii. pp. 199. 231.—Prout, Inquiry into the Origin and Properties of the Blood, in the Annals of Med. and Surg. vol. i. pp.10. 133. et 277.—Home and Bauer, Philos. Trans, for 1820.—Home, in Ibid, for 1826, p. 189. — Prevost et Dumas, Memoires de la Soc. de Phvsiq. et d'Hist. Nat. de Geneve, t. i., et Bibliotheque Unlvers. Juillet, 1821.—Author, Appendix to M. Riche- rand's Elements of Phvsiol. 2d edit. p. 637.— Scudamore, Essay on the Blood, &c. 8vo. Lond. 1824—Schultz, Re- vue Medicale, t. i. 1825, p. 136., et Journ. de Prog. des. Sc. Med. t. v.—Bostock, in Edin. Med. and Surg. Journ. vol. xxxi. p. 114.—Adelon, Physiol, de l'Homme, t. iii. p. 110, et seq.—Le Canu, Nouvelles Recherches sur le Sang, in Journ. de Pharmacie, Sept. et Oct. 1831. II. Exuberance of Blood, Plethora (TcXrj&wrir], repletion). Syn. Polyemia (AucL Var.). Hyperemia, plethore, Fr. Die VolU bliitigheit, Germ. Pletora, Ital. Excessive Fulness of Blood. Classif. Pathology — Etiology. IV. Class,II. Order (Author, see Classif. in Preface). BLOOD — Excess of — Plethora. 169 13. Defin. Greater fulness of the vascular system than is compatible with the continuance of health; or repletion of this system. 14. The importance of attending to the varying states ofthe circulating system, in respect of both exuberance and deficiency of the fluid contained in it, has been acknowledged since the time of Galen. After the doctrine of nervous influence had superseded the humoral pathology, the state of the blood in disease experienced a more gen- eral neglect, than the part actually performed by this fluid in the causation and perpetuation of morbid actions ought to have procured for it. Yet have there always been a succession of able ob- servers and writers, who have never lost sight of the influence of the quantity as well as quality of the blood in producing, as well as in modifying, disease; and more recently the subject has de- servedly received an increased and an increasing attention. Plethora is the opposite of anemia .- both may be, to a certain extent, compatible with health; but both predispose more or less to dis- order, and, beyond certain limits, constitute distinct and opposite states of disease. 15. A. General plethora.—Galen, Baillou, Fernel, Riviere, and others, considered ple- thora to be of two kinds; to which subsequent writers added two more. As these distinctions are still, in several respects, founded in truth, notwithstanding the neglect into which they had long fallen, I will here briefly notice them. 1st, True or absolute plethora—plethora ad vasa; 2d, Apparent or false plethora—plethora ad volumen; 3d, Plethora relative to space—plethora ad spa- tium; 4th, Plethora in relation to vital power— plethora ad vires. It will be observed that the first and second of these, the species recognised by the earliest writers, are still upon the whole the most important. In the first, the blood is permanently increased beyond the wants of the system. In the second, plethora is merely a pass- ing occurrence, arising from temporary causes, as the general turgescence occasioned by sudden or high ranges of temperature, &c. In the third, the blood may not be increased, but its relative quan- tity may be too great, as is observed after ampu- tations of one or two limbs. In the fourth, the quantity may not be too great, if this fluid were actuated by a healthy state of the vital energy: but it may be excessive in respect of the influence by which it is circulated in all parts of the body. Now, those distinctions are actually founded in nature; and although they may all be resolved into one pathological proposition, viz. greater repletion of the vascular system than the wants and condi- tions ofthe economy require, still they must have become matters of experience to every one whose range of observation has been such as entitle his opinions to respect. I shall merely remark upon such of them as admit of dispute. 16. False plethora is very generally observed to occur in persons suddenly exposed to elevations of temperature, and depends more upon the effect of heat in exciting the vital turgescence of the capillary vessels, whereby a craving for fluid is created, and a larger quantity is absorbed, than upon the expansion of the fluids themselves, owing to the increase of temperature. A state of false plethora is very frequently occasioned,—and is often productive of more serious consequences than have generally been imputed to it,—by in- 15 gurgitation and increased temperature conjoined; and it should not be overlooked, that these com- bined influences not infrequently affect those who are already permanently plethoric. This will be more forcibly and truly shown by what must have fallen under the observation of many. A red faced, full veined, and robust looking person, of from forty to sixty, sits down to dinner with a good appetite. He eats three times as much as his body requires, and he excites the stomach to digest it by drinking stimulating fluids to six times the quantity that is necessary. All this, moreover, is done in a close and overheated apartment. The vital turgescence and expansibility of the capil- laries and veins are excited to the utmost; the whole surface is full and plump, and the extremi- ties even swollen. Now, a person thus circum- stanced, particularly from four to eight or more hours after such ingurgitation, actually has the quantity of his circulating fluids increased from one sixth to one third, at a moderate calculation : but the increase is generally soon diminished by the pulmonary exhalation; the urinary, the per- spiratory, and intestinal secretions; which are all greatly augmented, and are thus the safety valves of the circulation. But how often, notwithstand- ing, do we observe the vessels at last yield before the mass which distends or overloads them, and apoplexy, and various other haemorrhages and congestions, result; particularly when any one of these safety valves are obstructed or tardy in their action — when the nervous or vital influence is either depressed or much exhausted by the previ- ous excitement, and the vessels are irritated, or their actions otherwise changed by the state of their contents. 17. That plethora is a not infrequent result of amputations cannot be disputed, although the privation of sufficient exercise, which is thereby occasioned, will partly account for the occurrence; at the same time we generally observe that the same quantity of food is taken, and the same quantity of blood is prepared for the body, when deprived of one fourth part of the structures re- quiring support, as was provided for its nourish- ment when it was in a state of integrity. 18. That plethora may exist in conjunction with deficient vital or nervous power, and that, although the quantity of blood in the system may not exceed that of health, and yet be too great for this power to control, cannot be doubted. We are constantly observing such pathological condi- tions, both at the commencement and in the pro- gress of disease ; and frequently remark their influence in its advanced states and terminations. (See article Congestion.) 19. The causes of plethora are so manifest as scarcely to require enumeration. They may op- erate either singly or in conjunction. They con- sist, 1st, Of the introduction into the vascular system of a greater quantity of the nutritions elements than is necessary to the support of the organization; and, 2d, Of the retention in the blood of those parts which are usually removed by the secreting and excreting organs. It must be evident that the former is owing to excess of nourishment and stimulating fluids ; whilst the latter proceeds most commonly from insufficient exercise, suppressed natural secretions and ex- cretions, or accustomed morbid discharges. Howfa remarkably the habits, indulgences, luxuries, and** 170 BLOOD — Excess of — Plethora. refinement of modern life contribute to these, is sufficiently apparent. At the same time it should not be overlooked that there are certain consti- tutions, and particularly those of a lax fibre, more disposed to plethora than others, even in- dependently of temperament; that this disposition is often hereditary; and that it is frequently so strong, notwithstanding precautions to overcome it, as to constitute a distinct diathesis. Plethora, particularly in conjunction with a rich state of the blood, is generally most remarkable in those who live highly, drink much, and are very often out in the open air, without taking active exercise. 20. There are also certain epochs of life at which it is most apt to occur, particularly when the energies of life are beginning to wane, and when the balance between sanguifaction and se- cretion preponderates in favour of the former. (See articleAcE.) Plethora is also more frequent in females than in males, owing to their more sedentary occupations, and to the wants of the female economy, particularly during the period of utero-gestation, and subsequently to the cessation of the menses. It is justly remarked by various writers, that the plethora of early life is generally arterial and capillary; that of advanced age alto- gether venous. - 21. Plethora has been too generally considered as always existing in fat persons, and as occurring at least in them most commonly. But obesity is no sure criterion of plethora; it may even co- exist with a deficiency of blood. I have known the supposition, that obesity indicated at least a sufficiency of this fluid, lead to dangerous results. Indeed, the opinion entertained by several of the older writers, that fat persons do not bear deple- tion, is quite as well founded as its opposite. There are other circumstances besides this which must be taken into consideration, when we estimate either the simple existence of plethora or its ex- tent. This state of the vascular system is some- times associated with leanness; but when this is the case, the pulse is also full and strong, and the veins very large, full, and rapidly filled upon being emptied by friction. It is more generally observed in persons passing middle age, who, with a ruddy, flesh-like, or lively surface, are beginning to as- sume greater fulness of the frame without loss of firmness; and in whom the pulse is full and the veins well marked. 22. Symptoms. — Plethora, in its slightest grades, is generally productive of little incon- venience. There are usually observed merely a greater disposition to sleep than in health; less quickness and aptitude to mental or corporeal ex- ertion; and a more marked disposition to suffer from and to be affected by the more energetic causes of disease. In an advanced degree it occa- sions lassitude, indolence, vertigo, or weight or pain of the head; heavy, snoring, dreamy, and often unrefreshing sleep; turgescence of the coun- tenance, suffusion ofthe eyes; fulness ofthe veins, and of the pulse; occasionally palpitations of the heart, and slight amaurosis. Such are the usual signs of plethora, short of actual disease, at least of such as may alarm the patient. When it pro- ceeds further, it assumes either the features of inflammatory fever, with excess of action in some organ or part, or passes into general visceral con- gestion, according to the states of vital action and power. It may moreover occasion, or terminate in, haemorrhage, visceral inflammations, conges- tions, and obstructions, active dropsy, morbidly increased secretions, convulsions, spasmodic dis- eases, morbid states ofthe vessels, &c. 23. B. Local plethora. — The vessels of an organ or part may be loaded with blood, and yet the state of their vital action may be neither generally or locally exalted to the pitch of active determination, nor reduced so low as that of pas- sive congestion. There are, perhaps, few such cases that are entirely independent of some degree of excitement, arising either from the condition of the nerves ofthe organ, or from an irritating cause of some description influencing the state of the capillaries. The best exemplifications of this state are the plethoric states of the ovaria and uterus previous to the menstrual discharge; ofthe generative organs during the venereal orgasm; of secreting glands and parts when then- func- tions are unusually active; of the brain during the exciting passions and emotions (see Local deter- minations of Blood), and various internal viscera, particularly the spleen, during the cold stage of an ague, &c. These last, however, more nearly approach to congestion than to simple local ple- thora. It should not be overlooked, that what- ever excites the nerves and irritates the tissues of a part, will occasion turgescence of the capillaries, increased flux of blood through the arteries sup- plying them, and a quicker return of this fluid through the veins. If the part thus excited perform secreting functions, these will be augmented ; and thus increased flux and local plethora will both exist, and constitute local determination of blood, — a state which will be considered here- after. But still this is not inflammation; for as soon as the cause of excitement ceases, this state disappears, without terminating in any ofthe ways in which inflammatory action terminates, and without having assumed any part of the for- mative process which in some state or other fol- lows upon inflammation occurring in a previously sound frame. It cannot, however, be denied, that although local plethora does not constitute either inflammation or passive congestion, it will often favour the production, not only of these, but also of haemorrhages, convulsions, &c, accord- ing to its seat and extent, the state of vital power, the nature of the exciting causes, and other con- tingent circumstances. It is evident that local plethora may occur either with or without general plethora. It may even coexist with insufficiency of blood (§ 34.). 24. C. The treatment of general and local plethora consists almost entirely of avoiding its causes. Simple plethora does not require, and is seldom permanently benefited by, vascular de- pletion alone; indeed, it is more generally in- creased after a time by this practice, unless more efficient measures be also employed. Abstinence, and a free state of the secretions and excretions; active and regular exercise; abridging the period of repose; early rising; a moderate use of diluents, and abstaining entirely from malt and spirituous liquors; cooling and acidulous beverages, when thirst requires to be quenched; are the chief means both of prevention and cure. Bibliog. and Refer. — Galen, De Plenitudine, vide Opera. Fischer, De Plethora Mult. Morb. Causa. Erf. 1723. — Hoffmann, De Plethora insufficiente Morborum Causa, Opp. sup. ii. pp. 1. 506. — Stahl, Theoria Medica Vera, BLOOD-Det Juncker's ed. Halae, 1737. pp. 303.483, kc ; et De Plethora. Erf. 1736. — Juncker, Conspectus Medicinas. Hala;, 1724, p. 7. et seq.—Nicolai, De Singular, quibusd. ad Poly- femiam Spectantibus. Jenas, 1790 —Rudolsteller, De Morb. ex Abundantia Sanguinis oriundis. Helms. 1777. —Weickard, Vermischte Schriften, h. iii. p 89.—Gregory, Conspect. Med. Theoret. ed. vi p 152 —Horn, Beitrage zur Medic Klinik vol. ii. p. 88. — Calemard Lafayette, Essai sur la Plethore ou Poly.'mie, 4to. Paris, 1809.— Vaidy, Diet, des Sciences Mt'd. t. xliii. p 178 —Parry, Elements of Pathology, 2d ed. p. 30. ap.—Rochoux, Diet. de Mtd. t. xvii. p. 123. III. Local Determination of Blood. Syn. Afflux of Blood; increased Momentum of Blood. Fluxion, Fr. Classif. Pathology. Therapeutics— (Derivation, Revulsion). 25. The determination of a larger proportion ofthe circulating fluid to an organ or part, than is usually sent to it in health, not infrequently takes place independently of inflammation. This state of the local circulation has been, singularly enough, doubted by some writers, and too much insisted on by others, more particularly by Dr. Parry, who assigned to it a greater importance in pathology than it is entitled to, and overlooked the fact that it is a part only or link in the chain of morbid causation. 26. i. Pathological Doctrine.—Determin- ation of blood is intermediate between inflamma- tion and local plethora. Inflammation is an ac- tively morbid state of the capillaries; congestion a passive condition of both them and the veins; whilst determination is a simply active or excited, but not otherwise diseased, state of both the arte- rial branches aiid the capillaries, the veins being unaffected, and readily returning the blood con- veyed by the arteries. More or less determination of this fluid accompanies acute and sub-acute in- flammations, and haemorrhages; but it never at- tends congestion, unless this state pass into either of the former diseases, or be followed by aug- mented secretion from the congested organ. Local Plethora (§ 23.) is a lower grade of local deter- mination, or rather an intermediate state of the vascular system between determination of blood and congestion. In other words, (a), Congestion of blood is repletion of the veins, attended by depressed vital power—(b) Local plethora, in- creased fulness of the vessels generally, with in- tegrity of vital power—(c) Local determination, augmented circulation and vital functions of the vessels—and (d) Inflammation, an actively morbid state of the vessels, and organic nerves supplying them, tending to change of structure and to disor- ganization. A3 these pathological states are often referred to, and are sometimes improperly con- founded, it is therefore necessary to attend to the distinctions now drawn. 27. That determinations of blood actually oc- cur, and may even be excited at pleasure for a Bhort time, are matters of daily observation even in health; and that such changes in the circula- tion of a part are occasioned by the influence of the nerves, particularly of the organic nerves sup- plying the vessels, seems an equally well esta- blished fact When these nerves are excited, whether by heat, stimuli, friction, or irritating bodies, the capillaries experience a degree of ex- pansion,—a property withj^hich they are na- turally, or rather vitally endowed. The erythism, expansibility, or slight erectility, which is evinced by the capillaries of certain organs in a very re- RMINATIONS OF. 1 7 1 markable manner, exists more or less throughout the frame, especially in mucous or cellular parts. When, therefore, this property is influenced by any agent possessed of the power, the diameter of the capillaries running between the arteries and commencement of the veins being increased, an enlarged stream of blood will necessarily pass through them, and a correspondent demand will be made upon the arteries supplying them, owing to the less resistance opposed to the current, and freer circulation in the part thus circumstanced, provided that the return of blood by the veins be not impeded. If the circulation be thus in- creased as respects the volume of blood passing through the vessels, and continue thus facilitated^ the demand thereby made upon the larger vessels and the heart will ultimately tend also to acce- lerate it; and hence will result augmented volume and quickened circulation—the states constituting determinations of blood. 28. The circulation of an organ or part may long remain in this state, particularly if its vital manifestations do not become exhausted, and if its nervous power continue excited by the agent or cause which first occasioned this condition, or by other influences operating in a similar manner. But if the vital or nervous power become depressed, or otherwise changed, either congestion, or some form of inflammation, will generally ensue, or even haemorrhage may take place, — a result which is not infrequent when the determination takes place to membranous viscera or parts, and to mucous surfaces. These being, therefore, not unusual terminations of simple determination of blood, means should generally be employed to remedy this state. The agent or cause exciting the vessels should be removed, and other measures directed that may equalise the circulation and di- minish its fulness, when the determination is con- nected with plethora, as it not infrequently is. 29. Determinations of blood to an organ are very frequently occasioned by whatever rouses its natural actions. If the part thus excited perform secreting functions, the increased secretion, in addition to whatever excitement of the vessels may be produced, will of itself determine a greater flow of blood to it. Numerous proofs of this are furnished us by the progress of various diseases, and the appearances presented by others after death; and, endeavouring to follow nature, we attempt to remove determination or inflammations in vital organs, by inducing artificially an afflux of blood to parts and surfaces where it cannot be injurious, as to the skin, mucous digestive surface, extremities, &c, with the view of assisting other agents in soliciting or recalling it from the seat of disease. The exercise, also, of organs which possess not secreting functions, will likewise fa- vour an augmented flow of blood to them. Thus, exertion of the mental faculties and the passions determine an afflux of blood to the brain; and of the muscular organs, to the spinal cord, muscles, and heart. It is of importance to be aware that the irregular distribution of the blood, whether of this or of other kinds, may take place either when this fluid is more abundant and richer than natural, or when it is deficient as well as poor; and that the change from the healthy state of the circulation is to be imputed primarily to the state of influence exerted by the organic class of nerves distributed to the vessels, which, thus influenced, 172 BLOOD —Deficie ncy of—Anemia. control the volume of the blood circulating through them (§ 27.), as well as modify its states and the rapidity of its circulation. The particular deter- minations of blood are noticed in their respective articles. BlBLlOG. and Refer.—Stahl, De Commotionibus San- guinis Activis et Passivis. Hala;, 1698.; et De Motu San- guinis et pendentibus Vitiis, &c. Hala>, 1709 —Fischer, De Motu Sang. Naturali, Non-naturali, et Mixto. Erf. 1720. — Barthez, M^moire sur les Fluxions, qui sont les Elt- mens essentiels dans divers Genres des Maladies, in Mi- nioires de la Socitte M6d. d'Emulation, t. ii. p 1.—Parry, Elements of Pathology and Therapeutics, 2d ed. Lond. 1825. — Author, in Lond. Med. Repos vol. xxiii. p. 409.— Barry, Exp. Researches on the Blood. 8vo. Lond. 1826. 30. ii. Therapeutical Doctrine. — De- rivation — Revulsion. The doctrine of deter- mination of blood sufficiently indicates the pro- priety of having recourse to means in the cure of various diseases, calculated to solicit a flow of blood to parts where this may be done safely, and thus to diminish the quantity sent to the seat of disease. This mode of practice was well understood, and very generally employed by the older physicians, upon the well-known pathologi- cal principle that " ubi irritatio, ibi fluxus." It must not, however, be overlooked that irritation will not always procure afflux of blood; and that it is therefore not altogether identical with deriva- tion, either in a pathological or a therapeutical point of view. It does not come within my limits to point out the difference; but they are so far alike, that, in order to produce the latter, we fre- quently have recourse to the former. At the same time we must recollect that irritation will some- times be of service even independently of any afflux of blood that may accompany it, or even although it should fail of producing this effect. 31. It is almost unnecessary to enumerate the means, which we occasionally have recourse to in order to occasion a local determination of blood, and thus derive it from the seat of disease. These consist of numerous agents:—a, Such as increase the circulation in the rete mucosum, as rubefacients, sinapisms, external heat, &c. : 6, Those which, in addition to augmented circula- tion, procure a discharge from the surface or part to which they are applied, as scalding water, blisters, irritating ointment, &c, purgatives and cathartics, &c: c. Those which, by procuring a flow of the natural secretions, solicit an afflux of blood to the secreting organs, as certain purg- atives, diuretics, and diaphoretics: d. Those which evacuate the viscera, increase the dis- charges from their mucous surface, and augment the secretions in adjoining organs, as emetics, cholagogue purgatives: e. Those which influence the circulation in the limbs and extremities, as frictions, the semicupium, various forms of pedi- luvia and manuluvia; abstraction of blood from the feet or hands, by venesection, leeches, or cupping; stimulating or scalding pediluvia, Sac: and, /. Those which permanently irritate and procure a continued discharge, as deep scarifi- cations, incisions, setons, issues; caustic applica- tions, as the alkalies, the inner bark of mezereon, moxas, &c. 32. All these occasion, in the first place, irri- tation in the part to which they are applied, and, consequent to this, an afflux of the circulating fluid. Some of them produce the primary, more remarkably than the secondary effect; and when this is the case, the pain which is felt is often an index of the extent of the former. This is the case with blisters, rubefacient epithems, shiapisms, and scalding applications; and therefore much advan- tage is obtained from them in various diseases, independently of their secondary operation, par- ticularly when we wish to rouse the torpid or oppressed functions of an adjoining or subjacent organ. When derivation is, however, our princi- pal object, they cannot always be depended upon, particularly in irritable habits, and in the early stages of acute diseases. They ought never to be employed in the stage of excitement in fever, unless this stage be irregular, imperfectly de- veloped, or inefficient; nor in inflammations, until acute action is subdued by depletions, evacuations, and other means,—when only artificial derivation can be expected to have any influence in dimin- ishing the remaining disorder, and lessening the risk of effusion. This caution is especially de- serving of attention in respect of blisters, — the cantharides of which, particularly if improperly allowed to remain too long on a place as they often are in diseases of excitement, being often absorbed into the circulation, thereby increasing the general as well as local vascular action. These applications, also, ought not to be directed to the vicinity of parts suffering from vascular excitement. I have often seen mischief produced by blisters having been directed to the head and throat in acute diseases ofthe subjacent parts. 33. The means usually employed in order to derive the flux of blood from diseased parts are variously combined, and much discrimination is requisite both in the choice and in the combination of them, appropriately to the state and nature of the diseased action at the time. The scope and limits of this work preclude my entering upon this important branch ofthe subject; but it has received attention when discussing the treatment of those diseases in which the various means of derivation are required : and the appropriation of those means to the different states of vascular action is there attempted with some degree of precision. Bibliog. and Refer.—Dumas, Nova Constitutio Artis Revellendi et Derivandi per Vena;sectionem, 4to Tig. 1557. — Sennert, De Revulsione et Derivatione, 4to. Vit. 1604.— Bohn, De Revulsione Cruenta, 4to. Leip. 1704 —Fildar, De Revulsione Lugd. Bat. 1731.—Segner, De Derivatione per Venaescctionem. Goet. 1749. — Bolten, De Revulsione Generatim. 4to. Hala?, 1750 —Mrazer, De Lege Revul- sionis Virium Systematis Nervosi. Prai.-a", 1784. — Gericke, Derivations et'Revulsionis Histor. ef Prwsid. 4to. Jena>, 1787. — J. H. F. Jutenrieth, Observationes Veritatem Methodi Revulsoris Spectantes, 8vo. Tubing*, 1802.— (Recommends the tart, antimonial ointment, the first employ- ment of which has been incorrectly attributed to Dr. Jen- ner. It was first recommended "by the late Dr. MONRO, in his Lectures on Morbid Anatomy. I attended these lectures, and employed it long before "the publication of Dr. Jenner's letter on the subject. See cases adduced bv me illustrative of its good effects, in London Med. Repos." voL xvii. p. 310.) — Pinel et Bricheteau, in Diet. Sciences Mtdicales, t. xlviii. p. 384.—Jenner, Letter to C. H. Parry, on the Influence of Artificial Eruptions in certain Diseases. Sec. 4to. Lond. 1822. IV. Deficiency of Blood. Syn. Anemia (from the privative a, and a'iua, blood). Bloodlessness. Anlmie, Fr. Der Blut- mangel, Ger. Dyspepsia Anemia (Young). Marasmus Anhemia (Good). Classif. 3. Class, Diseases of the San- guineous Functions; 4. Order, Cachexies (Good). I. Class, V. Order (Author). 34. Defin. A deficiency of blood in the whole BLOOD — Deficiency of — Anemia. 173 body or in some important organ, not proceeding from natural or artificial hemorrhage, giving rise to a waxy, bloodless state of the countenance and surface, emaciation, feeble quick pulse, and great languor and debility. 35. Defect of blood, bloodlessness, or anaemia, although not of frequent occurrence, is yet occa- sionally met with, particularly in its less remark- able, or local forms. In connection with chlorosis it is oftener observed. Cases of anaemia have been recorded by Reiselius, Swhenke, and others ; and the disease fully described by Beck- er, Albert, Janson, Hoffmann, DeHaen, ISENFLAMM, LlECTAUD, HALLE, AnDRAL, and several pathologists and practical writers of the present day. I shall first offer a few general observations' on local anaemia ; and afterwards describe more fully general anaemia and its com- plications. The deficiency of blood, occasioned by natural or artificial losses of it, is considered under a distinct head. 36. i. Pathology of Anaemia.—1st, Local anemia. Deficiency of blood in an organ or part is evidently the result of one or more of the fol- lowing pre-existing lesions :—a, Of diminished influence of that portion ofthe ganglial or organic class of nerves which supplies the blood-vessels ofthe organ ; b, Of defective vital expansion of its capillaries, probably owing to the depressed state of the influence exerted on the vessels by the nerves supplying them ; c, Of mechanical impediments in the way of a sufficient supply of blood ; d, Of imperfect developement, or dimin- ished calibre of the arteries by which blood is conveyed to the organ ; e, Of disease of the or- gan or part, or an imperfect exercise of its func- tions ; and, /, Of unusual flux of blood to other quarters, causing a proportionate diminution of it in others. It is evident that these states are merely local, and are capable of co-existing with other changes affecting the whole mass of the circulating fluid, as respects both its quantity and its quality ; and that various disorders of func- tion, according to the particular state on which the anaemia depends, and the extent to which it may exist, will be the consequence. 37. The organs most subject to this condition of their circulation are, according to M. Andral, the lungs, the brain, the liver, the substance of the heart, the stomach and alimentary canal, and some of the voluntary muscles. To these I would add, the spleen, the ovaria, and the gene- rative organs of the male. In many of these, as in other parts, atrophy is associated with the anaemia ; and may be considered, in the majority of cases, as the consequence of it. The symptoms of local anaemia are not always manifested during life ; but they frequently are, as I shall have oc- casion to point out, when considering the morbid conditions of those organs most subject to this change. Thus, in the completest of all the states of local anaemia, as when the obliteration of an artery cuts off all supply of blood to the organ, gangrene will result ; frequently, when anaemia is seated on the brain, a form of convulsion is the consequence, with other symptoms stated in the article on this subject (see Brain—Anemia of); and when the ovaria, at the period of pu- berty, is not supplied with the requisite quantity of blood, owing to deficient influence of the gan- glial nerves distributed to the organs of genera- tion, chlorosis, sometimes with more or less of general anaemia, is the constant effect. 38. 2d. General anemia.—The blood circu- lating through the body may be most remarkably deficient, in respect both of its quantity, and of the relative proportion of red particles. In many cases in which the absolute quantity of blood in the body is diminished, the globules are still more remarkably deficient, they being insufficient to give the blood its usual deep colour. General anaemia presents itself in practice, 1st, as a pri- mary disease; 2d, as a consequence of pre-exist- ing lesions of some one of those organs which are concerned in conveying the nutritious fluids into the blood, or in the processes of sanguifaction ; 3d, associated with other diseases, resulting equally with it from some antecedent affection, the nature of which cannot, perhaps, be readily recognised. 39. A. The primary forms of anaemia, when closely analysed, seem to proceed, 1st, from deficient nourishment ; 2d, from deficient vital power,—from a torpid or depressed state of the influence of the organic class of nerves on the digestive, assimilating, sanguifying, and circulat- ing organs which they supply.—a. The influence of deficient supply of nourishment in producing anaemia may be readily imagined, and instances showing it are numerous ; I will merely allude to one: — M. Gaspard, whose researches have tended much to advance the state of the patholo- gy of the fluids, has illustrated this part of the subject by observing the remarkable degree of anaemia which existed in a large proportion of the ^habitants of a district devastated by famine, who lived upon grass. A more common and less expected form of general anaemia is that which arises from the injudicious restriction of diet and regimen, during convalescence from acute dis- eases, particularly those which have required large depletions. Several instances of this state of disease have come before me, and would, I am confident, have terminated in dropsical effusions (§ 44.) or in death, if a different system had not been adopted. 40. b. A torpid state of the organic class of nerves, in one of the most influential, if not the most frequent, antecedent affections to which we can impute this state of the circulating fluid. It is extremely probable that those instances of its occurrence from being shut out from the sun's influence, and the constant respiration of an un- wholesome air, arise from the continued priva- tion of salutary stimuli to this important class of nerves, upon which the sanguifying processes depend. 41. The influence ofthe sun's rays in promot- ing all the vital actions, particularly those of or- ganic life, probably from modifying the electro- motive state of the frame, must be evident to all. The good effects of light and air are shown in the vegetable kingdom, the circulating fluids of which cannot be duly formed without exposure to both. The sun's rays diffuse a genial influence through the frames of the aged, and excite the organic and generative functions of the young. It has been observed that those persons who are entirely ex- cluded from the light of the sun, and breathe the close air of mines, are particularly subject to general anaemia. M. Chomel has given a very interesting account of the disease which affected 174 BLOOD —Deficie ncy of — Anemia. the workmen employed in a coal mine at Auzain. It commenced with colicky pains, meteorismus, blackish green stools, dyspncea, palpitations, great prostration of strength, followed, in ten or twelve days, by a yellowish or waxy and bloodless ap- pearance of the countenance. The capillary vessels disappeared from the conjunctiva and mucous surface of the mouth ; and the pulsation of the arteries could scarcely be felt. The pa- tients complained of palpitations, anxiety, op- pression and suffocation on exertion, paroxysms of fever, profuse perspirations, oedema of the countenance, and rapid emaciation. This state continued for six months or a year ; and in some cases terminated fatally, with the reappearance of the invading symptoms. Four of these patients were sent to Paris for treatment, and were order- ed light nutritious diet, bitter infusions, &c. One of them died ; and on dissection, the arteries and veins were found almost void of blood, contain- ing merely a little sanguineous serum ; and little or no blood flowed from the parts divided during the inspection. The appearances in this case led Mr. Halle to prescribe iron-filings in the dose of a drachm daily, with tonics and opium ; and, under this treatment, all the symptoms gradually vanished, the capillary vessels reappearing on the surface. 42. B. It is probable that general anaemia will not take place, unless consecutively of remark- able torpor of the vital influence, or of some other morbid condition of one or more of the or- gans which contribute to the formation of blood. Where the digestive powers and the functions of the liver are weakened, anaemia to a slight de- gree is not infrequent. Its connection with chlo- rosis is merely that of an associated effect of pre- existing depression of the influence of the system of organic nerves. (See Chlorosis.) The lungs have been considered by some authors as the or- gan which is chiefly concerned in the production of anaemia, and consequently have been viewed by them as the seat of haematosis, or at least the place where this process is completed. Without disputing that such is the case to a certain extent, I am disposed to view the liver as being equally, if not more, concerned in this function,—an opin- ion long since contended for in my Physiological Notes (See Appendix to M. Richerand's Ele- ments of Physiology); and consequently as being in many cases very influential in the production of general anaemia. It is probable, however, that other viscera or parts may also give rise to it. Thus it may be admitted that total obstruction of the thoracic duct will occasion it; and I have repeatedly observed it in children affected with various chronic diseases of the viscera of organic life ; being here, as in most cases, one of the re- sults of imperfect digestion and sanguifaction, as well as of obstruction to the passage of chyle into the blood. One of the most remarkable cases of general anaemia was recorded by Dr. Combe. In it all the viscera were found nearly bloodless, excepting the spleen; but not diseased in other respects, at least not to the extent of impeding their functions. The thoracic duct and absorbent system were not examined. 43. The symptoms of anemia have been near- ly all alluded to in the foregoing remarks. I may, however, enumerate them briefly at this place. They consist of a pale, waxy, or blanched ap- pearance of the countenance and integuments, in which the cutaneous veins are scarcely seen ; and those which appear are pale, apparently empty, do not fill quickly, or scarcely at all, upon pressure made upon them ; and, when emptied, fill very slowly. The conjunctiva has lost its red vessels ; the lips, tongue, and inside ofthe mouth are pale; the pulse feeble, small, irregular, and readily made still quicker or fluttering upon mental emo- tion ; the patient is languid and very weak ; com- plains of flatulence, borborigmi, and an irregular state of the bowels, with want of appetite, and an occasional nausea ; a sense of sinking and syn- cope, particularly upon assuming the erect posture, followed by palpitations ; oppressed, short, hur- ried, and sometimes gasping respiration ; irregular convulsive or spasmodic movements ; tremors ; cedema ofthe ancles; and in some cases the more severe symptoms described as following sinking after large depletions (§ 54.) In the more un- favourable cases the patient may be carried off by a fit of syncope upon assuming quickly the erect posture ; or by a convulsion ; or sink with the symptoms of exhaustion, or with those of effusion on the brain, or in the pleural or pericardial cavi- ties. It most commonly runs into one or more of the complications about to be noticed. 44. 3d, Complicated anemia.—Deficiency of blood, as respects both its diminished quantity and its poor quality, or the defect of red globules, is often associated with visceral disease, of which it is generally the consequence ; but it also may give rise to various affections, both functional and organic. That anaemia should be complicated with certain chronic diseases of the liver, mesen- teric glands, and absorbent system, chlorosis, &c. may be expected ; but that it should give rise to diarrhoea, and to dropsical effusions in various parts, particularly in the shut cavities and cellular tissue, without any alteration of the solids, may not appear so obvious, although admitting of ex- planation. M. Andral states, that he has ob- served anaemia in the bodies of persons who had died dropsical; and in persons who had com- plained of diarrhoea, profuse perspirations ; and very justly considers both the dropsical effusions into the shut cavities and into the cellular tissue, and the exhalation from the digestive mucous surface and skin, as perfectly independent of any local congestion or irritation, and to be analogous to the profuse diarrhoea and perspirations which occur in persons who are brought near to disso- lution by long protracted disease. In all such cases, whether attended with effusion into shut cavities or cellular tissue, or with increased ex- halation from mucous surfaces, we may consider nearly the same pathological conditions to exist as their principal sources, viz. diminished tone of the exhaling orifices, with lessened vital cohesion of the tissues in which they open ; a poor and thin state of the blood, the crasis of which is much lowered ; and a more rapid circulation of the remaining fluid. 45. Anaemia, when existing even in a moderate degree, will often give rise to various functional disorders, which are, however, of no constant character, but differing with the temperament, habit of body, &c. The chief of these are hys- terical and epileptic convulsions, palpitations, lei- pothymia or syncope and palpitations alternately, irregular or anomalous convulsions and spasms, BLOOD — Morbid-Effects of its Loss. 175 chorea, and various nervous tremors resembling chorea, dyspncea, sickness or vomiting, oedema of the ancles, diarrhoea, headach, &c, with weak, small, quick pulse; pale, waxy, or doughy state of the countenance; listlessness, flatulent state of the abdomen, gastralgia, colic pains, very weak digestion, vermination, and irregularity of the faecal and urinal evacuations. It will also be fol- lowed by atrophy and softening of several of the internal viscera, and general emaciation. 46. In cases where general anaemia is not ex- cessive, it may be admitted that both inflamma- tion and haemorrhages may still occur, particular- ly the latter, from the causes usually producing them; and that they will have a remarkable ten- dency to terminate unfavourably, owing to the state of the system causing the deficiency of blood, to this defect itself, and to the want of vital resistance, as well as to the incompatibility of most of the means of cure with the state of the constitutional powers and of local action. 47. Causes.—Several of the causes of anaemia have been already alluded to (§ 39—42.). There may be others which have not yet been ascer- tained. I may state, however, briefly and gene- rally, those which have been usually acknowledg- ed. They consist of insufficient and poor food; excessive secrections and evacuations; masturba- tion practised early in life, and long continued; long exclusion of the body from the direct influ- ence of solar light and rays; protracted confine- ment in crowded apartments, in the stagnant and impure air of manufactories, especially when af- fecting children or very young persons; and the constant respiration of a moist, impure, and miasmal atmosphere, from which the sun's rays are shut out. All these exhaust or depress the vital and nervous powers; whilst some also either cut off the necessary supply to the circulating fluid, or waste its richer constituents. To these causes may be added certain malignant organic diseases, as carcinoma, &c, which, in the latter stages, is always attended with more or less of anaemia; impeded developement of organs, par- ticularly those belonging to the generative func- tions, whose perfect evolution is requisite to the salutary excitement of all the organic actions, es- pecially those of digestion and sanguifaction; and lesions which either impede these latter functions, and interrupt the passage of chyle into the blood, or vitiate these fluids. 48. Treatment.—The most rational and the most successful means that can be employed con- sist of such as are calculated gently to excite and permanently to promote the organic functions. Of these, the most appropriate appear to be the various preparations of iron, bark, sulphate of quinine, camphor, ammonia, small doses of iodine, aether, &c. combined occasionally with opium, hyosciamus, extract of hops, conium, &c. when the disease is attended with colicky pains. Con- joined with these, the chalybeate mineral waters, stimulating frictions of the surface, light and di- gestible food, gentle exercise in the open air, particularly on horseback, and change of air, will be found of much service. During the employ- ment of tonics, due attention should be paid to the state of the secretions and excretions; and, when the bowels are constipated, the more tonic and less irritating aperients be resorted to. Of these, perhaps, the best are rhubarb, and aloes, the aloes and myrrh pill, the compound iron pill, &c. 49. When the state of the system is attended with hysterical, convulsive, and other nervous affections, a combination of tonics and chaly- beates, with antispasmodics, as the preparations of valerian, ammonia, zinc, myrrh, extract of hops, galbanum, aether, strychnine, and various others, is indicated. If we have reason to suspect that the anaemia is a consequence of obstruction or of torpor, combined with an enlargement of some organ or part concerned in the formation of blood, the preparations of iodine, the liquor po- tassae alone or combined with tonics, the subcar- bonate of soda, the boracic acid, and sub-borate of soda, are the best medicines with which I am acquainted. Bibliog. and Refer.—Reiselius, Miscell. Curios, dec. ii. an. 7. obs. xiv.—Swhenke, in Haller's Disput. kc vol. vii.—Becker, Diss. Resol. Casus Pract. Anaemia?, &c. Leid. 1663.—Albert, Diss, de Ana?mia. Hal. 1732.—Janson, De Morbis ex Defectu Liquidi Vitalis. Lugd. Bat.1748.—Lieu- taud, Precis de la Medicine Pratique, p. 71. Paris, 1761. —Halle", Journ. de Medecine, &c. par M. Corvisart, kc t. ix. p. 3.—Gaspard. in Journ. de Physiol. Experiment, kc. t. i. Octobre 1821.—Chomel. art. Animie, Diet, de Med. t. ii. p. 238.—Roche, art. En&mie, Diet, de Med. et Chirurg. Pract. t. ii. p. 372. — Andral, Clinique Medicale, t. iii. p. 558., also his Pathological Anatomy, translated by Townsend and Mist, vol. i. p. 91.— Combe, Trans, of the Med. and Chirurg. Soc. of Edin. vol. i. p. 194. V. Morbid Effects of Loss of Blood.— 50. This is a subject of greater practical impor- tance than has generally been attached to it; and one which I have had numerous occasions to con- template, particularly from the years 1816 to 1828, —an epoch during which blood-letting was either more generally adopted, or carried further, than the nature of several diseases, and the constitu- tions of many patients, warranted. The effects of large depletions have been well illustrated by the experiments of Dr. Seeds, which have shown, what indeed might have been anticipated from the physical condition of the circulation within the cranium, viz. that we can never hope by depletion alone to materially diminish the quan- tity of blood in the vessels of the brain. Dr. M. Hall, and the Author, have also shown that several morbid states may be occasioned by large losses of blood, or by too large a proportion of this fluid circulating in the head, relatively to the rest of the body, as a consequence of large blood- letting; and M. Piorry has illustrated the same subject by numerous experiments, and has offered many instructive and practical observations on it, particularly in relation to diagnosis. 51. The morbid effects of loss of blood may be advantageously considered in relation, first, to a person previously in health, or not affected by dangerous disease; and, secondly, to persons la- bouring under different diseases in which loss of blood may occur, either naturally or from inju- dicious practice. My observations on both these branches of the subject must necessarily be brief, more particularly on the latter, as the topic is not overlooked in the consideration of the treatment of those diseases in which such losses are most likely to be met with. 52. i. Morbid Effects of Loss of Blood in persons not previously affected with serious disease.—These effects will naturally vary with the suddenness or rapidity of the loss, the extent to which it has proceeded, and the habit of the person, especially as regards vascular 176 BLOOD — Effects o* large Loss of. plethora, at the time when it occurred. It is evi- dent that an evacuation which has been rapid will have a more marked and serious effect, than the same quantity removed at several times, or in a slower manner; and that, when blood is discharg- ed at intervals, a much larger quantity may be lost without producing the morbid effects often result- ing from the sudden loss of a smaller quantity; or, if they occur, they may be of a different kind from those which follow rapid discharges. The sub- jects, therefore, which chiefly require considera- tion are, 1st, The immediate effects of large loss of blood; 2d, The more remote consequences; and, 3d, The slow and insidious effects superven- ing on repeated losses, each occurring to a small or moderate extent. 53. A. Ofthe immediate effects of large losses of blood.—These are, vertigo, leipothymia or a sense of sinking, syncope; feeble and slow, or sometimes quick fluttering pulse; slow or appa- rently suspended respiration for short periods, interrupted by deep sighs; eructations from, and sometimes sickness of, stomach; a cold, pale, and bedewed countenance and general surface; irre- gular sighing and yawning, generally followed by a return of the pulse and of consciousness; and, if the haemorrhage is not renewed upon the re- storation ofthe circulation, recovery soon follows. Where, however, the loss of blood is greater, the above symptoms are more marked; the syncope is more profound; the respiration, which is car- ried on during this state entirely by the diaphragm, is nearly imperceptible, until it suddenly returns at intervals, with deep sighs: sickness and vomit- ing occurs, and restores consciousness for a time, but the patient again relapses into syncope, which is broken in a similar manner; and, if the loss of blood has ceased, a more permanent restoration follows the sighing and sickness, and recovery slowly takes place. 54. When, however, the loss is still greater either absolutely or relatively to the energies of the patient, or if it continue after the above effects supervene, the return of consciousness is often at- tended with some degree of delirium; a difficult stertorous breathing; dyspncea; gaspings for breath; occasionally retellings, and discharge of the contents ofthe large bowels; an irregular, in- termittent, feeble, or imperceptible pulse; loss of animal heat; great restlessness, violent shudder- ings, or general tremors, and jactitation, sometimes so violent as to shake the bed upon which the patient lies; a sense of sinking through the floor; convulsions, or tetanic spasms, and contractions; terrible gaspings for breath, and death. 55. Such is the common grouping of the mor- bid effects; but some of them are more marked than others. Thus, when the loss of blood is very large, the patient may suddenly and unex- pectedly expire in one of the fits of syncope which occur, or he may sink more gradually, without any appearance of delirium or convulsion, some- times with the faculties entire to the last. The former may occur after excessive blood-letting or haemorrhage, when the patient has been incau- tiously raised up, or when he has not been in- stantly placed in the recumbent posture when syncope occurred: the latter has taken place un- expectedly when blood-letting has been carried too far, or too often repeated, in the recumbent posture. 56. Convulsions are often the most marked effect, either of excessive haemorrhage or of large and repeated venisection in the recumbent posi- tion; particularly if it be carried to leipothymia or syncope in this position, which ought always to be avoided. This symptom is very common after puerperal haemorrhagy, or any large losses of blood occurring in females, particularly those of an epileptic or hysterical diathesis, and in children or young subjects. 57. Delirium is another prominent effect of ex- cessive evacuation of the vascular system; but it usually presents something peculiar. The caro- tids are often neither full nor strong, the counte- nance is pale, and the head cool, — symptoms indicating, with the character ofthe delirium, im- paired vital energy of the brain. In some cases the delirium is associated with convulsions, and both may ultimately be followed by coma or lethargy. Delirium more rarely occurs in chil- dren or young subjects from excessive loss of blood, than in adult or advanced age; but coma, as will be shown hereafter, is not infrequent in the former, particularly when the loss of blood has occasioned convulsions, which in them usual- ly terminate in coma. 58. B. Ofthe more remote effects of large loss of blood.—When the patient is not carried off" by the more immediate effects of excessive loss of blood, reaction generally supervenes, and often becomes excessive. It usually commences with palpitations, and throbbings through the body, but particularly in the carotids and arteries of the head, giving rise to the peculiar noises, of which patients so often complain after large depletions. The pulse now becomes quick, sharp, and soft; and there is sometimes distressing nervous pulsa- tion of the aorta. In the more marked cases of reaction, the patient complains also of pain ofthe head; intolerance of light and of noise; a sense of tightness or pressure around the head; hurry of mind, and sometimes delirium, particularly in the night; restlessness, agitated sleep, often ac- companied with a sense of sinking or impending dissolution, fearful dreams, &c. The arteries throb; and the pulse ranges from 110 to 140, is jerking, sharp, open, and bounding, but readily compressed. The respiration is hurried, panting, and frequent; often attended with sighing, a desire of fresh air, great restlessness, and in females for aromatic perfumes, or the smelling bottle. The mouth and throat are dry; there is much thirst; and the skin is usually hot, but the extremities, particularly the lower, are generally cold. 59. This state has not infrequently been mis- taken for one requiring depletion; and I have met with cases in which the idea of inflammatory action had so taken possession of the mind of the practitioner, as to induce him to employ large or repeated depletion, which had been followed by this state of reaction, for which he was proceed- ing again to deplete, mistaking the morbid effects of the previous excessive loss of blood for a return of the inflammation. If this state of reaction be not judiciously managed, exhaustion rapidly su- pervenes; and almost as soon as it occurs death may take place, frequently upon some muscular effort, or upon getting up from the recumbent posture. In some cases, particularly in children and young subjects, the delirium or morbid sen- sibility of the brain, characterising the reaction, BLOOD—Effects passes rapidly into a state of lethargy and coma, which on numerous occasions I have seen mis- taken for effusion of serum within the cranium, or hydrocephalus, particularly when it has been preceded by convulsions, as is often the case in children. In many such cases, either no effusion is found, or the effusion is to an extent insuffi- cient to account for the comatose symptoms. 60. Under more favourable circumstances the reaction is gradually followed by returning health, or lapses into a state of chronic exhaustion or as- thenia, which is variously characterised. In some cases it is attended by somnolency, alternating with slight delirium, &c. : in others, by fits of dyspnoea, palpitations, frequent cough ; hurried, laborious breathing; a flatulent, tympanitic state of the abdomen : in several, by pale, emaciated, or discoloured countenance and skin; amaurosis, nervous tremors, or jactitation ; delirium, or mania : and in puerperal females by a form of mania which requires to be carefully distinguish- ed, and which is particularly noticed under the article on Puerperal Mania. In addition to these functional disorders following reaction after large losses of blood, organic changes may supervene; such as effusion of serum and extravasation of blood upon the brain, effusion into the bronchi and air-cells, dropsical effusions in various parts, and flatulent distension ofthe stomach and bowels. When recovery takes place, the pulse always con- tinues small and frequent for a long time, owing to the remarkable diminution of the fluid in the vessels. 61. C. Of the insidious effects produced by small but often repeated losses of blood.—Loss of blood occurring in this manner produces effects diflerent from those now described. They gene- rally, as may be expected, advance slowly, and often exist either altogether, or a long time, with- out detection. They are extremely various, ac- cording to the age and constitution of the person. They most frequently occasion a pale, leuco- phlegmatic, and lax appearance of the counte- nance and surface; a very quick, weak, and irri- table pulse; hurried, and oppressed respiration; frequent palpitations, and sense of sinking; borbo- rygmi, and hysterical symptoms ; flatulent dis- tension of the colon, and colicky pains; swellings of the ankles, and dropsical effusions in other parts: in females, difficult and scanty menstru- ation, chlorosis, deviations of the spinal column, epileptic convulsions, pains in the loins, and various anomalous affections of a painful or spasmodic kind; tremors, and irregular action of muscles; chorea; paralysis; dyspeptic disorders, with irregularity of the bowels; a disposition to syncope; amaurosis; and all the symptoms of anaemia, which indeed is the primary or real state of disease produced, and constitutes the chief change detected upon examination after death; together with serous effusion in some situations, and a pale bloodless state of the viscera, and of the heart itself. 62. ii. Of excessive Loss of Blood in the course of various diseases.—There are two important considerations which should not be over- looked in practice; viz. that in many diseases, apparently attended with excitement, we shall meet with cases in which the actual quantity of blood in the body is much less than usual; and in various others, blood-letting will often not be of large Loss of. 177 borne, although seemingly indicated, and although the quantity of blood in the frame be not lessened. In illustration of the former of these, I may state that many years ago I had an opportunity of remarking minutely the appearances on dissec- tion of a man of middle age, and somewhat fat, who had complained of an acute and painful disease, obviously functional, for which he had been blooded only twice on successive days, and on neither occasion to above thirty ounces; and yet the symptoms of excessive loss of blood ap- peared, from which he died in twenty-four hours after the second depletion. The most careful examination could detect no organic change, ex- cepting the remarkably bloodless and pale state of all the viscera. Even the brain was less vascular than usual. That in various diseases, unattended by diminution of the circulating fluid, depletion will produce marked symptoms of de- pression and sinking, owing to the state of the vital power being insufficient to accommodate the vessels, by their tonic or vital contraction, to the reduced bulk of the blood, is well known, and has been fully discussed in the articles on Adyna- mic Fevers, Erysipelas, and Puerperal Fevers ; in which, as well as in puerperal mania, and va- rious other acute diseases, large vascular depletion is often most injurious. 63. A. Of excessive loss of blood in diseases of excitement. — The morbid effects of large deple- tions will necessarily vary with the nature of the disease in which they are employed. When carried too far, in cases of excitement, where the nervous or vital power is not depressed, and the blood itself rich or healthy, reaction generally follows each large depletion, and thus often ex- acerbates or brings back the disease for which it was employed, and which had been relieved by the primary effects of the evacuation. This is more remarkably the case in acute inflammations of internal viscera, particularly of the brain or its membranes. Thus, every observing practitioner must often have noticed, that a large depletion, when carried to deliquium, will have entirely re- moved the symptoms of acute inflammation when the patient has recovered consciousness; and that he expresses the utmost relief. But it generally happens that the inordinate depression — the very full syncope that is thought essential to the securing of advantage from the depletion — is fol- lowed by an equally excessive degree of vascular reaction, with which all the symptoms of inflam- mation return; and the general reaction is ascribed entirely, but erroneously, to the return of the in- flammation, instead ofthe latter being imputed to the former, which has rekindled or exasperated it, when beginning to subside. The consequence is, that another very large depletion is again pre- scribed for its removal; and the patient, recollect- ing the relief it temporarily afforded him, readily consents. Blood is taken to full syncope—again relief is felt — again reaction returns — and again the local symptoms are reproduced : and thus, large depletion, full syncope, reaction, and the supervention on the original malady of some or all of the phenomena described above as the conse- quence of excessive loss of blood, are brought before the practitioner, and he is astonished at the obstinacy, course, and termination of the disease; which, under such circumstances, gene- rally ends in dropsical effusion in the cavity in 178 BLOOD—Effects of large Loss of. which the affected organ is lodged; or in con- vulsions, or in delirium running into coma ; or in death either from exhaustion or from one of the foregoing states; or, more fortunately, in partial subsidence of the original malady, and protracted convalescence. Such are the consequences which but too often result — which I have seen on numerous occasions to result, when blood-letting has been looked upon as the only or chief means of cure—the "sheet anchor" of treatment, as it too frequently has been called and considered during the last twenty years. 64. B. Ofthe mode by which excessive loss of blood in disease may be best avoided.—Method of conducting blood-letting. From the above it will appear obvious, that if blood-letting were better managed, and directed so as to make an impres- sion on the local ailment, but in such a manner as to avoid being so readily followed by the reaction which reproduces the malady for which it was employed, great advantage in practice would result, and much less blood require to be removed even in the most acute cases, a. In order to accomplish this, I have long been in the habit, ■—and have inculcated it in my lectures on the practice of medicine, from 1824,—of directing the following mode of practice when large blood- lettings were required in the treatment of visceral inflammation :—The patient should be either in bed, or on a sofa, and in the sitting or seini- recumbent posture, supported by several pillows. The blood is to be abstracted in a good-sized stream, and the quantity should have some re- lation to the intensity and seat of the disease, and the habit of body and age of the patient, but chiefly to its effects; it should flow until a marked impression is made upon the pulse, and the countenance begins to change. Further deple- tion must not now be allowed; but the finger should be placed on the orifice of the vein, the pillows removed from behind the patient, the recumbent posture assumed, and the arm secured. Thus a large quantity of blood may be abstracted, when it is required, without producing full syn- cope, which should always be avoided ; and when a large loss of this fluid is either unnecessary, or might be hurtful, the speedy effect produced upon the pulse and countenance by the abstrac- tion of a small quantity will indicate the impro- priety of carrying the practice further. In this manner I have often removed about forty ounces of blood, where large depletion was urgently required, before any effect was produced upon the pulse, but always carefully guarding against syncope; and by the subsequent means used to prevent reaction, no further depletion has been required. 65. b. In order, however, to obtain this object, a treatment varying with the nature of the disease is required. Repeated doses of tartarized anti- mony, either given in small quantities at very short intervals, or in large doses, combined with opium ; full doses of calomel, antimony, and opium ; of camphor, nitrate of potash, and col- chicum; or of ipecacuanha, nitre, and opium, &c, particularly the first of these, exhibited 'so as to excite nausea, but guarding against retching as being liable to induce reaction; and the in- dividual antiphlogistic remedies, appropriately directed, and combined according to the cir- cumstances of the case, are the chief means which I have employed to prevent the return of increased action after blood-letting conducted as now stated. The particular measures which may follow blood-letting are fully explained in the articles on Inflammation of the different Organs; but I may now mention, that when opium is given with the view of preventing the recurrence of reaction, it ought to be exhibited in a large dose at once, (two or three grains,) either with a full dose of James's powder, or any other anti- monial, or with two or three of ipecacuanha, con- joined with some one of the other substances above mentioned. 66. It should be kept in recollection, however, that reaction after large depletions is chiefly apt to occur in idiopathic inflammations, and other diseases of excitement, in which the constitutional or vital powers are neither remarkably lowered nor depraved; and when the circulating fluid is not vitiated by the retention of those substances in it which require to be eliminated, nor by the absorption of matters which are foreign to its na- ture, and injure its purity. Reaction is very apt to follow large losses of blood in acute rheuma- tism ; in inflammations of the membranes of the brain, and, indeed, of all serous or fibro-serous membranes; and by its recurrence to reanimate the local action; so that a person may be blooded to that state which has been described as the extreme result of large loss of blood, (§ 54.) and yet, trusting to this practice alone, the local disease has either not yielded, or has passed into one or other of the unfavourable terminations it is liable to assume, particularly dropsical effu- sions. In the course of practice I have frequently seen persons who had experienced attacks either of pleuritis, pneumonia, peritonitis, enteritis, or of some other inflammation, and who had recovered with great difficulty, and after a long convales- cence. Upon enquiry, I found that they had always been blooded largely, and to syncope,— some of them four, five, or even six times, but scarcely ever less frequently than thrice; and yet, upon a subsequent attack of inflammation in its most acute form, in the same or some other organ, a single depletion, practised as I have recom- mended above, and followed by the means most likely to prevent the return of reaction afterwards, to subdue the local action, to solicit the flow of blood to other parts, and to equalise its distribu- tion over the body, has been sufficient; or, at most, a single repetition of the vengese"ction has been all that has been required. 67. c. When the chest is dull on percussion, the heart congested, the liver large, and the veins distended ; or when the circulation is full and strong, the capillaries injected, the lips and mu- cous surface red, the muscles firm and large, or the respiration oppressed, blood-letting is generally required, and is well borne. It is also necessary even when the pulse is languid, the external venous circulation difficult, and the surfaces pale, if these symptoms be conjoined with those in- dicating internal congestion. (See Congestion.) On the other hand, persons with an open, soft, full pulse, florid countenance, lax muscles, &c, although they may bear moderate loss of blood, yet suffer more from large depletions than those of a pale, dry, thin, but muscular and rigid habit of body. 68. Under no circumstances ought a patient to BLOOD — Effects of lar< be blooded whilst his head is nearly on the same level with the trunk ; and the utmost care should be taken in having recourse to venaesection in ca- ses of dilatation of the cavities of the heart, par- ticularly those of a passive nature. It is seldom necessary in such cases : and if circumstances should arise to require it, the blood should be tak- en, in the manner I have inculcated (§ 64.), from a small orifice and to a small extent. In the ma- jority of cases, the state of the venous circulation, if duly examined, furnishes some information as to the quantity of blood in the system, and there- fore sometimes becomes a valuable guide to blood- letting in some doubtful cases. 69. When the superficial veins are distended, of a deep or dark colour, and the blood flows quickly, and the veins fill rapidly on applying fric- tion and pressure—indicating that their usual state of fulness does not depend upon interrupted cir- culation about the right side of the heart, or hi any part of their course—we may infer that the system is sufficiently supplied with blood. But if the veins are small or pale, the body not being fat; if they swell slowly upon a ligature being applied above them ; or are readily emptied by friction, and very slowly refilled ; we must infer the existence of a feeble state of the circulation, and a deficient as well as poor state of the blood: and the inference will be further verified if we find this state associated with a pale sickly ap- pearance of the countenance and integuments ; a small, feeble, and quick pulse ; and paleness of the lips, conjunctiva, tongue, and gums. (See §43.) 70. C. Of loss of blood in relation to diseases of depressed vital power, fyc.—There is a numer- ous class, or rather classes, of diseases, in which blood-letting, either in small quantity, or carried too far, is especially injurious. All those in which the circulating fluid is poorer and thinner, or less pure, than in health, particularly chronic and ma- lignant diseases presenting more or less of the symptoms of anaemia, and disorders occurring in ill-fed and emaciated subjects ; those in which the vital endowment of the blood-vessels, or their tonic contractibility, is partly lost, or manifestly reduced, as various forms of fever, puerperal and other diseases in which hurtful matters are apt to pass or to be absorbed into, or not to be eliminated from, the blood ; all those in which the vital cohesion of the soft solids is diminished, and the fibrine of the blood is incapable of coher- ing in the manner necessary to form a tolerably firm coagulum, are injured by large bleedings, or even by depletion to any extent. In the first of these, it is obvious that blood cannot be spared : in the second, although its loss might not be felt in other respects, the vessels cannot accommodate themselves to the state of their contents when any considerable quantity is abstracted : and in the last, as well as in them all, the vital manifest- ations of the circulating system, and of the solids generally, of which cohesion is one, is so far in- jured, that the primary morbid condition from which they all proceed is increased by the opera- tion ; and, moreover, a greater disposition to the absorption of morbid matters is imparted to the ab- sorbing function, when such matters are within the ephere'of its operation, by the vascular depletion. 71. I may, in conclusion, remark, that all dis- eases essentially spasmodic, and consisting of ge Loss of — Treatment. ]7g irregular action of muscular parts, or of altered sensibility of nerves, or of morbid exaltation of their peculiar sensibilities, even when affecting in- ternal organs, or the heart itself, and when no con- clusive evidence of inflammation exists, will eith- er be aggravated by loss of blood—in some cases even to a moderate extent—or be readily follow- ed by the effects which have been described as consequent upon an excessive evacuation of this fluid. But I may further add, that, in many cases, where the above reasons for abstaining from large or repeated depletions, or from venaesection, strictly apply, local depletions, under due restric- tions, may be resorted to with advantage. 72. iii. Treatment of the Effects of large Loss of Blood.—This will necessarily vary with the particular effect produced, and the state of the patient and of the disease in which excessive loss of blood occurred. The more im- mediate effects of the loss are the first to claim attention ; the other morbid conditions, which re- sult from it more remotely, will be considered in succession. 73. A. Treatment of the primary effects of loss of blood.—The more immediate effects (§ 53.) generally require the recumbent posture, free ven- tilation, and airy apartments ; in the extreme cases, stimulants, sprinkling the face with volatile and fragrant fluids, and even the transfusion of blood. In the worst cases, and particularly when the loss of blood has occurred from the rectum or vagina, the head and shoulders should be placed lower than the pelvis ; and care should be taken to as- certain whether or no internal haemorrhage is going on, as far as this may be accomplished (see Uterine Hemorrhage). In all cases of haemorrhage, the involuntary discharge of urine and evacuation of the bowels ought to be considered most dangerous symptoms—even more so than the occurrence of convulsions—and the most decided measures should be instantly adopted. Where we have reason to suppose that'transfusion will be required, it should not be delayed too long, as the risk from delay is infinitely greater than that from the operation per- formed by an expert surgeon, and with a proper apparatus. In cases where convulsions or delirium occur, or when these pass into coma or lethargy, it will be necessary to exhibit, internally, stimuli, as aether, spirits of ammonia, and camphor, with a little tincture of hyoscyamus ; to sprinkle aether, or lavender water, or eau de Cologne, over the face and head ; to apply a blister to the nape of the neck, or on the epigastrium ; to support the animal heat in the trunk of the body and extrem- ities ; and to administer the lightest and blandest nourishment. Recovery from large loss of blood is usually quick, when the functions of digestion and assimilation have not been greatly injured by it ; but when they remain imperfect, or remarka- bly disordered for some time afterwards, we may dread the formation of visceral disease, and should direct change of air, voyaging, and travelling, with the use of tonic and deobstruent mineral waters, and appropriate internal medicines. 74. B. Treatment of reaction after large loss of blood.—Careful reference ought to be had by the inexperienced practitioner to the symptoms indicating this state (§58.), so as to distinguish between them and the general excitement conse- quent upon internal inflammation. This state will require means modified according to the fea- 180 BLOOD —its Alte rations in Disease. tures it assumes. But generally the morbid reac- tion existing in the head, and rendering all the senses remarkably acute, and the system suscep- tible of impressions, as well as the distressing pal- pitations of the heart, require the utmost quiet, and small doses of hyoscyamus, or extract of hops, with the preparations of ammonia, and mild nourishment. Where the throbbings or pains in the head are urgent, the surface of the head warm, or delirium exists, cold spirituous lotions, applied over the head, and full doses of hyoscyamus with ammonia,or moderate doses of the acetate or the muriate of morphia, with weak brandy and water, and warmth applied to the lower extremities, will be required. 75. C. Treatment of consecutive exhaustion, or sinking.—Here stimulants are required in larger doses ; and should be administered by the mouth, in the form of enema, and externally. It is possible that transfusion would also be of ser- vice in this state of the system. If coma be pre- sent in this stage, large doses of camphor, aether, and ammonia are required, with the tepid effusion on the head ; blisters, or mustard cataplasms to the nape of the neck, or epigastrium, or to the feet. In more chronic cases of exhaustion or sinking, gentle nourishment, in small quantities and often ; warm tonics, combined with gentle ape- rients, in order to remove morbid secretions, and relieve flatulence ; nutritious enemata, or injec- tions of gruel or mutton broth ; and small quan- tities of weak brandy and water ; are the best means that can be adopted. 76. D. Treatment of certain effects of deple- tion in relation to disease.—a. Large loss of blood during diseases of excitement (§63.) requires a treatment but little modified from that already re- commended. When it has occurred during in- flammations, a certain degree of irritative action may still continue, notwithstanding the excessive loss of blood, occasioning dropsical effusion into shut cavities ; and, when the disease is seated in the lungs, effusions in the bronchi or air-cells, which the powers of life are insufficient to throw off, or to expel. In such cases external deriva- tives, and a combination of gentle stimuli, with diuretics, anodynes, and diaphoretics, in order to equalise the circulation, and to lower the irritative action in the part affected, often prove of service. When the primary disease is seated in the head, the tepid or cold affusion, cold lotions to the head ; external revulsants applied to the nape of the neck, or to the lower extremities ; anodynes, cam- phor, with hyoscyamus, or with acetate of mor- phine ; and the promotion of the alvine and cu- taneous secretions and excretions ; constitute the principal measures, together with those already enumerated (§74, 75.). 77. b. Loss of blood occurring during diseases of vital depression (§ 70.) requires the most ener- getic means. The objects very generally are to restore, as far as may be, the vital endowment__ the tonic contractility, of the vascular system, and to enable it to act with sufficient energy on the fluid circulating through it ; to increase the vital cohesion of the soft solids ; and to excite the se- creting organs to remove the hurtful ingredients that may have passed into, or accumulated in, the remaining fluid, and which tend to vitiate the whole of the structures, and to sink still lower the already depressed powers of life. These ends can be attained only by exhibiting, in frequent doses, the various tonics and stimuli ; particularly those which tend to arrest or to counteract the morbid changes going on in the frame, and to ral- ly the powers of life. Of this kind are the prep- arations of bark, or quinine, combined with cam- phor, the aethers, particularly muriatic aether, the preparations of serpentaria, spirits of turpentine, wine, opium, and various remedies of the same description, combined according to circumstances, and generally exhibited in small or moderate doses frequently repeated. External stimuli, rubefacient cataplasms and liniments, stimulating and tonic enemata, injections of mulled port wine,with opium and camphor, are often of great benefit. When the secretions require to be carried off, rhubarb and other tonic aperients may be employed. When the disease is attended with coma, blisters or sin- apisms to the nape of the neck, epigastrium, or the feet, may be employed ; and either of the fol- lowing formula, in the Appendix, exhibited (see F.423. 496. 845. 906.). If low muttering delirium be present, the same treatment as is recommend- ed for this state in typhoid fevers is required. Bibliog. and Refer.—Monlrin, Des Eft'ets des Dif- ferentes Especes d'Evacuations Sanguines, &c. Lyons, 1810.—Seeds, in Lond. Medical Gazette, vol. v. p. 433__ M. Hall, On the Effects of Loss of Blood, in Trans, of Med. and Chirurg. Society, vol. xiii. p. 121.; and Researches rel- ative to the Morbid "and Curative Effects of Loss of Blood 8vO. Lond. 1830.—The Author, in London Medical Re- pository, voi. xx. p. 15.—Piorry, Memoires sur la Circula- tion, kc Paris, 1831. VI. Alterations of the Blood in Dis- ease. 78. It will be necessary to the accurate estima- tion of the causes and results of the various changes of the blood in disease, briefly to consider the re- lation in which the different functions of the body stand to the blood. These functions are of the fol- lowing kinds : viz. of sanguif action, nutrition, de- puration, and secretion; one organ performing, or contributing to two, or even three, of these offices. We know that digestion, absorption, arterial cir- culation, and respiration, are necessary to the for- mation of the blood, and to the nourishment of the tissues : we also know that absorption, nutrition, secretion, and venous circulation, are concerned in rendering the blood impure, by conveying hurt- ful ingredients into it, or allowing others to accu- mulate in it, or by destroying the relative propor- tion of its constituents ; and that various organs, particularly those of secretion and respiration, are actively concerned in eliminating such matters as become injurious by excess, or pass into the circu- lation from the various sources of impurity which surround it. Hence it must be evident,that changes in the solids, and particularly in those viscera which are concerned in the supply and waste ofthe blood, as well as in its depuration, must be followed by changes in the state of this fluid ; unless when one or two organs merely have their functions inter- rupted, and others performing analogous actions to these disorders assume a vicarious office. It must be evident, therefore, from this, that the doc- trines of solidism and humorism are, to a certain extent, both correct ; that, although disorder may originate in either, it cannot be long limited to one or the other, but must extend more or less to both, according to the nature of the causes, and the organs or parts where their impression is made. We observe in the course of practice, that certain morbid or poisonous ingesta make but little im- BLOOD—its Alterations in Disease. 181 pression on the system, until it is absorbed into the circulation, and by its presence there disor- ders various organs or parts; whilst other sub- stances make an immediate impression on the nervous system, and, through its medium, impedes the functions of secretion and depuration, and thus the blood itself is rendered impure, and the source whence all the frame is more or less viti- ated. Various fevers furnish most satisfactory illustrations of this position. 79. Having already considered changes in the quantity of the blood, alterations in its qualities are next to be viewed. The facts which have been observed, connected with this subject, are few and deficient in precision; and the majority of those who have directed their attention to it, have merely described chemical conditions and combinations presented by this fluid after it had been for some time removed from the body, and had lost whatever vital endowment it may have received from the vessels and tissues in which it circulated, or had undergone important changes incidental to this state; instead of describing at the same time such vital manifestations as it may have presented upon its removal, and the relation of its chemical states to the pathological conditions of the body. 80. As we have seen that organization com- mences in the chyle, and that this fluid is the chief source whence the blood itself is formed, the importance of studying the alterations of the blood, in connection with the state of this fluid, is evi- dent; but the difficulty of the investigation gene- rally precludes many from engaging in it. At the 6ame time it must be admitted, that very important changes may take place, not only in the blood, but also in the fluids which supply it, and are secreted from it, without being made manifest to our senses upon the most careful examination. I shall now, first, furnish proofs of important changes in the constituents and state of the blood iu various diseases; and next consider the causes of such changes, and the results to which they usually lead. 81. i. Proofs of Change.—A. In the pro- portion of the chief constituents of the blood, a. The quantity of albumen varies considerably in disease. It is not sensibly diminished by large or repeated blood-letting, unless the quantity of blood, in relation to the bulk of the body, be much di- minished. In many inflammatory diseases, and in a large proportion of cases of active dropsy, the relative proportion of albumen is often very much increased. This has been shown by Blackall, Trail, Gendrin, Bright, and several authors. I have always found it remark- ably increased in most of the exanthemata, par- ticularly before the eruption has come out. Gen- drin shows that, in inflammatory diseases, the serum of the blood often contains twice as much albumen as in the healthy state. When this is the case, the blood feels remarkably viscid to the touch. In diseases of debility, and when the blood is apparently deficient in quantity, and poor in quality, the albumen is generally very much diminished, being sometimes less than half its usual proportion. M. Gendrin and M. Andral think that it may also be altered in its nature as well as quantity; and I believe, from appearances which I have observed in the advanced stages of several diseases, that their opinion is correct. In these 16 cases, the albumen seems either precipitated to the bottom of the serum, or suspended in it like a cloud, giving it a turbid opacity. 82. b. The proportion of the watery part of the blood has been shown to vary in health; but it varies still more in disease, and even in different stages of the same malady. This change is not, however, limited to one, or even a few, of the constituents of this fluid; but sometimes is ex- tended to the most of them. Blood-letting, in acute diseases, diminishes the proportion of co- agulum ; and, if diluents be supplied, increases greatly the proportion of serum, without lessen- ing the quantity of albumen, unless the depletion be carried very far. In several chronic diseases of debility, in the stages of excitement and ex- haustion in fevers, and in the last period or decline ofthe acute exanthemata, the proportion of serum is very considerable, owing to the interruption of the secreting functions; but in acute inflamma- tions, and the early stages of some of the exan- themata, the blood is of a deep colour, and rich in cruor, with an increased proportion of albumen and of fibrine. In the advanced stages of dis- ease, attended with fluid evacuations, the watery part of the blood is diminished. This is remark- ably the case in the pestilential cholera, dysentery, and in some forms of dropsy. 83. c. The colouring matter of the blood evi- dently undergoes some alteration during febrile and malignant diseases. It has recently been supposed that such change has an intimate con- nection with the proportion of the saline constitu- ents of this fluid,—a diminution of these rendering the colouring matter dark coloured, whilst an in- crease of them has an opposite effect; and cer- tainly various facts seem to confirm the opinion. But this alteration is one merely in relation to colour, which is unquestionably rendered much more deep or black in the last stages of the dis- eases now alluded to. But besides alteration of colour, there are others which may be termed dynamic, inasmuch as they relate to the vital en- dowment of the globules, or, if not of the globules, of the fluid generally. In the diseases referred to, and after the operation of virulent poisons, the condition of the colouring matter is remarkably changed : it separates readily, and almost before dissolution, from the central corpuscles which it surrounds ; and, passing through the exhalent vessels of mucous surfaces, with the serous or watery part of the blood, gives rise to the sanious cruor, and the dissolved blood, which we some- times observe issuing from these parts shortly before or after death; and probably to the black vomit in yellow fever. In cases of infection by animal poisons or morbid secretions, this separation of the colouring matter, and solution in the serum, take place very early, indeed almost immediately after death; and it is evidently owing to this change in the blood, that the interior surface of the blood-vessels becomes so deeply coloured, without any other appearance of inflammation. Indeed, the evidence adduced byM. Trousseau •• fully proves this to be the case. (Archives Gin. de Mid. t. xiv. p. 321.) This further accounts for the coloration of the interior of arteries in fatal cases of adynamic or malignant fevers,—an ap- pearance first particularly noticed by J. P. Fr a n k , and subsequently by many others, and by some incorrectly ascribed to inflammation. 182 BLOOD — its Alterations in Disease. 84. d. The fibrine varies greatly in its quan- tity, and as to the states in which it presents itself in the blood removed from the body. Its con- dition will be somewhat modified by the manner in which blood-letting is performed; but generally it soon separates from the serum, and, with the red particles, forms the crassamentum or clot, which will vary in its appearances with the de- gree of nervous energy exerted by the organic nerves on the vascular system, and the quantity of fibrine. a. First, the fibrine and red globules may be in much greater proportion relatively to the water and albumen, and still the crassamentum formed therefrom will be very different, according to the state of vascular action and nervous energy at the time when the blood was abstracted. If the vascular action be increased, or in a healthy state, and the vital energy unexhausted, the fibrine will contract into a firm and large coagulum. If the fibrine retain its relatively large proportion, and vascular action be exhausted, it will contract so imperfectly or loosely, as to enclose a large portion of the serum, and to leave but little of this fluid surrounding it. In the former case the coagulum possesses much density: in the latter, extremely little; indeed, sometimes not sufficient to separate it sensibly from the serum. In such cases the blood is rich, although otherwise very different in appearance, owing to the state of action and vital power. 85. p. In the second place, the fibrine may be in small quantity, and yet present a state of firm attraction, forming a small coagulum in the midst of a larger proportion of serum than is usual in health. Or the proportion being still small, the cohesion of the fibrine may be so weak as to form a tolerably large coagulum; whilst, in other cases, it will scarcely separate from the serum, owing either to its diminution, or the weak attraction of its corpuscles. I have met with it in several cases so nearly wanting, and so deficient in at- traction in other instances, as not to form any coagulum; the red particles having been, as it were, precipitated to the bottom of the vessel in a dark or blackish sediment, without any cohesion in the form of clot. From this it will be inferred, that the quantity of fibrine cannot be reckoned from the apparent size of the coagulum merely, but from the size in connection with density or degree of cohesion. When the blood is deficient in red globules, and fibrine, it has usually re- ceived the appellation of poor blood; the degree of cohesion existing between the particles of fibrine in it, as well as in rich blood, being the general index of the degree of nervous power. But there are apparent exceptions to the indications it pre- sents. Thus, in acute rheumatism, after repeated depletions, injudiciously resorted to,—injudicious- ly, because a frequently injurious, and seldom a beneficial practice—and during the reaction con- sequent upon repeated blood-letting, the fibrine, although much reduced in quantity, will often still continue to adhere firmly, or even to form, in some cases, a buffy coat, and yet the powers of life are reduced very far beyond what the state of the fibrine would seem to indicate. In these cases, the cohesion of the coagulum, and the formation of the buff, are, as well as in many other circum- stances of disease, principally the result of vascular reaction, occasioned by morbid excitement of the nervous influence; and as long as these states exist, this condition of the coagulum will occur, although depletion be carried to the utmost extent. 86. y. Whilst the blood is still circulating in the body, particularly in the last stages of various chronic diseases, the repulsion existing between its existing globules may be so far destroyed as to admit of the fibrinous corpuscles adhering to each other, in some part of the vascular system, or even in one of the cavities of the heart. The fibrinous concretions thus formed are attributable, 1st, To retarded or obstructed circulation of the blood in the part. Van Swieten and Haller state that flocculent and fibrinous coagula have formed in the blood ofthe pulmonary artery during syncope and the cold stage of agues; and they, as well as numerous later observers, have fouxd these productions after exposure to extreme cold, and when death has been preceded by a very languid, obstructed, and irregular state of the circulation. 2d, To effusions of a small portion of coagulable lymph from the inside of a part of the vascular lining, during a state of inflammatory irritation; which lymph may have become the nucleus around which the fibrinous particles may have collected, or the bond of cohesion between them in the first instance : and, 3d, Particularly as respects those fibrinous concretions, in the centres of which purulent or tubercular matter has been found, as in the instances adduced by MM. Legroux, Marechal, and subsequently by others, to the absorption of these matters, or to their passage into the blood from the internal coats of the vessels on which they may have been formed; and from becoming nuclei around which the fibrine has concreted. In some instances, in which these fibrinous masses have been found, little or no connection with the surrounding vessels can be traced. M. Andral supposes that these con- cretions are possessed of a separate vitality, and that the matter detected in their centres is a pro- duct of vessels previously formed in them. This opinion, however, cannot be supported, inasmuch as the matters formed in their centres have no re- lation to, nor have they been found often sur- rounded by, blood-vessels ; and, when vessels have been detected, the firm attachment of the concretions to the inner surface of the vessels at- tests the manner of their formation to be identical with that of other productions of a similar kind. 87. not to attach too much importance to the aspect of the blood in inflammations, and also not to forget that, whatever may be its condition, phleg- masia will develope itself when the causes from which it springs are sufficiently powerful. 104. A whitish appearance of the venous blood has been long observed, arising from the presence of white flakes or streaks. This has been ascribed 186 BLOOD —its Mo rbid Relations, to various causes; but with greatest truth to the existence in it of a large portion of unaswimilated chyle. The separation ofthe blood into a soft or natural coagulum, and a milky serum, is much more common. This, as well as the foregoing state of the blood, has been imputed to various causes. Emmert considered that it was owing to a substance analogous to buff. Some have as- cribed it to milk ; others to albumen ; a few pathologists view it as owing to a matter analo- gous to fibrine; and several, as proceeding from the admixture of liquid flit. Haller imputed it to liquid chyle. Of these opinions, the two last are the most accurate. There can be no doubt that both the milkiness of the serum, and the whitish streaks observed in venous blood, are owing in a great measure to unassimilated chyle; and the more ac- curate researches of modern chemists, particularly Christison, Babington, Le Canu, &c. have detected in this kind of blood an unusual proportion of oily matter. This state of the serum is occa- sionally met with in various diseases, functional as well as organic; and seems connected with defi- cient assimilating power. Sydenham states, that he observed the blood drawn from a young con- valescent to resemble pus,—an appearance prob- ably owing to the great quantity of chyle carried during convalescence into the' blood, which had been poor and defective, and to the circumstance of this fluid not having then experienced the pro- cess of sanguifaction. Nicolas and Guende- ville have noted, that the blood of diabetic pa- tients contains an increase of serum, and very little fibrine: this seram contains, according to Rollo, a saccharine matter; about the thirtieth part of what is found murine, according to Wollaston. 105. During the prevalence of scurvy hi Ad- miral Anson's fleet, the blood taken from the veins, after the eruption had appeared, was marked with dark or with vermilion streaks; on first issu- ing from the veins it was dissolved and very black, but after standing some time it thickened, and as- sumed a dark colour ; no regular separation of its serum took place, and its surface was greenish in several places. When the disease had arrived at its third stage, the blood was as black as ink; and although it was kept several hours in a vessel, its fibrous part precisely resembled wool or hairs floating in a muddy substance. The blood issu- ing from the mouth, nose, stomach, intestines, or any other part, in the last stage of this malady, was entirely decomposed, black, or yellowish. It was found after death entirely dissolved in the veins, so that by cutting some branch of a rather large vein, it was possible to empty all the neigh- bouring branches with which it communicated of the yellowish black fluid they contained. The extravasated blood was of the same nature. In a scorbutic patient, opened by order of Cartier, the cavities of the heart were stated to have been entirely filled with corrupted blood. 106. In four cases of scurvy, Rouppe has found the right cavities of the heart filled with black and coagulated blood; and a greenish yellow po- lypus-like matter filling the left cavities of this organ, the aorta, and the pulmonary artery and vein. Amongst the scorbutic subjects opened at Paris in 1699, by Poupart, it was found that in those who had died suddenly, the auricles of the heart were dilated by coagulated blood, the muscles loaded with black and corrupt blood, and the cellular sub-cutaneous tissue infiltrated by extravasated, black, coagulated, and congealed blood, in some cases, and by red blood in others. 107. Bichat found in a dead body, instead of venous blood; a greenish sanies, which tilled all the divisions of the splenetic vein, the trunk of the vena porta, and all its hepatic branches; so that when cutting the liver, he distinguished by the flowing of this sanies all the branches of the vena porta from those .of the hepatic vein, which contained blood in a natural state: this body was remarkable for such an excessive obesity, that Bichat never remembered seeing any thing equal to it. Unfortunately he does not give us the s\ mp- toms of the disease of which this person died. 108. According to Coyter, Gendrin, and many others, a black pulverised-like substance deposits itself at the bottom of the vessel con- taining blood taken from persons affected with typhoid, malignant, and gangrenous diseases; the clot being often either completely dissolved, or not formed at all. I have seen these appearances, and various modifications of them alluded to above (§94.), not only in these diseases, but also in hematemesis, dysentery, severe infectious erysi- pelas, phlebitis, the dangerous forms of puerperal diseases, puerperal mania, and in purpura hemor- rhagica. 109. Remarkable fluidity of the blood is al- ways observed after death from severe blows on the epigastrium, and from lightning. J. Hunter states, that he has also found it fluid after death from a violent fit of passion. Morgagni observed it in a similar state after death from hunger; and M. Audouard relates, that it was uncom- monly fluid in a man who died from coup de so- ldi, voiding blood from the mouth and nostrils. In two cases of hydrophobia I found the blood black; so fluid in the heart and veins, that it flowed out abundantly from the vessels of the head and neck, presenting an infinite number of oily points or particles on its surface; and, when removed from the vessel, it did not afterwards coagulate. The same appearances were observ- ed in a large proportion of the numerous cases described by M. rl rolliet, and other authors on this disease. M. Trolliet states, that in several of his cases, a considerable quantity of gas escaped from the heart and aorta. 110. iii. The Causes of Changes in the hfatlhy state of the Blood.—The causes which occasion morbid changes in the state ofthe blood, are either such as are confined in their op- erations to individuals, or such as influence whole classes, or the community generally. Thev may thus be sporadic, endemic, or epidemic. In re- spect to their mode of operation, they may be ar- ranged, 1st, Into such as vitiate the fluids from which the blood is formed ; 2d, into those which impede the functions of secretion and depuration; 3d, Those putrid or septic matters which contam- inate the tissues and fluids to which they are ap- plied, and act chiefly by absorption ; 4th, Those which act upon the vascular system, either direct- ly or indirectly, through the nerves which supply it; and, 5th, The passage into the blood of mor- bid matters formed in the same body that is the seat of disease. 111. A. Of vitiation of the blood by the fluids which form it.—The fluids which supply the waste of the blood are not infrequently vitiated, BLOOD — its Morbid Relations. 187 and thereby change the state of the circulating mass. The chief sources of this vitiation are hurtful or unwholesome ingesta. Many articles, even of food, will be hurtful when too long con- tinued. The injurious effects of salt provisions on the blood, when exclusively employed, and par- ticularly if depressing causes cooperate with this diet, are evident, and are fully illustrated in the article on Scurvy. The influence of diseased rye, in first changing the condition of the blood, and inducing a state of chronic arteritis, termin- ating in gangrene of the extremities, is also well known; and the effects of diseased or putrid flesh upon the system have been often noticed, although not always correctly traced to the quarters where the principal changes are produced. M. Bertin states that a numher of negroes in Guadaloupe, having eaten the flesh of some animals dead of an epizooty, were seized with fever, and violent ileus, of which the greater number died : and nu- merous cases are on record, where persons shut up in besieged towns, having partaken of putrid animal matter, or ofthe flesh of animals that have died, have been seized with malignant states of disease; and the blood has been found fluid, dis- solved, blackish, grumous, &c. upon examination after death. In these, and numerous similar in- stances which might be adduced, although the state of the blood has been alluded to in general terms, the information has been deficient in pre- cision, and has been furnished incidentally, the attention of the observer having been directed to other quarters. 112. M. Magendie adduces, in his Journal, the instance of a man, who, after a long use of vegetables in which the oxalates abounded, underwent the operation of lithotomy, and a large oxalate of lime calculus was removed from hiin. We know that a large proportion of both our mineral and vegetable medicines operate by being absorbed into the circulation (see art. Ab- sorption, &c); and there is every reason to suppose that various morbid or foreign matters may pass with the chyle into the blood, and modify its condition. The excessive or long con- tinued use of alkalies, or of alkaline salts with excess of base, has the effect of diminishing the cohesion and the viscosity of the blood, and of preventing it from coagulating after it has been removed from the vessels; and while these sub- stances thus, as it were, dissolve, or attenuate this fluid, they also diminish the vital cohesion and tonic contractility of the extreme vessels and of the tissues, and create a disposition to extrava- sation of blood hi the parenchyma of the organs, and to exudation of it from the mucous surfaces. On the other hand, the acids — particularly the mineral acids — turpentine, the superacetate of lead, and all the salts — especially those with excess of acid — have the effect of increasing the healthy crasis of the blood, and of producing an opposite change to that now stated. When used in excess, however, or injected into the veins, they have been conclusively shown to give rise to fibrinous concretions in the vessels, to coagulate the albumen of the blood, to darken its colour, and thus to render it grumous and unfitted for circulation through the minute capillary vessels, particularly those of the lungs. The influence of salted provisions long and exclusively employed, in which the soda is generally in excess, in | attenuating the blood, in preventing its coagula- tion when removed from the vessels, and in re- laxing the soft solids; and the effect of acids in removing these morbid states; are well illustrated by the nature, progress, treatment, and prophy- laxis of scurvy. 113. That the nature ofthe food materially affects the state of the blood is further shown by the general character of the diseases most pre- valent in various communities, living chiefly on certain kinds of aliment. The inhabitants of several places in the north of Europe, who live principally on fish, a large proportion of which is usually kept until it has become remarkably stale, or even ammoniacal, from incipient decomposi- tion, who seldom partake of flesh meat unless in a similar state of change, and who dry or smoke both these kinds of food, instead of salting them, are generally subject to diseases which arise from, or are connected with, an impure state, or weak cohesion, of the circulating fluid. It should not, however, be overlooked, that the more complete changes which respiration affects on the blood in cold climates, and the active exercise of the func- tions of depuration, under the influence of the vital energies, serve to counteract the morbid alterations which this cause would induce. Yet still the prevalence of disorder in these eliminating organs, particularly the mucous and cutaneous surfaces, which preserve the purity of the blood; and the marked disposition, which all febrile dis- eases evince, in persons thus circumstanced, to- wards vitiation of the circulating fluid; and the consequently low or adynamic symptoms which characterise their progress and termination; are sutficient indications of a change in the constitu- tion of this fluid. It is worthy of notice, that com- munities which live in the manner now alluded to, generally employ remarkably acid beverages, usu- ally consisting of the fermented whey of butter- milk, and a fermented farinaceous infusion. I believe that nothing could be used as common drink better calculated than these to counteract the ill effects of their diet on the blood. Besides the acid existing in these beverages, they also contain much carbonic acid gas, which likewise contri- butes to their wholesome influence on the blood. 114. The effects of living upon much fresh animal food, in increasing the quantity of fibrine, in rendering the blood rich and abundant, and in disposing to inflammatory diseases, are too well known in all their relations to require illustration. But when we consider the influence of various kinds of aliments in modifying the state of the blood, we ought never to overlook that, as its organization and vital manifestations commence with the chyle, and depend upon the vital con- dition of the vessels and tissues, and upon the perfect discharge of all the functions which con- tribute to its formation and purification, the extent of mischief produced by unwholesome food will be commensurate with the deficiency of vital energy, and the imperfection of the various or- ganic functions. A person of a robust constitution, breathing a pure air, and assisting the eliminating functions by regular exercise, will suffer much less, than the debilitated, the indolent, and those placed in unhealthy localities, from either un- wholesome food, or from the accidental ingestion of injurious substances. A person thus circum- stanced will also suffer less from the habitual 188 BLOOD — its Morbid Relations. indulgence in too much animal food; but more commonly such indulgence will give rise to a superabundant secretion of uric acid, and favour gravel. In such persons, also, there is reason to suppose that urea, or uric acid, may exist in the blood, and be deposited from it in various parts of the body, particularly the small joints. 1 he uric acid, which becomes thus abundant, is a highly azotised animal principle, obviously formed from the excessive use of food which abounds in azote; and when its appropriate emunctory, the kidneys, fail of carrying it out of the blood, it is secreted in other parts. 115. B. Imperfect performance of the functions of depuration, a chief cause of morbid states of the blood.—The evident influence of this class of causes renders it a matter of surprise that it has been so long overlooked in our estimation of the causation of disease. When the facts which have been brought to light by the successful investigation of the animal functions are duly weighed, and estimated in connection with the sources of impurity to which the circulating fluid is exposed, the importance of assigning a due rank to this kind of morbid agency will become mani- fest. When we consider the important changes that take place in the lungs — the quantity of carbonaceous fluids constantly discharged through this organ, and of watery vapour loaded with various impurities continually exhaled from its surface, and passing out with the expired air; or the abundant perspiration, sensible as well as insensible, constantly issuing from the cutaneous surface, and holding dissolved in it substances which require to be eliminated from the circula- tion, owing either to their excess or their foreign and hurtful nature; or the varying state of the urinary secretion, the quantity eliminated, and the changes it manifests from variations of tem- perature, atmospheric moisture, and especially from the abundance and nature of the ingesta; or the discharges which the female experiences during the greater part of her average duration of life; or the secretions formed by the liver, the interned surface of the bowels, the pancreas, &c. out of elements which, if not combined into these new forms, and destined to ulterior purposes, would become poisonous to the frame, by vitiating the blood; it must be evident that an interruption to any one of these several functions, if not com- pensated for by the vicarious increase or modifi- cation of some others, must be followed by alter- ations ofthe quantity, of the quality, of the relative proportion of the constituents, and even of the vitality of this fluid. 116. a. Under the due dominance of the vital energy of the system — and particularly of that influence exerted by the organic nerves on the great secreting viscera, and on the whole vascular system—no sooner does any substance, which may have been carried into the circulation, or accu- mulated in it, become injurious, than it is elimi- nated by the appropriate action of some organ, which often evinces a kind or degree of disorder, either in its actions, or in the state of its secretions, according to the nature of the substance which affects it. Thus, we perceive various substances and kinds of food, even in health, affect the actions and secretiorfs ofthe kidneys, of the skin, and of the bowels; certain of their constituents becoming sensible in the halitus of the expired air, in the perspiration, or.in the urine, where they could be transported through the channel of the circulation only. The fator, &c. of the breath, and of the perspiration, &c. consequent upon interruptions of the abdominal secretions, also indicates that impurities have accumulated in the circulation, and that they are being elimi- nated by means of the lungs and skin. So long as the vital energy is sufficient for the due per- formance and harmony of the functions, injurious matters are seldom allowed to accumulate in the blood to the extent of vitiating its constitution, without being discharged from it by means of one or more organs; but as soon as this energy languishes, or is depressed by external agents and influences, and the blood is thereby either im- perfectly formed, or insufficiently animalised and depurated, some one of its ultimate elements or proximate constituents becomes excessive, and the chief cause of disorder, which terminates either in the removal of the morbid accumulation, or in a train of morbid actions and organic lesions. These very important pathological facts are so fully proved by the history of the most prevalent and serious diseases, and by their terminations and results, and are so perfectly unopposed by acci- dental or occasional exceptions, that proofs or illustrations of their value and uniformity are superfluous. 117. Thus it will appear that, although changes in the secretions and in the blood itself are most influential in the production, perpetuation, and aggravation of disease; yet such changes are prevented, controlled, and even in some cases promoted, by the state ofthe nervous energy and vital actions of the frame; to which influence they are always more or less subject, unless when the causes of the disorder are so intense, in relation to its state, as entirely to annihilate it, as is occa- sionally remarked in respect of the most pesti- lential diseases, and of the operation of some virulent poisons. Thus, also, will it appear, not only that hurtful matters carried into the circula- tion, and ultimate elements or proximate constitu- ents allowed to accumulate in it, owing to the imperfect performance of some eliminating func- tion, will be removed from it, wheu the vital influence is sufficient for the task; but that both kinds of injurious agents will, according to their natures, become productive of a vitiated state of the blood, of the secretions formed from it, and even of the various tissues themselves, when the state of vital manifestation, particularly as display- ed in the organic nerves, is insufficient to remove them from the frame, or to control their combina- tions, or to direct them to salutary changes. 118. Before leaving this important subject — important in as far as it involves the fundamental doctrines of disease, and points to rational indi- cations of cure — I may briefly illustrate it by a reference to two or three facts, which are of every day occurrence. It has been long known that affections impeding the functions of the lungs are frequently attended with an increased secretion of bile. This I have shown to depend upon the liver being excited to increased action by the car- bonaceous and other elements accumulated in the blood, owing to their elimination by the lungs being interrupted; and thus we readily recognise the cause of the frequent complication of biliary disorder with pulmonary disease, particularly in BLOOD — its Morbid Relations. 189 some hot countries. In cases, also, where, owing to asphyxia, or to disease, as pestilential cholera, &c, the requisite changes by respiration are not effected in the blood, if recovery take place, the diseased states of the secretions of the liver and bowels indicate that the favourable result has been chiefly owing to the increased performance, under the influence of life, of the functions of these organs. When death occurs from asphyxia, and particularly if it be occasioned by the vapour of charcoal, the black, fluid, or dissolved state of the blood, the presence of yellowish globules like oil, sometimes observed on its surface, and noticed by M. Rater, sufficiently indicate the changes produced in this fluid, and-the influence these changes exert on the chief functions; and if re- covery is effected, the evacuations evince that the principal secreting organs have been the means of removing the morbid matters from the blood. A strict enquiry, also, into the changes which pre- cede a favourable termination of the latter stages of malignant diseases, manifestly detects the in- fluence of the secreting and eliminating organs in bringing about this result, and chiefly by their operation, under the influence of life, upon the blood. 119. b. That high ranges of temperature occa- sion very important changes in the state of the blood, had been remarked by several of the an- cients, and by some of the best writers of the eighteenth century; but the chief mode of its op- eration was first pointed out in a thesis written by me in 1815. I there showed that increased atmospheric warmth, particularly when accom- panied with moisture and miasmal exhalations, greatly diminish the changes effected during re- spiration on the blood in the lungs; and that the carbonaceous, and other elements and impurities, are imperfectly discharged from the blood through this channel. I further showed, both in that pro- duction, and in my physiological notes, that these materials are partly combined to form bile, thus occasioning an increased as well as vitiated secre- tion of this fluid, and partly excreted by the mu- cous surface of the intestinal canal, and by the skin; and that, if the functions of these organs,— the liver, skin, and intestinal mucous surface,— which thus compensate the diminished actions in the lungs, be at all impeded under such circum- stances, the elements, which they should have eliminated from the blood, necessarily accumulate in it, and influence the functions of the nerves, ramified on the blood-vessels, and ofthe principal secreting organs and surfaces, ultimately vitiating the blood and all the soft solids ofthe body, when the vital energies become depressed or exhausted, and the train of morbid phenomena experiences no change tending to health. 120. Thus, we perceive that, during high ran- ges of temperature, particularly when the air is loaded with miasmata, and the liver is inactive, the elements of the bile will accumulate in the blood, sometimes even to the extent of giving the countenance a darker or more dusky tint than natural, and the blood will be changed, 1st, by the superabundance of the materials whence bile is secreted; and, 2d, by the passage of this.ffuid, or of certain of its constituents, into the blood, after its secretion has taken place. In th,e foregoing manner (§ 119.), I explained the prevalence of biliary disorders, particularly bilious cholera, diar- rhoea, dysentery, increased secretions of bile; and, in warm climates and seasons, andwhen vegeta- ble and animal miasms are superadded to this in- fluence, the occurrence of fevers of various kinds —remittent or continued, simple or complicated, biliary or malignant, inflammatory or dysenteric, endemic or epidemic, sporadic or pestilential— according to the circumstances of individuals, the kind of locality, the nature, combination, and source of the miasm, and the state of the atmos- phere. This doctrine, now many years since contended for, later experience, and the concur- rent opinions of more recent observers, have fully confirmed. (See Fever.) 121. c. Several states of disease, which occur in the puerperal state, may be referred to the ar- rest of the secretions or discharges incidental to it. The secretions from the internal surface of the uterus, and which partly consists of the bloody serum poured into the uterine cavity from the open mouths of the vessels which communicated with the placenta, are not infrequently arrested or impeded. In such cases, the blood does not undergo that salutary depuration which this evac- uation occasions; and, consequently, either expe- riences further disorder, or it creates a disposition in the system to the invasion of other causes of disease. Besides, the fibrinous and albuminous parts of the blood, which are generally in excess during pregnancy, not having been discharged by this route, determine the occurrence of inflamma- tion of the uterus, peritoneum, &c. upon the co- operation of exciting causes. Or, if such causes have produced these diseases, the obstruction or interruption ofthe secretions and discharges, which is generally thereby occasioned, aggravates the mischief, and the post mortem appearances often furnish more or less evidence of the suppression having been concerned in modifying the results; the matters poured out from the diseased parts frequently resembling, or containing constituents of, the secretion which was suppressed. How are we to account for this ? We find it demon- strated, that the materials of both bile and urine, owing to obstruction of these secretions, may be mixed with the blood, and give rise to certain well known symptoms. We may, therefore, ex- tend the same principle to suppression of the puerperal secretions; and infer, that the matters which constitute them, having accumulated in, or not been eliminated from, the blood, are discharg- ed along with those effusions of albuminous serum which frequently follow the diseases of this state, even although they may not actually be the causes of these diseases. 122. Graeffe of Berlin (Rev. Mid. Jan. 1827.) states, that a female, in a favourable state, and suckling her child, experienced a fright on the eighth day after delivery, which occasioned a complete suppression of her milk. Febrile ex- citement followed, and effusion took'place in the peritoneal cavity and cellular tissue. Upon tap- ping a few weeks afterwards, a bucket of fluid, resembling whey, and exhaling an acidulous odour, was drawn off. Upon being boiled with dilute sulphuric acid, it furnished a substance re- sembling caseum. When tapped six weeks after- wards, the fluid was of a greenish yellow, and without the least trace of caseum. 123. That changes in the composition or state of the blood are also followed by alterations of hology in Fevers. 190 BLOOD —its Pat the natural secretions, is fully shown by both physiological and pathological facts. It is not, therefore, unreasonable to suppose, that modifica- tions or changes of morbid secretions will be oc- casioned by a similar cause. Indeed, alterations of the latter are quite as likely to be the conse- quence of pathological conditions of the blood, as changes of the former. 124. d. In cases, where the functions of the skin, or of the kidneys, are interrupted, not only are the watery parts of the blood frequently in- creased, but also various irritating matters accu- mulate in it, unless eliminated by other organs. These excite more or less disturbance of the whole vascular system; and if the cause continues, or is assisted by concurrent causes, the blood itself be- comes very evidently changed, in respect both of the state of its cruor and of its serum. The ef- fects of obstruction of the bile on the blood, and mediately on the tissues, are sufficiently apparent to the sight; and the actual presence of this fluid in the circulation, or, at least, the peculiar matters which characterise it, has been shown by several modern chemists, and completely demonstrated by the recent researches of MM. Proust, Orfi- la, Gmelin, and Le Canu. But it is unneces- sary to prosecute the subject further, as I consider that the grand pathological inference, that the in- terruption or obstruction of any important secre- ting or eliminating function, if not compensated by the increased or modified action of some other organs, vitiates the blood more or less; and, if such vitiation be not soon removed, by the re- storation of the function primarily affected, or by the increased exercise of an analogous func- tion, more important changes are produced in the blood, if the energies of life are insufficient to expel the cause of disturbance, to oppose the progress of change, and to excite actions of a salutary tendency. 125. e. Illustrations.—The importance of this conclusion will become still more manifest, if we illustrate it by reference to the pathology of fever, and observe the train of morbid phe- nomena produced by its causes. These, although modified even still more infinitely than the combi- nation of causes in which they originate, present the following almost unvarying characters and mode of procession:—A person exposed to the miasmata generated from vegetable or animal matter in a state of decay, or from persons affect- ed with fever, inhales such miasmata into the lungs, where they produce a morbid impression on the nerves of organic life, followed by depres- sion of the vital influence: the functions of diges- tion and spcretion languish, and, owing to the im- perfect performance of secretion and assimilation, the necessary changes are not fully effected in the blood; and thus irritating or otherwise injurious matters accumulate in it. These phenomena gen- erally proceed gradually, until, owing to the con- tinued and augmented depression of the vital powers throughout the frame, and the increasing change in the state ofthe blood, marked disorder is occasioned. The vascular system becomes ex- cited by the quantity and the quality of its con- tents; and, when the vital energies are not too far depressed for its production, the excitement be- comes general. The accelerated circulation tends still more to disorder the state ofthe blood; but it also has the effect, in the majority of cases, of ex- citing the organic functions, of restoring the se- cretions which were impeded or interrupted, and thereby of removing the morbid state of the cir- culating fluid; after which the return to health is rapid. When, however, salutary reaction of the vascular system is not brought about, owing to the morbid depression of the vital energy, and to changes which had taken place in the blood; or, if reaction occur, but, owing to the state of this fluid, and of the nervous influence to which it is subject, it is irregular, imperfect, or excessive; the vitiation ofthe blood proceeds; the secretions are also vitiated; the solids affected; one or more vi- tal organs suffer in an especial manner; the ener- gies of life are exhausted; and various organic lesions are induced, having reference to the pre- vious state ofthe system, the kind of change pro- duced in the blood, and the agencies in operation during the progress of disease. 126. Such is the general procession and char- acter ofthe morbid phenomena; and we observe in them certain prominent features, by means of which the various species of fever are recognised. They may be briefly stated to be,—1st, The im- pression of the causes on the nerves of organic life, the depression of their energies, and imperfect performance of all the functions which they in- fluence: 2d, More or less vascular excitement or change in the state of vascular action, and of the circulating fluid: 3d, Frequently predominance of disorder of some one general system, or vital or- gan: 4th, Consequent exhaustion, with either a gradual restoration of the functions, followed by a return to health; or more marked vitiation of the blood, of the secretions formed from it, and of the solids of the body, often terminating in organic changes, or death. 127. Here we observe three different states of vital action, in each of which the blood generally presents very different appearances. 1st, The state of depression and invasion of fever, in which the blood taken from a vein is of a very deep or dark colour; flows with difficulty; frequently oc- casioning syncope, or great depression upon the loss of a few ounces; and generally coagulates rapidly, and separates into a very dark, large, and soft coagulum, which falls low in the serum—the quantity of which is extremely small in propor- tion to the clot. Not infrequently the separation is very imperfect, and the coagulum extremely large and soft. 2d, The state of reaction, or fe- brile excitement, in which the blood flows more freely from the vein, and of a brighter colour, oc- casioning little immediate depression until a more considerable quantity is abstracted; is apparently thinner than natural; coagulates much more slow- ly, and separates into a somewhat more firm co- agulum, than in the former state of disease; and occasionally exhibits a thin fibrinous layer on its surface: in several malignant cases, however, even in this stage, either the separation of seram is very imperfect, consisting chiefly of a deep ge- latinous layer, beneath which the colouring mat- ter is deposited in an extremely loose state, and dark colour; or the blood remains imperfectly coagulated, and of a gelatinous consistence. 3d, The state of exhaustion, in which the blood gen- erally flows readily; but is uncommonly thin, dissolved or attenuated, and dark coloured; occa- sions great increase of exhaustion; and either scarcely coagulates, or separates into a remark- BLOOD — its Pathology in Fevers. 191 ably loose coagulum, which lies at the bottom of the vessel; the serum varying much as to quan- tity and colour ; being often turbid, clouded, watery, or slightly viscous, and less saline in its taste. Sometimes the coagulum which falls to the bottom of the vessel is so loose, that it appears as a precipitation of the colouring matter, of a very dark colour, and is readily stirred up into the supernatant serum (§ 94. 108.). In nearly all the cases where I have seen blood taken, either in the state of depression or in that of exhaustion, but particularly in the latter, either little or no fibrine could be collected from the coagulum; or what was obtained was scanty, remarkably loose, and even flocculent, and nearly albuminous. Throughout the progress of typhus, the venous blood is generally watery, and without consist- ence,—a fact to which my attention was called many years ago by the late Professor Hilden- brand, at Vienna. In the later stages of typhoid or malignant fevers, it seems nearly altogether deprived of fibrine. In two or three cases, the blood was abstracted in these states chiefly with the view of examining its appearance. But sev- eral instances have occurred to me, in which I have found that blood had been drawn, although the nature of the symptoms, and the state of this fluid, equally contra-indicated the propriety of the practice. 128. With respect to the post mortem appear- ances of the blood in the vessels, I stated, many years ago, when describing the symptoms and morbid appearances of yellow fever, several cases of which I had an opportunity of examining with- in five hours after death, in the years lSi6 and 1817, that it is generally half dissolved, or fluid and grumous, dark coloured, and speedily undergoes complete decomposition. (Quarterly Journ. of Foreign Med. vol. ii. 1S20, p. 446.) A similar state ofthe blood has been noticed by Arejula, Bally, Palloni, and others, in the epidemic yellow fever of Spain; and more recently by Dr. Stevens, who has described the appearances of the blood in tropical fevers with greater minute- ness than his predecessors, has referred to most important changes of the saline constituents of this fluid, and has fully confirmed some very detailed observations adduced by myself several years previously (Appendix to M. Richerand's Phy- siology, p. 640, et seq.), comprising the general results obtained from noting the appearance ofthe blood in a number of febrile and malignant dis- eases. Dr. Stevens states (Paper read to the College of Physicians in May 1830.), that the blood, in these fevers, loses its property of coagu- lating, becomes more fluid, and thin or watery, of a much darker colour, and has its fibrine and saline ingredients exhausted,—changes which I have as- certained to obtain in a greater or less degree in the fevers of this country, particularly in their latter stages, and have described in my lectures since 1825. (See Fever.) 129. Besides other proofs of the diseased state of the blood in fevers, I may adduce the follow- in a ■—In those who were victims to malignant fevers, Chirac found the blood in the ventricles of the heart, and the vena cava, more or less clotted; and all the ramifications of the vena porta were filled with grumous blood. In those who died of typhus, at Brest, in 1757, the blood was found grumous, unnatural, black, and decomposed, par- ticularly in the liver. Soulier observed blackish blood coagulated in the vessels; and extremely foetid black blood in the stomach, of those who fell victims to the plague at Marseilles. Larrey found the blood black and liquid in those who died ofthe plague in Egypt. After intense fevers, Andral has found the blood contained in the heart, and in the larger arterial and venous ves- sels, remarkable for its great liquidity, and its black and deep colour: in some subjects it pre- sented a clear rosy tint, and was like water col- oured red; some small fibrous grains were then dispersed over the internal surface of the vessels. In one individual, the liquid contained in the larger vessels was no longer really blood, but a matter the colour of wine lees, sanious in some parts, nearly resembling the ill-elaborated fluid contain- ed in unhealthy abscesses. 130. M. Bouillaud found, in two or three cases, the blood clear and rosy,after putrid fevers; but it nearly always appeared blacker and more liquid than in its normal state : this alteration varied, from the degree in which the clot was simply flabby, to that in which the blood formed only a blackened and liquid mass, without any trace or clot. This blood, being put into a basin, was brilliant, shining, and full of micacious specks; in some cases it has been found mixed with puru- lent matter, or pure pus; at other times it was so altered and disorganized that it resembled a putrid mass. Bouillaud justly adds, that in such in- stances it is not rare to meet with a quantity of gas, more or less considerable, in the circulating canal; and also that, although it be difficult to describe these changes, they should nevertheless be taken into consideration, if we wish to explain satisfactorily the phenomena attendant on putrid fever. 131. The malignant febrile diseases which very frequently attack horses and cattle are always at- tended with a remarkable alteration of the blood, even early in their progress. These diseases are less frequently met with in this country, than' in marshy and warm climates. In some ofthe most pestilential of those, horses cannot be reared; and when brought into those places, they generally experience a febrile attack, with adynamic or malignant symptoms, and speedily die. This is constantly the case in some parts of Africa, where the vegeto-animal miasms from the soil are abun- dant and concentrated. I had an opportunity of observing the examination of a horse brought from the interior to an unhealthy situation on the coast, where it died, as all others had done, a few weeks afterwards. It was not much emaciated; but the blood was black, decomposed, fluid, and sanious; and the liver, spleen, lungs, heart, and, indeed, all the internal viscera, softened, ecchymosed, and lacerable with the utmost ease. 132. C. Contamination of the blood by putrid or septic matters applied to the tissues.—These substances Were not inappropriately said, by the older writers, to occasion a putrid ferment in the part to which they were applied. The ferment may be disputed, but that they produce change of the blood is undeniable. If we examine the subject closely, we can arrive at this conclusion only,—that the substance applied changes the part to a state somewhat similar, as respects sensible properties, to itself; and that this contamination soon extends, either by its immediate effects upon rioN of—Poisoning of. 192 BLOOD —Contaminai the organic nerves supplying the vessels, and con- secutively on the blood, or by the direct introduc- tion of the contaminating matter into the divided vessels, or by its imbibition or absorption, or by one or more of these channels, to the whole body, affecting, more or less, the blood, the secretions, and the solids. That these changes take place is undeniable, although the precise channel of pri- mary infection cannot be easily demonstrated; and is sufficiently proved by the facts already ad- duced (§ 92.), and by those whichfollow (§ 133.). The instances of gangrenous or diffusive inflam- mation of the cellular tissue, arising from contact or inoculation of putrid animal matter, as record- ed by numerous writers, and recently by Drs. Butter and Duncan; the not infrequent in- stances of it from injury in the dissecting-room (see Cellula r Tissue, Diffusive Inflammation of); and the occurrence of putrid fever, with gangren- ous pustules and carbuncles, particularly amongst farriers, flayers, and knackers; furnish proofs and illustrations of the blood being one of the chief, although, perhaps, not the primary or only, chan- nel through which the whole frame becomes more or less infected in a large and important class of diseases. A most remarkable instance of this, and at the same time showing to how great an extent the fluids and solids of the body may be contaminated, and yet the patient recover, is re- corded byM. Gendrin. 133. A flayer was affected with putrid fever, and gangrenous pustules and carbuncles. His breath, evacuations, and whole body, were horri- bly fcctid ; and blood taken from a vein was, three hours and a half after its emission, unusu- ally dissolved and black; and gave out an odour resembling that of putrid flesh. A spontaneous discharge of a black, dissolved, sanious blood, also occurred from his mouth and nostrils. M. Gendrin introduced some of the blood taken from the arm of this person into the cellular tissue of a cat, and into the femoral vein of a dog. Both animals evinced symptoms of putrid fever, and died in a few hours. The blood throughout their bodies was dark and fluid; the heart soft and flac- cid; the viscera congested, and ecchymosed with dark spots, and speedily began to exhale a foetid odour. M. Gendrin also details some experi- ments, in which he injected into the veins of dif- ferent animals, the blood of persons affected with confluent small pox. Aery violent effects, rapidly terminating in death, followed; and, upon inspect- ing the bodies, several viscera were found highly inflamed and congested. 134. D. Contamination of the blood from causes influencing the state ofthe vascular system, either directly, or mediately through the nerves which supply it.—Under this head may be com- prised a very numerous class of causes: and, in- deed, many of those which were alluded to in preceding sections may also act in this way. a. Infectious and contagious miasms and secretions may change the state of the blood in a more or less direct manner, as well as by first affecting the organic nervous system generally, and thereby im- peding or changing the action of vital and secret- ing organs. Inordinate acceleration of the circu- lation appears to be frequently followed by serious alterations of the blood. The experiments of M. Dupuy on several animals show that the fibrine is either very much diminished, or otherwise changed, by their being coursed or hunted; as the blood remains fluid, or becomes dark coloured and grumous subsequently: M. Chaussier found that a portion of blood altered by this cause pro- duced gangrenous pustules and malignant fever, when inserted into the cellular tissue of sound an- imals; and the striking instance recorded by Du- hamel, and already alluded to, further proves that a morbid state of the blood is occasioned by overdriving animals. Haller and Buchner remark, that vehement exertion renders the urine foetid, acrid, and scalding ; the perspiration foetid and disagreeable; the boold very fluid, acrid, and vitiated; and, if long continued, occasions most ardent fever, terminating rapidly in death, and dissolution ofthe fluids and solids. Haller re- fers to two cases where he observed these effects produced by intense acceleration of the circulation by running; and adds, that the blood of hunted animals is often not only fluid, but foetid ; the flesh becoming quickly putrid. The attenuation and subsequent alteration of the blood observed in ardent or other fevers, attended with inordin- ate vascular action in their early stages, and the ecchymosis, petechia;, softening of the mucous tissues, &c. may doubtless be attributed, in part, to the rapidity of the circulation, or increased motion to which it is subjected. If we continue to agitate healthy blood as it flows from a vein, it becomes thinner than natural, a small portion of fibrine collects around the stick with which it is stirred, and the blood remains fluid, as must be familiar to every one, and long since demonstrat- ed by Schwencke. 135. b. If any of the neutral alkaline salts, particularly those with excess of base, be added to blood as it is discharged, the coagulation will either be entirely prevented, or imperfectly pro- duced; little or no fibrine will be formed, and its colour will become more florid. These facts have long since been noticed by Verheyn, Eller, Rutty, Haller, &c. The injection of acids, or the metallic salts, particularly those with any excess of acid, render the blood dark coloured, and changes it into a grumous fluid, from partially coag- ulating its albumen and fibrine. The experiments of Eller, Gianella, Duhamel, Friend Courten, Rutty, De Heyde, Sproegel, Aalsim, Borrich, Petit,and various others, prove this effect; and further show, that when these substances are added to blood taken from a vein they either accelerate its coagulation, render- ing the coagulum firm; or, if strong solutions are employed, the coagulation is irregular, the sepa- ration of the watery portion is more perfect, and the coagula are of a dirty black or dark brown colour. The attenuating effects of the fixed and volatile alkalies, and of their subcarbonates, both upon the blood and the secretions formed from it, particularly when long employed, will be consid- ered as proved by any one who will peruse the experiments of Schwencke, Friend, Eller, Rutty, Courten, Pitcairne, Thackrah, and Scud a m o r e , without the bias of system; and they are confirmed in my mind by some observa- tions I have made of the results when these sub- stances are mixed with blood immediately after venaesection, or when exhibited internally in large doses for sometime previous to abstraction ofthe blood; whilst directly opposite effects are observ- ed to follow the internal use of acids. In the BLOOD — Nervous Influence on the. 193 latter case, the coagulum is firm, the blood of a deep or dark colour, and the fibrine abundant: in the former, the blood is thin, of a brighter colour, the coagulum much less firm, and the quantity as well as the cohesion of the fibrine diminished. 136. The effect of the fluid extract or tincture of opium, alcohol, tonic or astringent tinctures, and of spirits of turpentine upon the blood, is to increase its coagulability; and, when injected into the veins in sufficient quantity, to produce death, as in similar experiments with acids and the metallic salts, chiefly from this mode of opera- tion. The experiments of Courten, Friend, Younge, Schwencke, De Heyde, Sproe- gel, Silberling, and Fontana, fully prove these facts. The accuracy of the results as to one of these substances has been confirmed by the ex- periments of the writer. That both alkalies, acids, and salts, act upon the system chiefly from their being absorbed and carried into the blood, has been satisfactorily demonstrated by Magendie, Tiedemann and Gmelin, Mayer, Wes- trumb, and various others, and will not be now doubted, although the active exercise of the eli- minating functions, which their very presence in the blood generally promotes, prevents their ac- cumulation there to any considerable or dele- terious extent, unless they have been taken in poisonous doses. They have, nevertheless, been absorbed in such quantity as to be detected both in the blood and in the various secretions by means of chemical agents, as demonstrated by MM. Grognier, Chaussier, Orfila, and by Buchner, Krimer, Bennerscheidt, Schu- barth, and Dr. O'Shaughnessy. 137. c. The interesting researches of MM. Gaspard and Magendie, in order to ascertain the effects of putrid vegetable and animal matter when introduced into the cellular tissue or in- jected into the blood, further illustrate the im- portance that is to be attached to morbid states of this fluid, as well as the origin and nature of various diseases. These physicians have fully proved that such substances, when thus employ- ed, produce symptoms very similar to those of yellow fever, and typhus ; and that, after death, this fluid is found remarkably altered, being near- ly altogether fluid, of a very dark colour, and partially exuded from the capillaries, both into the parenchyma ofthe viscera, and from the mu- cous surfaces. That the blood is really altered in its nature by this inoculation, is proved not only by those changes, but also by the circum- stance of its having lost the power of coagulating upon removal from a vein soon after it has been thus infected, and by its speedy putrefaction. The more recent experiments of MM. Leuret and Hamont furnish the like results; whilst those performed by M. Magendie show that dogs con- fined over, and breathing the effluvium proceeding from, animal and vegetable matters undergoing decay, experience similar symptoms to those now referred to, and the same alterations ofthe blood, of the secretions, of the excretions, and of the viscera, as observed in yellow fever : and, in all these cases, the morbid changes also extend more or less to the soft solids, and particularly to the mucous surfaces, the lungs, the liver, the heart, &c. 138. A most interesting fact has been stated by M. Leuret, and one which fully illustrates the 17 views I have entertained respecting the nature of certain forms ofpuerperal fever. This physician injected some blood from an artery of a living horse affected with gangrenous boils (pustule maligne) directly into the veins of a mare five months with foal. She died five days afterwards. The heart, lungs, and intestinal canal were stud- ded with dark ecchymoses, the uterus was gan- grenous, and the blood dissolved and dark colour- ed. • But, in all the cases where poisoning has resulted from the injection of septic or putrid matters into the circulation, or from virulent and rapidly fatal poisons, it must not be overlooked that, although the more manifest lesions are often observed in the blood, the injurious agent affects also the organic nerves terminating in the vessels, and consequently the vitality of the vessels them- selves, altering the blood they contain, and there- by ultimately contaminating all the secretions and solids of the body ; and that the mode of opera- tion of the greater number of these septic agents, whether applied in an aggregate or palpable form, or from being dissolved in the moisture of the air, is very different from that of the saline and mineral substances considered above, which affect the blood more especially. (See Infec- tion.) 139. d. The direct influence of the nervous system upon the blood was long since contended for by Barthez, and admitted by several phy- siologists. The chief error, or rather mischiev- ous fallacy in their theory, however, being, that this influence was imputed to the cerebro-spinal nerves, and not to the ganglial nerves, to which it almost entirely belongs. This great mistake also vitiates the opinions promulgated on the sub- ject by Mr. Brodie and Dr. W. Phillip. The opinions, which I have entertained, and frequent- ly expressed, that the power exerted by the ner- vous system on the blood is limited to the organ- ic or ganglial class of nerves, and that their func- tions are very distinct from those performed by the cerebro-spinal class of nerves, the influence of the former having been too generally and er- roneously imputed to the latter, have been al- ready alluded to. Since their promulgation many years ago, numerous proofs of the accuracy of these views have been furnished in different coun- tries. That the effects produced by the organic nerves take place chiefly in the minute vessels may be safely assumed ; and that a reciprocative influence is exerted by the blood upon these nerves will not be denied: but it may also be inferred that the effects produced by the organic nerves are not limited to the small vessels. Pro- fessor Mayer's experiments support this opinion. He found that, when both pneumogastric nerves were tied, the blood coagulated in all the pulmo- nary vessels, the colouring matter having sepa- rated from the fibrine ; and that this change was not the consequence of death, but its antecedent, since it was uniformly found upon opening the bodies the moment they expired. M. Dupuy- tren had previously ascertained, that a simple division of the pneumogastric nerve prevented the venous from being converted into arterial blood in the lungs. 140. M. Dupuy found that, when the pneu- mogastric nerves were divided in the cervical region, in horses, the quantity of fibrine in the blood became progressively diminished to a very 194 BLOOD — Operation of Poisons on the. remarkable extent; and that a similar result fol- lowed laborious breathing in disease. He further states, that the blood throughout the animal was entirely dissolved after the pneumogastric nerves had been divided; and he adds that, when a por- tion of this blood is injected into the jugular vein of another horse, a gaugrenous affection is pro- duced (§ 92.). But these effects are compara- tively slow ; for in order that they may take place, the division of these nerves must previous- ly affect the ganglia and plexi supplying the lungs and heart, and with which they are in intimate connection. When, however, these ganglia are immediately impressed, the effect is much more rapid. Such impression cannot, however, be readily made upon the ganglia themselves, owing to the protection their situation affords them from experiments of a conclusive kind. But as we find that agents, which do not affect the system when applied to the voluntary nerves, or the brain it- self, will act rapidly when brought in contact with parts which are especially provided with the other class of nerves, and manifest the effects of this mode of operation upon the parts more im- mediately influenced from this source, we must necessarily conclude that the morbid impression of poisonous substances is primarily exerted upon the latter, and not upon the former ; and hence the rapidity of their effects upon the blood,— effects which are productive, no doubt, of most important consequences throughout the economy, which I am endeavouring to estimate fully and fairly, but which should not altogether obscure our perception of earlier changes, which alone can account for all the phenomena. A severe blow over the conliac ganglion will produce in- stant death, and the blood will remain dissolved, and exhibit the same appearances as after death by lightning and the most virulent poisons. Here we can attribute these remarkable changes only to the sudden concussion, and annihilation ofthe in- fluence exerted by this important part of the or- ganic or ganglial class of nerves—by this central source of vital power, upon the vascular system, and to the effect thereby produced upon the blood. 141. Seeing, therefore, that the organic or ganglial nerves are chiefly distributed to the very internal membrane of the blood-vessels for the purpose of transmitting their vital influence to the blood itself, it must be inferred that, al- though various substances or poisons may seem to act more particularly and immediately upon the blood, and others more directly on this class of nerves, according as they are applied within or without the vessels, the action cannot be restricted to either ; for whatever changes the state of the one, must affect the other. That poisons, when introduced into the blood, will have an almost in- stantaneous effect, but not in the manner usually explained, may be readily granted and accounted for. The views upon the subject frequently stat- ed by the Author in the Medical Repository, and in his Physiological Notes, seem more in accord- ance with the resulting phenomena; and are moreover confirmed by experiments and obser- vations recently made by others ; for when the poison has been applied to the cerebro-spinal nerves, it has been found by Orfila, Fontana, and others, to have no further operation, or even less, than when applied to other tissues, because it is not directed to that particular organization, upon which the functions of life more immediate- ly depend. But when injected into the blood, it is applied to the terminations of the organic nerves in the blood-vessels—to that particular quarter where the life of the tissues and of the blood is either generated or supplied,—to the seat where the influence of these nerves affects, even if it does not vitalise, the circulating fluid, and the op- eration is instant and most manifest. The reader, who, possessing an intimate acquaintance with the healthy relations of the organic nerves to the blood-vessels on the one hand, and to the cere- bro-spinal system on the other, examines the nu- merous experiments which have been performed, —by one class of experimenters to show the ac- tion of poisons upon the nerves, confounding, as all have done, the ganglial with the cerebro-spin- al nerves,—and by another class to demonstrate the operation of these substances on the blood solely, both sides leaving reciprocity of action, or rather the rapid change occasioned by one system on the other, too much out of the question ; and is able to detect the fallacies with which they nearly all more or less abound, chiefly from con- founding distinct functions, and even different sys- tems, with one another ; will entertain but few doubts that the influence of various poisons, al- though more manifestly indicated in the blood, is chiefly exerted upon the nerves which terminate in the blood-vessels ; and that the alterations in the contents of the vessels arise principally from previous changes produced upon these nerves, however rapid the succession of the phenomena may be. 142. The celebrated and accurate experiments made by Fontana on the venom of the viper and the ticunas can be justly estimated only in accordance with this view ; for when these sub- stances were applied to the cerebro-spinal nerves no more rapid effect was produced by them than upon any other tissue: but, when injected into the veins, a fatal result was almost instantaneous ; the blood, in the words of this able experimenter, being suddenly changed to a livid black, and soon afterwards coagulated in the lungs, heart, auricles, and liver, as well as in the large veins, with violent disease of the structure of the lungs. Now, as these substances, when added to blood as it is drawn from a vein, preserve its fluidity, they must produce, on the organic nerves ramified to the blood-vessels, a most intense effect; the alteration in the blood resulting evidently from antecedent change in the vital influence of these nerves, since no such alteration is occasioned by them when added, even much more abundantly, to blood as it flows from a vein. And there can be no doubt that virulent poisons introduced into, or having access to, blood contained in the ves- sels of a living animal, however the vessel may be insulated from surrounding nerves, must come in contact with its interior, and thus have an oc- casion given them to act upon the independent class of nerves which is especially devoted to the blood-vessels. That the very instant and intense effects which I have, in three instances, seen produced upon the blood of the human sub- ject from the bites of serpents, and which have been minutely described by Orfila, Fontana, and many others, cannot arise from the diffu- sion of the poison in the blood, must be evident from the rapidity with which they occur, but BLOOD — Signs of its Disease. 195 from the morbid impression made by them upon the vital or ganglial nerves, and instantly propa- gated throughout the frame ; the effects of this impression first appearing as a manifest lesion in the part where the injury was inflicted, and in the blood, which, as a part of the vascular system, is co-ordinately affected with the class of nerves supplying both it, and the vessels which contain it, with vital-influence. From the mode of oper- ation, therefore, of all the most virulent poisons, as prussic acid, the venom of the viper, ticunas, &c, I infer, that, as the organic system of nerves may be intensely affected, without altering the state of the brain more than that of any other im- portant organ, and then secondarily merely, so may those poisons destroy life by their effects upon this system of nerves primarily and chiefly, other lesions being consecutive, amongst which the alteration of the blood is the next most im- mediate, and the next most important in its rela- tions and consequences. (See Poisons.) 143. E. The passage into the blood of morbid matters formed in the same body that is the seat of disease, has been particularly noticed in the a'ticles on Absorption and Inflammation of Veins. I have shown, when treating of these subjects, as well as of certain organic and malignant diseases, that vitiation of the blood, and ultimately of the soft solids more or less, is a very frequent occur- rence; that it is hastened or promoted by depres- sion of the vital energies; and that this fact, as well as the vitiation ofthe blood, should be taken into account in treating these maladies, parti- cularly in their more advanced stages. It is probable that morbid matters may sometimes exist in the blood without very materially affect- ing its condition; but they much more frequently occasion very important changes in its constitution, as must appear from what has been stated, parti- cularly when the powers of life begin to languish. Pus has been often detected in the veins which convey blood from parts undergoing the suppu- rative process, both by the older physicians and by recent writers, particularly Bichat, Fizeau, Velpeau, Rochoux, Gendrin, Andral, Dance, Breschet, and Ribes; and it seems very probable that, when thus absorbed, and not mixed with, or eliminated from, the circulation, it gives rise to various changes ofthe blood in the vessels, not only from attracting the fibrinous cor- puscles in the manner already noticed (§ 85.), but also from combining with albuminous or other constituents of this fluid. I further believe, that the sanies which flows from chronic ulcers, or from the inside of veins when affected with spread- ing inflammation of their internal surface (see Veins.), and from the internal surface of the uterus in certain states of puerperal disease; and that the tubercular and encephaloid matter which often forms in internal viscera; may all be carried into, and most sensibly affect, the circulating fluid, and, through it, all the functions and structures of the body. 144. M. Andral states, that he has often found in the blood-vessels, instead of blood, a curdy friable matter, of a dirty gray colour, and resembling either the semi-concrete pus of chronic abscesses, or the sanies of malignant ulcers, or encephaloid matter broken down and mixed with blood ; and similar instances are recorded by Bichat, Beclard, and Velpeau. In all these cases, abscesses, tubercles, or other morbid for- mations, also existed in some part of the body. (See arts. Absorption, Abscess, &c.) In many of such cases, it is difficult to determine what may have been the state of the general mass of blood in the latter stages of the disease, owing to the period which had elapsed from the dissolution of the patient to the examination; but it is very probable that the morbid matter found in the vessels had materially affected, either di- rectly, or mediately through the organic nerves, the constitution of the whole fluids and soft solids of the body. 145. iv. Phenomena materially depend- ing UPON A VITIATED STATE OF THE BLOOD, AND SERVING TO INDICATE ITS EXISTENCE.-- I have contended that the functions of depuration are very frequently concerned in occasioning, as well as in removing, a morbid condition of the circulating fluid. These functions will, therefore, evidently present some modification, when per- fonning this latter purpose, inasmuch as the state of the blood, and of the impurities requiring change and elimination, will excite in them, as well as throughout the soft solids, more or less disturbance. In the slighter cases, the disorder of function will be less apparent ; but even in these, and still more remarkably in the more severe cases, the particular function most dis- turbed will generally evince some relation to the kind of change existing in the blood. This re- lation of the change or impurity of the blood to the functions of viscera is very similar to the mode of operation and effects of very many medicinal substances, which, having been carried into the circulation by the function of absorption, act upon particular organs according to the cir- cumstance of their exciting or otherwise changing the vital condition of these organs, while they are being circulated through or eliminated by them. 146. i\s respects, however, this relation of the pathological states of the blood, much requires to be ascertained, or rather but little is yet known beyond a few facts evincing that such relation sometimes actually exists. Thus we observe that excess of carbonaceous elements in the blood is removed chiefly by means of the liver, occasion- ing an abundant and vitiated secretion of bile. We may frequently remark, that an imperfectlv elaborated chyle, or the partial absorption of sordes from the intestinal canal, renders the breath fret id, and the urine loaded, or otherwise changed; that accumulation of the materials usually eliminated by the kidneys produces copi- ous urinous perspirations, and the exhalation of a copious foetid halitus from the lungs ; and that putrid vegetable and animal matters, or morbid secretions carried into the circulation, derange the digestive mucous surface, and secreting organs, in a somewhat greater degree than other parts. 147. A. It obviously becomes most important to enquire if the phenomena resulting from change in the blood slowly brought about, or proceeding from pre-existing disease of important functions are different from, or are nearly the same as, those which arise from the introduction of putrid or morbid matters directly into the circulation. We observe in the last stages of malignant dis- eases, when the blood undoubtedly becomes changed, that all the secretions are remarkably offensive, acrid, and even excoriating. The 196 BLOOD —Signs of its Disease. breath, perspiration, urine, and stools, are foetid; and the surfaces and parts with which the secre- tions and excretions come in contact, experience more or less change in their vital actions, and are disposed to undergo rapid disorganization. All the circulating and secreted fluids have acquired septic and irritating properties; and discharges of sanguineous, or black, grumous, fluid matters sometimes take place from the digestive canal. The whole soft solids also lose their vital cohesion and tonic contractility, and are rapidly destroyed upon accidental injury and pressure. Hence the frequency and severity of the excoriations, ulcers, and sphacelating sores, which affect the promi- nent parts, sustaining the weight of the body in bed; and to this cause, in some measure, are to be imputed the ill effects sometimes following the use of blisters in the last stages of adynamic diseases. The whole surface of the body and countenance also present more or less of the characters which distinguish change of the other structures from this all-pervading cause : they lose their vital and animated hue, and become lurid, murky, or of a dirty pale tint; in some cases of a dirty or muddied pale yellow; in others slightly livid, or even altogether purplish; and in many instances, besides assuming a lurid and un- healthy colour, they are dotted with petechiae, ecchymoses, and blotches of various shades, from a reddish tint to a reddish brown and deep purple. In numerous cases, particularly in the last stages of yellow fever, the skin is of different shades of yellow, frequently disposed in large patches, some of which are deeper than others, but the whole surface being more or less changed from its healthy tint. All these appearances arise from the state of the colourless parts of the blood, transmitted by the minute vessels of the integuments ; and the admission, where ecchymosis, &c. occur, of colouring matter into vessels which did not cir- culate red blood in health, and the extravasation or escape of minute portions of a reddish serum, or attenuated or semi-dissolved blood, from the pores or extremities of the capillaries of the rete mucosum, — a change, however, which is not limited to the teguments, but which often exists still more remarkably in the mucous and sub- mucous surfaces, and parenchymatous organs. (§149.) 148. B. The rapid or direct introduction of vegetable or animal putrid matter, purulent sanies, or animal poisons, into the circulation, generally occasions, not only changes in the blood, destroy- ing its property of coagulating, and imparting to it a tendency to quick decomposition, but also most intense disease of the principal organs : — a. The nervous centres are remarkably impressed, giving rise to great prostration of strength, deli- rium, convulsions, or death, according to the intensity of the cause:—6. The digestive organs are affected by vomiting of morbid, brown, grumous, or other fluids; with purging of san- guineous, dark, putrid, or black matters; or dis- tended with foetid gaseous secretions : — c. The respiratory and circulating functions are remark- ably deranged — the respiration is quick, diffi- cult, or panting; the action of the heart quick, weak, or fluttering, and the impulse deficient; and the pulse, at first full, open, broad, and un- usually soft and compressible, soon becomes un- commonly quick, weak, and ultimately small, thready, or fluttering:—d. General disease of all the functions and soft solids, accompanied with speedy death when the cause is intense ; but, with the symptoms of adynamic, typhoid, or putrid fever, when acting more slowly, or to a less extent, and occasioning sphacelation or gan- grene of various parts, gaseous exhalations or secretions, and various serous, sanguineous, or sanious exhalations and infiltrations. 149. C. The effects upon the fluids and soft solids have been already mentioned incidentally, and may, indeed, be inferred from what has been stated. These chiefly consist, a. Of a foetid, de- composed, remarkably morbid, acrid, and dark or unnatural colour of all the secreted fluids: b. Of diminished cohesion of the tissues generally, but most remarkably of the mucous, cellular, muscular, and glandular parts,—the heart is soft and flaccid, the blood dissolved, and the internal surface of the heart and blood-vessels tinged of a more or less deep red colour, owing, as M. Trousseaux has fully proved, to the altered state of the blood; the muscles are easily torn, the mucous and cellular tissues are soft and pulpy; all the structures have lost their vital and physical elasticity, and they all undergo decomposition more rapidly than usual: c. Congestions, infiltra- tions, extravasation, &c. of fluid dark blood into the parenchyma of the lungs, liver, kidneys, and into the cellular, mucous, muscular, and other parts, with gangrenous spots, and a foetid odour. 150. Such are the consequences of putrid or morbid matters conveyed into the circulation, and the results, in respect both ofthe phenomena, and of the remote organic lesions, of changes pro- duced by these matters in the constitution of the whole fluids and structures of the body. When these matters are in a less concentrated state, or enter the circulation in a more gradual manner, they will then act in a relatively slower and less intense form, and their effects will more nearly approach those described as consequent upon a diseased state of the blood in malignant fevers (§125 — 130.). Yet their operation will still retain nearly the same distinctive characters, the symptoms varying chiefly in degree, but not ma- terially in kind, unless the nature ofthe cause has also varied. Whether we contemplate, therefore, the character and progress of the phenomena fol- lowing infection of the blood from these various sources, or the nature of the lesions which ulti- mately result, we shall be equally struck by the marked similarity existing between them. 151. That the blood is changed in various other maladies, although to a much less extent, may be inferred from the phenomena which are observed either essentially or contingently in their course. The secondary feVer in small pox is apparently connected with the partial absorption of the more fluid parts of the matter contained in the pustules, and the change thereby produced on the blood, and through it upon the economy. Instances have come before me, where, upon the rapid disappearance of the small pox eruption, purulent matter was secreted suddenly and in large quantity in the capsules of the joints, and with- out any previous or coexistent inflammation of these parts. In such cases the purulent matter had evidently passed through the current of the circulation. (See Abscess — Consecutive, and [ Absorption.) Similar occurrences are not un- BLOOD—Treatment of its Morbid States. 197 frequent in cases of inflammation of veins, and in puerperal metritis. (See Veins, &c.) 152. v. Therapeutical Indications and Mf.asuresin diseased states of the Blood. —The facts and observations now adduced in il- lustration of the pathology of the blood must ap- pear sufficient to attract greater attention to the state of this fluid in the treatment of diseases, than has been directed to it in modern times. How- ever scanty well ascertained facts connected with this subject may seem, they are at least sufficient to justify us in directing our means of cure to the removal of those changes which may be presum- ed to exist in this fluid. This indication is the more safely entertained, as those means are often at the same time the most efficacious in removing pre-existing or concomitant disorder ofthe nervous or other systems of the frame. And it should not be overlooked, in our anticipations of the benefit resulting from curative indications founded on these views, that the most certainly beneficial means of prevention and cure of a most dangerous disease admitted to depend chiefly on the blood, viz. scur- vy, is a remedy which acts principally on this fluid,—the citric acid. 153. There are certain facts, which a review of the foregoing observations will lead us to en- tertain as useful data for our guide, both in the recognition of changes in the blood, and in devis- ing means for their treatment. It will be apparent from what has been adduced, that remarkable di- minution or exhaustion of the vital manifestations of the organic nerves, or of the vital energy gen- erally, renders the blood dark coloured, prevents its fibrinous particles from adhering into a coagu- lum when removed from the vessels, disposes the colouring matter to separate from their central cor- puscles, and occasions a diminution of its saline ingredients. The effects of various matters, veg- etable, animal, and mineral, when gradually-and circuitously conveyed, or directly introduced, into the blood, have been particularly described, not merely as evidence of the very important changes produced by them on this fluid, but also as fur- nishing indications for the removal of similar al- terations, when they are the results, immediate or remote, of diseased actions. 154. A. Treatment of blood abounding with fibrinous and albuminous constituents—of buffy blood, fyc.—In various diseases, particularly those which are inflammatory, in the early stages of the exanthemata, especially in certain epidemic oc- currences of these maladies, the blood abounds in these constituents ; and hence partly the copious albuminous and fibro-albuminous exudations which are thrown out by the blood-vessels in their pro- gress. The knowledge, which we have already obtained as to the effects of certain substances on the blood, indicates the propriety of having re- course to such as possess the property of dilut- ing and attenuating these constituents, at the same time that they diminish the vascular ac- tion which is instrumental in secreting thein ; and experience fully proves, by its success, the propriety of the treatment. Blood-letting, and afterwards the free use of diluents holding in solution the alkaline carbonates and salts, more particularly cream of tartar and borax, or the tartarized antimony ; and digitalis, large doses of calomel, or other substances which have been shown to produce an attenuating effect 17* upon the blood, are especially indicated. Blood- letting in those cases is of the utmost service, as it diminishes general action, and removes a por- tion of the fibrine and albumen which are replac- ed by the thinner fluids absorbed from the prima via and tissues. 155. B. Treatment of blood with a loose co- agulum, Sec.—Rapid coagulation and deficient ad- hesion of the clot have been shown to arise from weak nervous influence and vascular action ; and indicate the propriety of having recourse to stim- ulating tonics, particularly when the smallness of the coagulum, and whey-like, milky, or turbid state of the seram, evince a poor and imperfectly elaborated blood. In this case, chalybeates, the sulphate of quinine, and the more permanent ton- ics, with the mineral acids, and the metallic salts, are especially required. When, in addition to this state, the blood is of a very dark colour, the com- bination of stimulants with tonics and the alkaline salts, especially the chlorides of potash or soda, w:iil be found most advantageous. In cases of this description, however, the preparations of ammo- nia, excepting the muriate and acetate of ammo- nia, although stimulating, will not be found so serviceable as other saline preparations. When, however, the muriate and acetate of ammonia are combined with excess of acid, the use of them will be advantageous. Camphor, serpentary, and arnica, the essential oils, the turpentines and bal- sams, are all beneficial in this state of the circu- lating fluid. 156. C. The treatment in other morbid states of the blood will necessarily vary according to the particular appearances it may present.—a. When the blood coagulates imperfectly, is dark coloured, is readily decomposed, or is thin and dissolved as in scurvy, and various malignant and adynamic diseases, especially when the vital cohesion ofthe tissues is also impaired, the use of most of the remedies recommended above (§ 155.), particular- ly the chlorides, the preparations of bark, anti- septic wines, the oil of turpentine, camphor, the chloric and muriatic acids, with vegetable tonics, the nitro-muriatic acid, vinegar, citric acid, &c. The influence of acids in restoring the state of the blood, particularly when morbidly attenuated, and deficient in fibrine, appears to have been well known to the ancients, and the indications there- by offered put in practice. Vinegar was adopted by the Carthaginians and Romans in all their cam- paigns as the chief beverage, as may be gathered from Virgil, Martial, Pliny, Galen, &o. ; and its advantages have been adverted to in modern times by Linn.*h;s. There cannot be a doubt that both it and citric acid are particularly serviceable in preventing the attenuation, and ten- dency to dissolution, of the blood generated, as has been shown, by excessive fatigue and exer- tion,—causes which have often been proved (§ 134.). powerfully to concur with unwholesome food, and vegeto-animal miasms, in the produc- tion of scurvy, dysentery, and typhoid fevers. It appears that the scurvy, which was found so destructive in Admiral Anson's fleet, was in no small degree promoted by the excessive labour of the men at the pumps,—a species of exertion which tends more than any other to acceler- ate the circulation, and exhaust nervous power, and consequently to produce a dissolved and incoagulable state of the blood, and to dimi- 198 BLOOD — Treatment of its Morbid States. nish its fibrine. When, however, the blood is morbidly thick and carbonaceous, when the re- spiratory functions are imperfectly performed, and when there appears to be a deficiency of saline constituents in the blood, as in the advanced stages of fevers, the fixed alkaline salts, and chlorides, are much to be preferred to acids. 157. b. Since the general neglect into which the humoral pathology has fallen, antiseptics have almost been discarded from practice ; at least, medicines have seldom or ever been given with an intention of preventing a tendency in the fluids and solids to dissolution. It must have been long known to every person who considered attentive- ly the operation of remedies on the frame, that many of them, either directly or indirectly, pro- duce this effect, m conjunction with other opera- tions ; and that they act in this manner, 1st, by exciting the organic nerves, and increasing the vital cohesion of the tissues, to which they are im- mediately applied ; and, 2dly, by their passage, to a greater or less extent, into the circulation, and operation on the blood itself, and, through its me- dium, on the nerves supplying the vascular sys- tem, and on the structures generally,-—the antisep- tic effect being the sum of those actions. Amongst the various antiseptic remedies with which we are acquainted, there is none more energetic than the chlorides or chlorurets, the spirits of turpentine, camphor, the barks, mineral and vegetable acids, the spices and aromatics, metallic, earthy, and al- kaline salts, spirits, and balsams ; and observation has proved to us, tliat these are actually the means which, when appropriately employed, are most successful in removing morbid states of the blood, secretions, and solids. Needham and Paulet found salt most successful in combating an epi- zooty characterised by a morbid state of the blood ; and I had an opportunity of ascertaining that, without a necessary supply of this substance, the natives of the more insalubrious districts in intertropical Africa are carried off in great num- bers by a putrid and liquescent dysentery, for which salt, lime-juice, and cayenne pepper are their principal means of cure. It should, how- ever, be remembered, that all stimulants are not also antiseptic in their operation on the blood. The preparations of ammonia have even an op- posite effect, unless the muriate combined with an excess of acid. 158. c. During the treatment of all diseases in which the blood becomes more or less changed, j it will be requisite to have strict reference to the | causes from which the change has arisen. Un- wholesome food, vegeto-animal miasms, imper- fect secretion and depuration, and deficient ner- vous and v'rtal power, have been shown to be the chief of these. That the first and second of these should be avoided, need not be stated ; and that the secreting and eliminating functions ought to be ' promoted, in order to purify the blood, is equally ] manifest. The nervous and vital energies must be not only supported, but also promoted and excited, in order that the power of secretion may I be afforded to the torpid and weakened viscera • I and that the crasis and vital condition of the blood may be thereby restored, and the tonicity ! of the capillaries, and of the tissues generally, be increased. In addition to these, also, morbid se- cretions should be frequently evacuated, in order that vital power may not be further reduced by ; their morbid impression on the nerves and mucous digestive surface, and that the possibility of the absorption of any part of them into the circula- tion may be thereby avoided. But, in carrying this indication into execution, care ought to be had as to the measures which we employ. Gen- tle means are generally requisite, as rhubarb, &c. But those substances, which, with an aperient op- eration, possess also a stimulating and antiseptic operation, as the oil of turpentine, should be se- lected ; or, if other substances be preferred, they should be combined with tonics, antiseptics, and stimulants. Formulae 266. 437. 572. in the Ap- pendix, are good examples of this combination. 159. d. In all the alterations of the blood re- sulting from the introduction or absorption of mor- bid matters from parts previously diseased, what- ever tends to lower nervous and vital power, or to promote absorption—more particularly blood- letting, which operates in both these ways—ought to be guarded against, and a diametrically oppo- site plan of cure adopted ; not neglecting at the same time the promotion of the depurative and excreting functions. 160. e. In diseases where it seems evident that the watery and saline parts of the blood are drain- ed off, by the continued exudations from the mu- cous surfaces, as in cholera, particularly epidemic cholera, diarrhoea and dysentery attended by dan- gerous symptoms, much advantage might accrue from the injection of warm water into the \ eins, holding a very small proportion of saline matter, particularly the muriate and sub-carbonate of soda, with a piinute quantity of some mild stimulant and I astringent, in solution ; care being taken that the latter ingredient be not in nearly such quantity as to affect the albumen of the blood. Spirit of I wine, ammonia, sulphate of quinine, &c. may be j thus employed. (See Poisons, for treatment of Poisoning of the Blood.) 161. D. Prophylaxis, or the prevention of morbid states ofthe blood.—T he extended en- quiry which has been entered into respecting the causes of the alterations which take place in the blood, furnish the chief indications for preventing their occurrence. The primary influence of the organic nerves upon the blood, and the effect rap- idly produced upon this fluid by a diminution or vitiation of this influence, having been conclusive- ly shown in respect of changes directly produced by this class of nerves, both on the blood circu- lating in the vessels, and on the functions of se- cretion and depuration, it becomes a matter ofthe first moment to preserve the vital manifestations of this important part of the nervous system from experiencing depression or exliaustion ; especially where causes having this effect are in operation, and where there is any risk of those morbid mat- ters, which have been shown in this article to be the chief sources of vitiation, being carried into the blood ; particularly those vegeto-animal, or animal effluvia, which, floating in a moist atmos- phere, act both by depressing these vital man- ifestations, and by infecting the blood itself. Persons exposed to those sources of disease should live on a due proportion of farinaceous and other vegetable substances, with a moder- ate proportion of fresh animal food, and pre- serve the energies of the digestive and assimi- lating organs ; always attentively promoting the functions of secretion, depuration, and excre- BLUE DISEASE —Pathology of. 199 tion. At the same time many of the substances mentioned above may be employed as beverages, condiments, or preventives; more particularly the medicines formerly denominated antiscorbutics, the citric acid, lemons, lemon-juice with sugar; vinegar in which the warm spices, as capsicums, have been infused; the chlorides, camphor, qui- nine, &c. As it has been satisfactorily shown that great excitement and acceleration of the cir- culation, besides exhausting nervous and vital power, have also the effect of changing, and even of corrupting, the state of the blood, such excite- ment should be prevented, and allayed when pres- ent, by appropriate evacuations, and by refrigerant saline medicines and beverages. Biblioo. and Refer.—Jessenius, De Sanguine ex VenaMisso Judicium. 4to. Prag. 1618.—M. Hoffmann, De Sanguine et ejus Observatione. 4to. Altd. 1660. — R. Boyle, Anatom. Observ. on Milk found in Veins instead of Blood, Phil. Trans. 1665, pp. 100. 139. ; and Natural His- tory ofthe Human Blood, 8vo. Lond. 1684.—Courten, Experiments on the Blood, by injecting various Sub- stances into the Veins, Philos. trans, vol. xxvii. p. 485. (abounding in important facts.) —Albinus. De Pravitate Sanguinis. 4to. Franc. 1689. — De Sandris, De Naturali et PraHernaturali Sanguinis Statu, 4to. Bon. 1696.— Rivinus, De Sanguinis Pravitate, 4to. Ultraj. 1702.__ Stenerlin, De Morbis ex Crasi Sanguinis Alterato oriundis. Halae, 1706. — F. Hoffmann, De Judicio ex Sanguine per Veiia-sectionem emisso. Hal*, 1727. — Friend, Emmenalogia, Opera Omnia, p. 130. fol. Lond. 1733. (Contains a number of important experiments.) — Schuri- gius, Hasmatologia Historico-Medica. 4to. Dresd. 1741.__ Schwencke Ha-matologia, sive Sang. Hist. 4to. Hagae, 1743. — Nico/ai, De Spissitudine Sanguinis. 4to. Halae, 1749.__ Buechner, De nimia Sanguinis Fluiditate, et Morb. inde oriundis. 4to. Hala;, 1749.— Meyer, De Signis ex San^. per Vensect. pelend. Hala;, 1753. — Haller, Elemenfa Physiologic, 4to. vol. ii. p. 17. et seq. (A collection of nu- merous facts, with important new observations.)__Hew- son, Experiment. Inquiry into the Properties of the Blood. 8vo. Lond. 1771.; and Philos. Trans. 1773, p. 303. — Bor- deu, Analyse Med. du Sang. Paris, 1775. — Mi/man, in Trans, of Lond. Col. of Phys. vol. ii. p. 478. — Lind, On Diseases of Hot Climates. "3d. ed. 8vo. Lond. 1777.__ Pringle, On Diseases ofthe Army, &c. 8vo. Lond. 1775. __ Hey, Observations on the Blood. Lond. 1779. — Ferris, De Sanguinis per Corpus vivum Circul. Putredine. 8vo. Edin. 1784.—Gruner, De Pathologia Sanguinis. Jen. 1791. — Deyeux et Parmentier, Memoire sur Fes Alterations du Sang. 4to. Paris, 1797. — Lentin, Bevtrage, kc b. iv p. 182—225. — Werlhoff, Opera, p. 748. J. Hunter, On the Blood, Inflammation, &c. 4to. Lond. 1795. — Wells, On the Colour of the Blood, Phil. Trans. 1797, p. 416. — Beale, Of the Diseases arising from vicious Blood. Lond. 1800.__ Bostock, Medico-Chirurg. Trans, t. i. p. 47. — Thackrah, On the Properties of the Blood, kc. 8vo. Lond. 1819.__ Wilson, Lectures on the Bl od and Vascular System, 8vo. Lond. 1819, pp. 24. 50. — Au.tenre.ith, Phvsiologie % f, 880. 922. 1034.—Wolff, in Hufeland's Journ. der Pr. Heilk. ix. b. 4 st. p. 97.—Michaelis, in Ibid. xiv. b. 3 st. p. 65.—Cop- land, in Appendix to M. Richerand's Elements of Phvsiol- ogy, 2d edit. p. 636. — Belhomme, Observations sur le Sang. Paris, 1823. 4to.—Home, in Philos. Trans, for 1826, p. 189. — Gendrin, Recherches sur les Fievres, kc t. ii. p. 145.: et Traite Anat. dej Inflam. t. ii. p. 565, &c. — Bellingeri, in Annali Universali di Med. Ap. 827. — Schultz, in Meckel's Archiv fur Anat. und Physiol. 1826, No. iv. p. 487.__Trous- seaux, in Archives Gen. de Mtd. t.'xiv. p. 328.__Leuret Archives, kc t. xi. p. 383.—Sigalas, in Ibid. t. xii. p. 103. —Dupuy, in Ibid. t. xiv. p. 289.—Rayer, Ibid. t. xv. p. 136. —Gaspard, in Majendie's Journ. de Physiol. Exper. t. ii. p. 1., et t. iv. p. 1. — Majendie, in Ibid, t.' iii. — Rochoux, in Nouv. Bibhoth.de Med. Sep. et Nov. 1823.—Diet, de Med. t. xvi. p. 206.; et Journ. Hebdom. de Med. t. ii. p. 530.__ Boisseau, Nosographie Oreanique, t. iii. p. 175. — Velpeau, Hecherches sur les Alterations du Sang. 8vo. Paris, 1826. — Christison, in Edin. Med. and Surg. Journ. No. ciii. p. 274. —Babington, in Trans. Med.-Chir. Soc. t. xvi.—Ribes, Ana- tomie Pathologique, kc t. i. p. 308.—Andral, Pathological Anatomy, by Townsend and West, vol. i. p. 638. —Piorry, Procede Operatoire, &c, et Collection de Memoires sur Pathologie, kc Paris, 1831.; Sur la Circulation, p. 208. BLUE DISEASE. Syn. Cyanosis, (*.;«,o?, blue, and rorroc, disease,) Beaumes. Morbus Ceruleus, Cyanopathia, Marc. Exangia Cy- ania, Good. Cyanose, Fr. Die Blausucht, Ger Blue Skin, Blue Jaundice. Classif. 3. Class, Sanguineous Function ; 4. Order, Cachexies (Good). IV. Class, II. Order (Author, see Preface). 1. Defin. A blue, violet, or purple colour of the integuments, particularly of parts usually presenting a rose or flesh tint, as the cheeks, lips, mucous surfaces, fyc. 2. A blue or purple colour of the integuments of parts, or nearly the whole of the body, may occur as a symptom in the last stage of various acute diseases. But it is present from the beginning of this affection, is frequently connected with com- paratively little disturbance until some sudden change takes place, and generally results from chronic organic lesion. In other maladies this colour is an accidental, occasional, and not the most important symptom; in this affection it ap- pears as the only, or the most remarkable, change observed during life. 3. Its Pathology.—According to M. Gin- trac, who has directed much attention to this affection, it always proceeds from organic change of the heart or large vessels; the admixture of venous with arterial blood, and the distribution of it to the surfaces ofthe body, being the immediate or essential cause of the alteration of colour. This pathology agrees with the opinion of Senac and Morgagni : it has, however, been disputed. M. Corvisart first threw out doubts ofthe constant origin of cyanosis in this source; and more recent- ly MM. Ferrus, Breschet, Marc, Louis, Fouquier, and Crampton, have adduced facts which seem to militate against it, while it has re- ceived the able support of M. Bouillaud. 4. M. Ferrus contends, 1st, That cyanosis sometimes has existed to an intense degree, and yet upon post mortem examination no lesion could be detected admitting of the admixture of venous blood; nor any organic change of the heart or respiratory organs : 2d, That the opening of Botal may continue unclosed for many years without blueness ofthe surface being occasioned: and, 3d, That the admixture and circulation of venous with arterial blood have been demonstrated to occur in some cases, without giving rise to this peculiar appearance. That the second and third objections are well founded'seems almost incontrovertible. Numerous instances have been recorded by Louis, and others, which fully prove these facts. I have met with cases in children, where the communication between both sides of the heart seemed very free, and yet no alteration ofthe natural colour existed; and others, in which the change was evident during the paroxysms of suffocation only. But I must agree with Corvisart, Richer and, Cloo,uet,Gintrac, and Bouillaud, that the existence of this open- ing is no certain proof of admixture of the venous and arterial blood; for if the contractile powers of both ventricles are nearly equal, in relation to the resistance to be overcome, and if the natural open- ings of the cavities be not obstructed, no admixture of the blood in both sides ofthe heart could take place. 5. The principal force ofthe objections, there- fore, urged by M. Ferrus, evidently rests upon the fact of the non-existence of organic disease of the heart, large vessels, or lungs, in some cases of the disease, — a fact which is still not satis- 200 BLUE DISEASE —Pathology or. factorily established. I believe that it may be safely concluded, that the blue disease of infants and children is very generally dependent upon a communication between the opposite sides of the heart, or some malformation ofthe heart or large arteries, particularly contraction of the origin of the pulmonary artery, or some other change af- fecting the circulation through the right cavities of the organ; whilst in older and aged persons, a similar colour of the surface may proceed from whatever obstructs the circulation through the large veins, lungs, or heart, and even from simple congestion of the venous capillaries from loss of vital power; and in these latter cases, the affec- tion more nearly approaches the blueness observed to occur as a dangerous symptom of various acute diseases of the lungs and heart, as of asphyxy, and of pestilential cholera. 6. Symptoms, progress, and terminations of blue disease.—The bluish tint of the external sur- faces, whence this malady derives its name, is not equally deep in every part. It is usually deepest over the whole of the face, and the lips in partic- ular, on the hands, feet, and genitals. During any effort, or when crying, this symptom is much more marked than during repose: at the same time the parts presenting a bluish colour, or a violet ofthe darkest shade, are more or less puffed. The cir- culating and respiratory functions are rarely with- out derangement. The disordered circulation is characterised by palpitations more or less violent; sometimes accompanied by a very distinct bellows sound, and by a purring tremor, tendency to faintings, and serous effusions. The breathing is laboured and panting after the slightest effort. The warmth of the body is considerably diminished, and patients are very sensible of cold. The func- tions in general, and principally those of locomo- tion, are more or less languid, and, as it were, benumbed. 7. The symptoms just described do not always exist in the same degree, during the continuation of the malady. It may even be said that the disorder is made up of a succession of paroxysms and remissions. In the paroxysms alone we ob- serve those frequent faintings, that tumultuous palpitation of the heart, and suffocations, which endanger the life of the patient. No rule can be relied on as to the recurrence of these paroxysms; in fact, if it be certain that they are often brought on by over-exertion, fatigue, and violent mental agitation, it is equally certain that they occur with- out any assignable cause, and are more frequent in winter than in summer. The length of the paroxysm varies: it sometimes lasts several hours, and generally abates gradually. The termination of cyanosis is fatal to most patients; but some appear to recover entirely; others live for many years. Cases of this kind have been recorded by Morgagni, Sandifort,and Richerand. The death caused by this disorder is sometunes very sudden; but in the majority of cases it is preceded by an intense suffering, characterised by the most acute anguish, difficulty of breathing, fainting fits, and cold sweats. In a case of remarkable blue- ness from birth, in a girl, who was for some time under my care, the colour changed, in the course of two or three years, to dirty yellowish, chlorotic tint, which is still retained up to the thirteenth year. The disorder of the heart's action and respiration, in this case, although more or less considerable, was never very severe; but the child was always remarkably delicate, and inca- pable of any bodily or mental exercise. 8. Lesions observed after death : and their connection with the symptoms. — 1st, The most common lesion is the persistence or the re-esta- blishment ofthe opening of Eotal. This commu- nication of the two auricles is generally accom- panied by an obstacle to the passage ofthe blood from the right auricle into the corresponding ven- tricle, or from the latter into the pulmonary artery. Twenty-seven cases out of fifty-three reported by M. Gintrac, presented such an obstacle. In twenty-six of these cases, the circulation on the right side of the heart was impeded either by a contraction or by a total obliteration ofthe orifice ofthe pulmonary artery, and in only one case by the contraction of the right auriculo-ventricular orifice. Co-existent with these lesions is usually a hypertrophy of the right ventricle and auricle, or of one only of these cavities, with or without dilatation. Sometimes the ventricular cavity is itself contracted. 2dly, The ventricular partition has often presented a solution of continuity of more or less extent. Sdly, The arterial canal remained open in some subjects. 4thly, In one ofthe cases reported by M. Gintrac the two auricles (in per- fectly divided) opened into the right ventricle : the latter being very large, communicated freely with the left, which (narrow and without auricular orifice) gave origin to the aorta. 5thly, In an- other case, the aorta and pulmonary artery sprung from the left ventricle, the right being almost ob- literated, and the inter-auricular partition perforat- ed. 6thly, In another instance, the opening of Botal was preserved; the aorta disappeared after having supplied the cephalic and brachial trunks; the pulmonary artery, receiving the blood from both ventricles, formed the descending aorta. Tthly, Such a transposition of the larger arterial trunks has been witnessed, as the aorta springing from the right ventricle, and the pulmonary artery from the left; the opening of Botal and the arte- rial canal still remaining, or only the latter. Sthly, In some cases the heart consisted only of one auricle and one ventricle. 9thly, Two superior vena? cavae were seen, the one opening into the left auricle. It is unnecessary here to enlarge upon the other lesions noticed in persons afflicted with this complaint, because they do not necessa- rily belong to the subject. 9. As respects the relation between the symp- toms and lesions, M. Bouillaud remarks, that the alterations pointed out in the central organs of circulation have usually the effect of permitting the black blood to mingle with the red; but some of these lesions, as previously observed, such as the opening of Botal does not necessarily entail this admixture; for which reason it is not invariably accompanied by blueness of the tegu- ments; either the black blood not having mingled with the red, or the mixture being insufficient to produce the bluish colour. But when the arterial canal remains open; when the aorta springs from both ventricles jointly; or when, to the commu- nication between the right and left cavities, is superadded an obstacle to the free current of blood in the former; a considerable quantity of black blood must necessarily mix with the red. Whenever an anormal communication between the cavities of the right and left divisions of the BRAIN — Alterations in its Membranes. 201 heart co-exists with an obstacle to the circulation of the blood in the right ventricle or in the pul- monary artery, the mixture ofthe blood is not the sole cause of the discoloration of the skin, the puffing of certain parts, of various serous conges- tions, &c. In fact, it is evident, that the impeded circulation contributes mainly to the production of these phenomena. Should we not also attrib- ute to the contraction of the auriculo-ventricu- lar, or ventriculo-pulmonary orifices, the bellows sound and the purring tremor remarked in some !»atients? However this may be, some of the esions coincident with blueness of the teguments are invariably congenital; while others (such as the communication between the right and left regions of the heart) may be either congenital or accidental. 10. The causes which develope most of the congenital lesions, from which blueness may en- sue, are not easily determined on. But a com- munication between the right and left cavities of the heart may be occasioned by ulceration of the auricular and ventricular partitions, or by the rupture of these partitions, especially of the au- ricular, in violent and lengthened efforts. An obstacle to the course of the blood through the right auriculo-ventricular, or the ventricuTo-pul- rnonary orifice, may also, particularly in the early stages of life, induce an anormal communication between the two auricles, by ungluing, as it were, the valvular laminae, which, by their agglutina- tion, have obliterated the opening of BotalT The existence of a similar obstacle at an intra-uterine period of life, when the opsning still remains, may be also deemed a sufficing cause for its ultimate non-obliteration. (Diet, de Mid. et Chirurg. Prat. t. vi. p. 7.) 11. I am of opinion, not only that such ob- stacles have very generally existed during intra- uterine life, and been the cause of the blueness observed afterwards, but that they have also occasioned, during foetal existence, a permanent state of distension; and thence, in some respects, malformation ofthe capillary system, particularly in the cutaneous and mucous surfaces, favouring congestion, and languid circulation through them after birth, and the consequent blueness, and the puffiness that generally attends it. I may add, as a matter of diagnosis, that very intense and gen- eral blueness is not uncommonly produced by the incautious internal use of the nitrate of silver. I have observed two or three such cases, and others are recorded by Albers, Roget, &c. (Med. Chir. Trans, vol. vii. p. 284.) 12. Treatment.—Art is of little avail in this malady. We must chiefly depend upon the ef- forts of nature in bringing gradually about a change in the lesions on which it depends; and attempt to assist her e Ibrts, by directing bodily and men- tal repose, and a pure, mild, dry, equable and somewhat warm air; by attending strictly to the state of the biliary and other secretions, and the digestive functions; and by recommending gently tonic medicines, with an easily digested and nu- tritious diet. During the paroxysms, M. Bouil- laud recommends blood-letting, — a practice which is by no means warranted by my experi- ence. Depletions, and all other lowering means, aggravate the symptoms, and seldom or ever suc- ceed in removing the severity of the paroxysms, for which he advises them. I have derived more advantage from stimulating pediluvia, frictions of the surface of the body and lower extremities, and the administration of gentle antispasmodics and stimulants. (See F. 348. 424. 663.) In one or two instances, I conceived that some advantage was derived from the preparations of iron com- bined with the fixed alkaline carbonates. (See also F. 94. 662. 718. 920.) Bibliog. and Refer.—Hunter, Medical Observat. and Inquiries, vol. vi. p. 299.—Ferrus, in Diet, de Med. t. vi. p. 296.—Good, Study of Med. t. iii. p. 482.—Gintrac, Obser- vat. et Recherches sur la Cyanose, Stc. Paris, 1824.—Louis, Mem. sur la Commun. des Cavit. Droites du Cceur avec les cavities Gauches, Archives Gen. de Med. t. iii. pp. 325. 485.; et Mem. et Recherches Anat. Pathol, p. 301,—Bouil- laud, Diet, de Med. et Chirurg. Pratiques, t. vi. p. 1.— Crampton, in Trans, of College of Phys. Dublin, N. S. vol. i. p. 34. J BRAIN — its Morbid Structures. Syn. 'EyxU{io:Xuq, Gr. Cerebrum, Encephalon, Lat. Cerveau, Enciphale, Fr. Das Him, Gehirn, Ger. Cerebro, Ital. Classif. Special Pathology and Mor- bid Structures. IV. Class, III. Or- der (Author, see Preface.) 1. With the view of avoiding unnecessary re- petition, and of furnishing a complete account of the changes and morbid phenomena connected with the parts contained within the cranium, al- terations of structure will be considered in the first place, and in systematic connection; and, af- terwards, inflammations affecting either the brain or its membranes, will receive attention. As similar lesions develope themselves in the brain, or its membranes, in the course of a variety of diseases; and as many of those which are most commonly found upon dissection give rise to very different phenomena during life; their arrange- ment in a separate form will facilitate reference to them, when those specific states of disease, which they either originate in, or occasion, are being discussed. Thus tumours formed in the brain, or purulent matter secreted there, or induration or softening of the cerebral substance, &c. are not infrequently found in cases of either palsy, epilep- sy, insanity, or encephalitis, without limitation to any one of them. Instead, however, of describ- ing these and various other lesions, when consid- ering each of these diseases, I shall here give a minute description of the morbid structures ob- served in the brain and its membranes, and refer merely, when discussing these and other diseases implicating the cerebral functions, to those chan- ges most commonly found on dissection of fatal, cases, as they are described in this article. 2. Of all the organs of the body, the brain is the most exquisitely and incomprehensively form- ed, and presents the least intimacy of connection between the results of dissection and the phe- nomena of disease. The most violent symptoms referrible to this organ often exist during life; and yet, on the most careful examination, after death, either no appreciable lesion, or none suffi- cient to account for the phenomena, can be de- tected. Whilst, on the other hand, many, and most important changes are frequently discovered in both the brain and its membranes, in cases which betrayed either no cerebral disorder, or none calculated to excite suspicion during life of any organic change. It is extremely important to be aware, not only of this fact, but of the cir- cumstance just alluded to, that the same morbid appearances, or, at least, states so nearly alike 202 BRAIN — Alterations in its Membranes. that they cannot be distinguished, will frequently be found after maladies very dissimilar as regards their cause, nature, and consequences. Thus, ir- ritation of the brain occurring in the progress of fevers, and the exanthemata; convulsions, insani- ty, drunkenness, puerperal derangements, metas- tasis of gout, and various other diseases, will be attended with congestions, injection of the blood- vessels, secretions of lymph, or serum, or of air between the membranes, &c.—states in every respect similar to those proceeding from idiopathic inflammation. Nor should it be forgotten, that the kind of death, the particular circumstances attending it, and the position and changes to which the body is subjected immediately after- wards, tend very materially to influence the ap- pearance and states of the parts within the cra- nium. In the view which I am about to take of the principal lesions of structure affecting the encephalon, I shall first notice the morbid states of its membranes; next, the lesions presented by its sinuses and other blood-vessels; and, lastly, the diseased appearances of the different parts of the encephalon itself. 3. I. Morbid States of the Membranes of'the Bkais.—The ultimate connection which the membranes ofthe brain have with the cranial bones on the one side, and the brain itself on the other, and their expansion between both, render them extremely liable to participate in all the malformations, diseases, and external injuries of those parts. Whilst they most commonly, with the limpid fluid exuded between them, separate those parts, and facilitate the motions of the lat- ter, they also often prevent the extension of mor- bid action from the one to the other. But they do not always succeed in thus limiting disease; for they frequently become secondarily affected dur- ing maladies commencing either in the skull or the brain; and, when thus involved, they, in some measure, become the medium of mutual infection. But the membranes are not only thus secondarily affected; they are also not infrequently them- selves the primary seat of disease; and when such is the case, the parts on each side of them, par- ticularly the brain, seldom fail of participating more or less in the disturbance. Thus we often find them the primary seat of congestion, inflam- mation, with its consequences, as eliusion be- tween them of various kinds of fluids; and the source whence disease has extended to the brain itself. Those changes are presented to our view, not only in the primary inflammations of the membranes, but also in several forms of fever; in morbid affections of the mind, tetanus, delirium tremens, convulsions, epilepsy, apoplexy, palsy, and other diseases, wherein we have reason to suppose that the brain itself is either primarily and principally affected, or participates largely in the morbid states of its envelopes. 4. i. The Dura Mater is often found un- usually adherent to the cranium, even when the brain and its membranes have been quite free from change, but more commonly when chronic disease has existed in either the one or the other. It is also sometimes slightly adherent to the skull, and occasionally this want of adhesion is very remarkable. In some instances, the dura mater is separated entirely from a portion of the cranial bones. In some rare instances, the space is filled with a watery fluid; but this has only been met with in hydropic children. The separa- tion is generally the result of external injuries; and either blood or pus, or even both, is usually found in the space between the bone and the membrane. In some cases, these effused fluids, particularly blood, either fluid or in coagula, are in considera- ble quantity, occasioning the usual symptoms depending upon pressure. Lymph, in various de- grees of firmness, is also found between a part of the dura mater and the skull; and this, as well as pus, with which the lymph may be partially mix- ed, are generally the result of inflammations con- sequent upon external injuries. These appearan- ces have been sometimes observed in fatal cases of epilepsy, but only when the patient has receiv- ed some injury during the paroxysm. They are often connected with a puffy swelling of a cor- responding portion of the scalp. 5. The dura mater itself may be here viewed as two membranes, closely united throughout by means of fine, close, cellular tissue : the exterior, or that applied to the cranial bones, resembling in structure, and performing the office of, periosteum; the interior, or unattached, being a reflection of the arachnoid, and having, as respects its functions, a more intimate relation to the included organs : the former being a fibrous; the latter, a serous membrane. 6. A. The fibrous structure ofthe dura mater is frequently more than usually vascular, particu- larly in fatal cases of apoplexy, paralysis, fever with cerebral symptoms, epilepsy, and in the con- gestions which occur in the last stages of whoop- ing-cough, pulmonary diseases, asphyxia, and poisoning by narcotics. This state is, however, very different from inflammation, as the minute capillaries do not present the same degree of redness, particularly in the unattached or arach- noid surface. This structure is sometimes tinged with bile, and of a deep yellow colour through its whole extent, as in cases of acute jaundice, which are attended with comatose symptoms. After contusions, or when suppurations exist be- neath or exterior to it, it is either yellow, dusky, bluish, brownish, or even blackish. It is also occasionally spotted with black, in some cases of melanosis. In some instances, this membrane seems distended from fluids effused in the cavities of the brain, or between the membranes: in others it is apparently corrugated or collapsed. This latter state generally proceeds from it having been punctured during the separation ofthe calvarium, the fluid which it had contained having thereby escaped. But it is sometimes noticed where no such accident occurs, particularly in extremely emaciated bodies, or in the very aged, when little or no water is collected beneath it. A more than usual dryness and transparency is occasionally observed in this as well as in similar structures. Unusual dryness is also sometimes conjoined with a shrivelled state, and deficient transparency. Otto thinks that this is one ofthe remote effects of inflammation. 7. It is but rarely inflamed, excepting from external injuries, and then generally in circum- scribed patches of greater or less size. In these cases, the injection and redness are very remark- able, particularly in the vicinity of purulent form ations and injuries of the bones, or where ulcera- tion, discoloration, fractures, abscesses, &c. exist in its vicinity. Suppurations, in which the pus is BRAIN — Alterations in its Membranes. 203 found between its layers, or on its outer surface, are very rare. Cases, however, are referred to by Otto of this occurrence. When suppuration does occur, it is generally seated in its inner sur- face. In some of these cases, the purulent matter has eroded, and perforated the skull and layers of the dura mater exterior to it. Thickening of the dura mater is not an unusual result of chronic states of inflammation. It varies extremely in degree, and it is sometimes so great as to occa- sion symptoms of pressure and irritation. It is sometimes found in fatal cases of epilepsy and paralysis ; and is occasionally conjoined to in- duration of the thickened part. Ossification of the fibrous structure of the dura mater is a com- paratively rare occurrence, whilst ossific deposits in its free or arachnoid surface are very common. In the former case, the bony matter follows the fibrous arrangement of the membrane, and in- volves its substance. Two interesting specimens of this change are referred to by Dr. Bright (Reports of Medical Cases, Sec. vol. ii. p. 663.). Ossific deposits may likewise be ascribed to slight, or chronic states of inflammatory action. 8. Tumours also form in the dura mater. Those which are most intimately connected with it have a fibrous structure; whilst the fungoid tumours sometimes observed seem to be common to both this membrane and the arachnoid lining it. Nor are they limited to the dura mater, as sup- posed by Louis and the Wenzels ; but they may arise also in the bones of the skull, as shown by Walther, Graaff, and Siebold; and even in the pericranium, as contended for by Otto, Eberjiaieb, and Cruveilhier. Os- teosarcoma, or fungus cranii, therefore, as stated by Von Walther, and fungus dure mairis, are merely different, although often simultaneously occurring forms ofthe same disease. (See § 17.) When fungous tumours originate in the dura ma- ter, they not infrequently perforate the skull, by occasioning absorption of the superincumbent por- tion of bone: but they also often involve the bone in a similar change, giving rise to fungus cranii as now stated. They occur in every part of the dura mater, commencing more frequently in its inner coat, and are found oftener in this situation, than in the bone itself, or the pericranium. (See Cra- nium.) 9. Other kinds of tumour are occasionally found in the dura mater. But those of a constitu- tional origin usually commence either in the arach- noid covering the dura mater, or in the fine con- necting cellular tissue. They, however, general- ly soon involve, not only this latter membrane, but also occasionally the cranial bones. Of these tumours, comprising the scrofulous, scirrhous, carcinomatous, and the hematoid, I shall make more particular mention in the sequel. Although sometimes found in the inner surface of the dura mater, they are met with only consecutively upon their original manifestation in some other part of the body. More rare than any of the foregoing, is the occurrence of fatty and encysted tumours on the exterior surface, or between the layers ofthe dura mater. They have been found in this situa- tion by Morgagni, Fricke, and Otto; and, in very rare instances, have been observed to con- tain hair. Scrofulous tumours are less frequently found exteriorly to, and between the layers of, the dura mater, than in its internal surface. 10. Unusual thinness has been observed in some parts of this membrane ; and some of its processes have been wanting, owing to their ab- sorption ; in some cases, without any obvious cause, but more frequently from the pressure of a tumour of the brain, or some other morbid en- largement. " The falciform process, and a part ofthe sensorium, have been wholly removed, and large portions of the dura mater and its processes have been found as thin as silver paper." (Hoop- er, Morbid Anatomy of the Brain, fyc. p. 29.) When portions of the dura mater are destroyed by any internal cause, or even by external injury affecting the bone, they are rarely or never re- produced, and never otherwise than by a thick or dense cellular tissue closely connected with the newly formed bone; or, if the bone be not produc- ed, after having been destroyed, it assumes a fibro- cartilaginous state, and becomes consolidated into a common cicatrix with the integuments. Rup- ture, or laceration of the dura mater is generally the consequence of fractures of the cranium and concussion. It has, however, proceeded from vio- lent coughing, after the superincumbent bone has been removed by fracture, or by trepanning, &c. 11. B. Morbid states of the arachnoid cover- ing the dura mater.—The internal surface of the dura mater is lined by a reflected portion of the arachnoid membrane, the unattached surface of the dura mater thus consisting of a true serous membrane, intimately attached to, although differ- ent in its nature from, the fibrous structure which it covers. Inflammation, whether originating in the dura mater itself, or in this surface, chiefly manifests its distinctive characters and effects on this lining : and generally presents, especially in the early stages of the acute disease, a minute- ly injected state of the capillaries, with a bright red tinge of the whole surface. This appearance has been beautifully illustrated in the first of Dr. Hooper's plates of lesions ofthe brain. When acute inflammation attacks this part, it is general- ly confined to one side, the longitudinal sinus or the falx furnishing the boundary of the disease. In very acute attacks, and in the advanced stages of inflammation of the dura mater, the internal surface becomes covered by a layer of fibrinous lymph, into which, as I have shown in respect of serous membranes generally, minute vessels may be traced, when the exudation of this substance has been proceeding for some days. It is usually diaphanous, very delicate, and forming a complete adventitious membrane. In other cases, a much thicker, opaque, and albuminous-like membrane, of much firmness, less vascular and less intimately adherent to the dura mater, is formed. Although the fibrine and albuminous matter exuded may be both abundant, and thus provided with vessels, it is seldom the medium of adhesion ; or, indeed, at all adherent, to the arachnoid covering the con- volutions : and if adhesions have formed, they are very slight in respect of this latter duplicature of the arachnoid, unless very acute inflammation also exists in the pia mater, directly opposite to the inflamed surface of the dura mater. 12. In more chronic forms of inflammation, this surface not infrequently assumes a spongy ap- pearance, with more or less redness and marked injection of the vessels. In some cases it has a villous aspect, from a slight exudation of albumin- ous matter, and interstitial effusion of serum in the 204 BRAIN -"-Alterations in its Mi.mbranes. texture of the arachnoid lining. Purulent mat- ter is seldom formed to any considerable extent ; but, when it is secreted, it usually spreads thinly over the membrane. It seems generally to pro- ceed from the inflamed surface, without any dis- tinct appearance of ulceration. In some cases, however, owing to adhesions of the membranes around it, circumscribed accumulations of pus are met with ; and these may cause the erosion of the dura mater and bones exterior to them. Al- though the productions now noticed sometimes are observed to follow idiopathic inflammations of this part, they are more frequently the results of external injuries ; and are more commonly met with in the parts which cover the hemispheres, than in the basis of the skull, unless there be a very general state of inflammation of the parts within the cranium. 13. Adhesions of the lining membrane of the dura mater to the arachnoid and pia mater are chiefly observed when both reflections of the arachnoid are inflamed, particularly in chronic affections of the cranial contents. The medium of adhesion varies considerably. It is frequently found to consist of a firm but thin exudation of fibrinous lymph or of albuminous matter : in some cases, delicate, diaphanous, and vascular ; in oth- ers, thick, opaque, and less intimately adherent to the internal surface of the dura mater than the preceding. In a few instances, it is formed of fine filamentous bands passing through a more than usually copious efiusion of serum; and occasional- ly the membranes are intimately and firmly join- ed, even without any very apparent medium of union, particularly at the centre of the part ad- herent. This is chiefly seen immediately over or near the situation of severe organic disease ofthe brain itself, as abscess, tumours, superficial ulcer- ations, &c. In some cases, the adhesions are so firm that, in attempting to raise the dura mater, the subjacent membranes, with a portion of the brain, are removed along with it. 14. Ecchymosis and purple spots arising from the effusion of blood, in minute patches, beneath its arachnoid lining, are sometimes observed in the unattached surface of the dura mater, and partake of the character of purpura. They are most commonly found in cases of cerebral dis- ease, which has been complicated with chronic change of the biliary organs and deficient energies of life,—or with general cachexia. Carbonaceous deposits, or melanosis, have also been sometimes observed in the situation. Dr. Bright believes them to be the result of extravasated blood. (See the art. Melanosis.) Ossific deposits, general- ly disposed in plates, or much thicker in the cen- tre than the circumference, and varying much in number and situation, are also frequently found towards the surface of the dura mater. They seem covered by the arachnoid, are closely ad- herent to the dura mater, and formed between them. They occasionally present an irregular surface, or assume a nearly conical form, and are often connected with nervous diseases, particular- ly epilepsy. They are most frequently met with upon the falx, and near the part where the dura mater separates to form the longitudinal sinus. 15. lumours not infrequently proceed from the internal surface of the dura mater. Many of those productions are actually formed in the arachnoid lining this surface ; being only adhe- rent, and often very slightly, to the proper struc- ture of the dura mater, and in no way changing its characters. As these tumours increase in bulk, they gradually produce debility of both mind and body, particularly the former. Much of the severity and rapidity of these effects will, how- ever, depend upon the rapidity of their formation. When small, and sources rather of irritation than compression, convulsive affections are oftener oc- casioned by them than paralysis: when large, they more frequently give rise to paralysis than convulsions : but either of them may be followed by any of those affections ; mental weakness being the more constant, and often the most re- markable effect. Many, also, of the tumours developed in the dura mater can scarcely be said to originate either in its fibrous membrane, or in its serous or arachnoidal lining : but should rather be referred, at their commencement, to the cellu- lar tissue uniting those layers. Amongst those which seem more frequently at least to originate in this latter situation,—although often involving, and in a very short time, all the layers of the dura mater, and even the parts adjoining,—the scrofulous, the cartilaginous, the haematoid, and the encephaloid or fungous tumours, require the most particular notice. The scrofulous tumour is found on the internal surface ofthe dura muter, having an organized, fleshy, solid, and humid ap- pearance ; and is but rarely met with, and only in connection with scrofulous disease in some other part of the body. 16. The caidilaginous tumour is generally seat- ed in close connection with the dura mater, and under its arachnoid lining. It varies as much in the perfection of the cartilaginous state, as in its size. It is sometimes perfectly cartilaginous ; at other times merely gristly. It is oftenest met with hi the falciform process and tensorium ; and is occasionally attended with ossific deposits in the same situations. Indeed, as remarked by Dr. Hooper and Dr. Monro, some of those tumours are partly ossified, so that the cartilaginous state seems to be often an intermediate stage between that of gristly firmness and complete ossification. A case is described, by Mr. Watson, in Dr. Monro's work, of a cartilaginous tumour, the size of a walnut, containing bony matter towards its centre, growing from the dura mater. The sub-cartilaginous tumours are often tuberculous, of a dirty white colour, always distinct, but often numerous, and varying from the size of a pea to that of a hazel-nut. They generally are found between the dura mater and its arachnoid lining, have a broad base, present a clean smooth surface when divided, are firm, and devoid of vascularity. They seldom affect much the superincumbent dura mater and bone, but deeply indent the sub- stance of the brain. 17. The malignant tumours, which are occa- sionally met with in the dura mater, assume the sarcomatous, the carcinomatous, and the fungoid characters. The fungoid disease may be either encephaloid, or hematoid. The encephaloid tu- mour is not common. Its divided surface is cel- lular and spongy, and gives out a pap-like matter when pressed. Its, structure is more generally approaching to the fungoid, than to the tubercu- lous. It seems to be entirely produced from the lining membrane ofthe dura mater, and is almost always connected with scirrhous or malignant BRAIN — Alterations in its Membranes. 205 diseases originating in some other part of the body. The hematoid tumour is of the colour of venous blood, has a broad base, and a fungous, some- times a tuberculous, structure. It is soft to the touch, is covered by a delicately lamellated tissue, thinner than silver paper. When divided, it ap- pears spongy, and extremely vascular. It is very rare, and is always connected with the primary occurrence of the disease in some other part of the body. The simple cyst, or watery tumour, the hygroma of Dr. Hooper, is seldom or ever observed in this situation, although frequently in other parts of the encephalon. A case of it, how- ever, occurred to Dr. Duncan. The acepha- locyst, or headless hydatid, has been found con- nected with the arachnoid of the dura mater, in a very few cases. 18. The Causes of malignant, or constitutional tumours in the dura mater, are generally external wounds or contusions, concussions, the scrofulous or syphilitic taint, and most commonly previously existing disease of a similar nature in other parts of the body. 19. The Symptoms by which their existence may be inferred are extremely equivocal. At the early periods of their growth, they frequently give rise to little or no disturbance. Much, how- ever, will depend upon the rapidity with which they are formed, and their situation. When they grow slowly, the portion of brain becomes gra- dually accustomed to, and, as it were, insensible of, the pressure; it seems to waste; and, if this compressed and atrophied part be not indispen- sable to the free exercise of the sensorial, intellec- tual, and locomotive functions, the disease pro- duces no evident or sensible indication of its ex- istence. But sooner or later the compression produced by them on the brain, or the irritation occasioned in the membrane, gives rise to symp- toms of the most serious nature; frequently in a very sudden manner, sometimes more gradually. These chiefly consist of paralysis, epileptic con- vulsions, and apoplexy, occasionally occurring as suddenly as in the sanguineous forms of these diseases. Most commonly, however, and espe- cially when the tumour is situated in or near the base of the brain, the symptoms, whether those of compression or of mental disorder, supervene more rapidly: sensation and volition gradually disappear from the limbs which correspond with the compressed portions of brain; the intellectual powers are obscured, and the patient soon be- comes hemiplegic and idiotic. The gradual acces- sion of hemiplegia, and of the other symptoms of compression, generally indicate that the paralysis arises from the developement of a tumour, rather than from the formation of an apoplectic effusion of blood. The frequent occurrence, also, of acute pain in the paralysed limbs, of epileptic move- ments, antecedent cephalalgia of a violent charac- ter, with obscuration of the intellectual powers, somnolency, a cachectic habit of body, or the oc- currence of disease in other parts of the body cal- culated to taint the system, as the scrofulous, syphilitic, carcinomatous, or fungoid diseases, are also circumstances indicating the formation of tu- mours in the membranes of the brain. 20. These tumours usually give rise to further disease of the brain, or its membranes, before terminating life; such as inflammation ofthe parts adjoining, effusions of fluid beneath or between 18 | the membranes, adhesions of their opposite sur- faces, destruction of the bones, softening and pulpy destruction, &c. of the cerebral substance; sanguineous effusion in this situation : and these increase the severity of the symptoms, and hasten the fatal termination. It should, however, be kept in recollection, that the effects produced by these tumours have ui general no relation to their bulk. One of the circumference of one or two inches will often occasion (the situation and nature of the tumour being the same) as violent effects as another of four or five inches. It is, moreover, not to the tumour itself that the symptoms are to be imputed, but to the effects it produces on the brain and membranes. 21. ii. Morbid Changes of the Arach- noid and Pia Mater.—A. The Arachnoid is so delicate, perfectly transparent, and so irftimate- ly adherent to the pia mater, except at the base of the brain, as to admit with difficulty of sepa- ration from it. That lesions, therefore, of the latter membrane should affect also the former, cannot be a matter of surprise. Indeed, the greater number of changes which I shall have to notice in this section generally invade both these membranes simultaneously, although either of them may be affected in a more or less marked degree. 22. Inflammatory action gives rise, though very rarely, about the optic nerves and between the lobes of the cerebellum, to small patches of beautiful vascularity in the arachnoid; the sur- rounding portions of this membrane being opaque, and adhering to inflamed parts of the pia mater. It is, however, very uncommon to find, even in the most intense inflammation of these mem- branes, red vessels in the arachnoid. The most frequent results of inflammation in this situation are, thickening, and the effusion of a watery or serous fluid under it, raising and separating it, in places, from the pia mater, particularly in the intergyral spaces. The fluid secreted in this situation is generally transparent, but it is some- times turbid and albuminous, occasionally opa- que, and tinged with bile in jaundice. In rarer eases it is tinged with blood. Thickening and opacity of the arachnoid vary much in degree. They are occasionally so great as to obscure the vessels and membrane underneath it. Less fre- quent than the foregoing is the secretion of a puriform matter, under the opaque and thickened membrane, giving the appearance of a diffused suppuration; and still more rare is the deposit of fibrinous lymph, unless in a state nearly approach- ing to an albuminous substance, or a puriform fluid. 23. The effusion of a serous fluid, in excessive quantity, exterior to the arachnoid of the pia mater, and in the bag of the arachnoid coat, around the encephalon, forming dropsy of the cerebral membranes, is sometimes observed. It has been fully demonstrated by M. Majendie, and confirmed by other enquirers, that this mem- brane secretes a fluid, in health, varying some- what in quantity with the state of the brain, and of its circulation; that this fluid cannot be ma- terially diminished, or entirely deficient, without morbid phenomena being produced; and that it may, in disease, not only be secreted in too large quantity, but also in modified quality. In some cases of chronic and congenital hydrocephalus, 206 BRAIN — Alterations in its Membranes. particularly when accompanied with spina bifida, the effusion is cluefly in this situation. In those, it is usually pellucid, and the arachnoid is not materially changed in its appearance. In more rare cases, however, this fluid has been observed somewhat turbid, as well as excessive in quan- tity; and the arachnoid opaque and thickened. In these, it would seem to have proceeded from increased vascular action affecting this membrane and the pia mater. Effusion of a watery fluid, however, in this situation, is much less frequent than in the ventricles. It is commonly congenital and chronic in these latter cases; and it some- times protrudes the membranes, in large watery tumours, through apertures in, or between, the bones of the head. Several cases of this kind have occurred to me in the Infirmary for Chil- dren. In dropsy of the ventricles, which is most common, producing almost all the large watery heads, the fluid is collected in the bags of the arachnoid and vascular membranes lining the cavities ofthe brain, so that it is contained, either in all, or the greater number of them, at the same time, which is most frequently the case; or in one of them only. Serum effused from the arachnoid and vascular membrane (pia mater) may thus be situated :—1st, In the sub-arachnoid cellular tis- sue; that is, between the arachnoid of the pia mater and this vascular membrane : 2d, In the great cavity ofthe arachnoid around the encepha- lon : 3d, In the different ventricles, and even in the cavity between the two folds of the septum lucidum (Breschet). The quantity of serum effused in these situations varies remarkably. In congenital and chronic cases, it is sometimes un- commonly great, filling up and distending enor- mously the cranial cavity; impeding or arresting the developement, altering the form, and even in- juring or destroying the texture, of the cerebral substance, which is expanded in the form of a sac; that part of it above the ventricles sometimes con- sisting of the meninges merely. In acute hydro- cephalus, the effusion takes place in a few days, and to a much less extent; and in serous apoplexy it may occur in a few hours. In these latter dis- eases, however, it is often a matter of dispute, whether the symptoms are more the result of the effusion, or of diminished vital endowment, and the state of circulation ofthe brain. (See Dropsy of the Encephalon.) 24. Dryness of the arachnoid is occasionally found after cases of excessive cerebral irritation, and where inflammatory action has been suspect- ed. There can be no reason wherefore deficient secretion should not sometimes occur here, as well as in other serous membranes, as a result of inflammation. An unctuous state ofthe arachnoid is sometimes observed, particularly after erysi- pelas, abscess of the brain, discharges from the ear, paralysis, &c, and other states of disease, in which there was reason to infer the existence of inflammatory irritation of the membranes of the brain. Adhesions of the arachnoid to the opposite surface of the dura mater, by means of a cellular or firm albuminous false membrane, &c. have been already described (§13.). Dark carbona- ceous deposits, similar to those noticed (§ 14.) in the internal lining of the dura mater, are also rarely observed in the arachnoid and pia mater. Osseous deposits also occur in the arachnoid, and are likewise rare. 25. B. The Pia Mater partakes in all the in- flammatory states, and their consequences now described in respect of the arachnoid. The vas- cularity of this membrane varies greatly. Some- times it consists chiefly of engorgement of its veins, imparting to it a dusky or purplish hue, without any sign of inflammatory or other change. Occasionally this congestion is attended with in- jection ofthe arteries, and increased redness only, or with these in conjunction with one or more of the lesions now referred more immediately to the arachnoid. 26. Slight effusions of blood, and patches of ecchymoses, varying from the size of a split pea to that of a half-crown, are occasionally found lying upon the surface of the convolutions, and re- tained between the meshes of the pia mater. This state aries from concussions ofthe brain, and con- gestions consequent upon suffocation, poisoning by narcotics, and the advanced stages of disease; also from obstructions in the vessels returning the blood from the brain. A layer of fibrine is sometimes, but rarely, observed as a consequence of effusions of blood between the pia mater and brain; the serum and red particles of the effused blood having been absorbed, and its fibrine re- maining. 27. The pia mater and arachnoid are occasion- ally separated from the convolutions inconsequence of concussion; and in some cases, particularly after acute or recent inflammations, they may be removed from the cerebral substance with scarcely any force, or with much less than in. health, the vessels being loaded with blood. Otto thinks that the easy separation of the vascular membrane from the brain originates in the effusion of lymph beneath the membrane, loosening its connection to the cortical substance. On the other hand, after chronic inflammation, occurring without efiusion under the membranes, but with a considerable ef- fusion into the ventricles, they are often found so closely adherent to the convolutions, that they can- not be separated, but in very small fragments, and then not without bringing away with them portions of the cineritious substance of the brain. 28. Patches of yellow, albuminous, or albumi- no-puriform matter, are sometimes found on the upper surface of the pia mater, between it and the tunica arachnoidea. These patches are usually small; but they are occasionally very large, and diffused over nearly the whole of one hemisphere. Dr. Hooper has observed them covering nearly the whole of the base of the brain, so as to en- velope most of the nerves. This appearance seems to result from a more than usually intense state of inflammation, as all the membranes are found inflamed, and the blood-vessels loaded with dark blood, and to differ but slightly from the effusion of pus and lymph already described in connection with changes of the arachnoid. Ul~ ceration and mortification are very rare conse- quences of inflammation of the pia mater. They may, indeed, be rather considered as superficial ulceration and gangrene of the brain. Cases, however, have been met with, sometimes con- nected with superficial suppuration, affecting chiefly this membrane. (Buzzi, Morgagni, Dubrevil, Otto.) 29. Tumours often grow from the pia mater. The scrofulous kind of tumour or tubercles are not very rare in this situation. When they occur, BRAIN—Alterations in its Membranes. 207 they sometimes reach a large size, and break down into a puriform fluid, forming circumscribed or encysted abscesses on the surface of the brain. Leiveille found them as large as an egg, in an idiot Cases are also described by Earle, Abercrombie, Otto, and others. Tumours of a sub-cartilaginous structure are very rarely met with in the pia mater, although occasionally in the choroid plexus. They are usually of the size of a pea, round or oval, laminated, cartilag- inous in the centre, exteriorly tuberculous, and covered with a delicate vascular membrane. 30. True encysted tumours are also sometimes met with in the pia mater. Otto describes one of immense size,—six inches long by three broad, —found on the right hemisphere of the brain of the Duke of Saxe-Gotha. Eso.uirol met with a tumour of this kind containing fat; and similar instances have been recorded. Ossific deposits and earthy concretions have been rarely observed on the internal surface of the pia mater, dipping down into the structure of the brain. 31. Serous cysts, the hygroma of Dr. Hooper, consist of a delicate and transparent membrane, filled with a clear, limpid serum. There is in some cases only one, in others two, three, four, or even more. When solitary, they vary from the size of an orange-pip to that of a walnut; but they are seldom much above the bulk of a large pea. When numerous, they are usually much smaller. They are very rare in the membranes of the exterior surfaces of the brain; but they are very common in the choroid plexus, where they are frequently in -clusters. They have been mistaken for hydatids, but are merely simple cysts, containing a serous fluid. They have like- wise been found in the adventitious membranes formed on the surface of the brain. They gene- rally furnish no symptom by which their existence can even be suspected during life. The acepha- locyst, or headless hydatid, is seldom or never found in the pia matter. Five species of the Cysticercus, or the bladder-tailed worm, namely, the C. tenuicollis, the C. Fischerianus, the C. di- cystus, C. punctatus, and the C. Finna, have been discovered respectively by Brera, Fischer, Laennec, Treutler, and Werner, either in the pia mater or choroid plexus. (Art. Cysti- cercus, Diet, de Med.) 32. Fungoid, hematoid, and other malignant tumours, are sometimes found in the pia mater and arachnoid; but I believe they are seldom or never met with as a primary disease, but asso- ciated, as a consecutive change, with fungoid or malignant disease in some other part of the body. When they grow to any considerable size, they become deeply indented into the convolutions; producing at first irritation, and afterwards, as they increase, symptoms of pressure. When, therefore, such phenomena present themselves in persons with fungoid disease, we may suspect its developement also in the brain. 33. C. The Choroid Plexus, and the vascular plexus of the fourth ventricle, which are all pro- ductions of the pia mater, are often found remark- ably distended with blood, and their vessels varicose, particularly when the pia mater has its vessels overcharged. The choroid plexus is also sometimes uncommonly pale and exsanguine. This generally occurs when considerable effusion of serum has taken place in the ventricles, especially when the effusion is connected with debility. Sometimes the plexus contains a number of transparent vesicles (see § 30.), and it occa- sionally presents a granulated or fleshy appear- ance. This has been ascribed to a morbidly enlarged state of the glandular apparatus, with which, in the opinion of some anatomists, this structure is naturally provided. Gelatinous tu- mours about the size of a bean, and surrounded by a cyst, have also, though rarely, been observed in this situation. Tumours of a cheesy or sub- cartilaginous consistence, the size of a pea, are likewise foundi in some rare cases; and occasion- ally these tumours contain ossific deposits in their centres. Bony and earthy concretions are still more rarely met with in the choroid plexus than in the membranes. All these morbid changes have been most frequently observed in apoplectic, epileptic, and paralytic cases; but they have also been frequently detected where no particular symptom referrible to the nervous system had manifested itself during life. 34. The membrane which lines the ventricles is naturally extremely thin and transparent. No blood-vessels, excepting those which ramify over the corpora striata and thalami from their trunks, which pass by the side of the taenia semicircularis, are usually observed in it. The vessels, however, of this membrane are sometimes found much en- larged, and gorged with blood, particularly when a fluid is collected in the ventricles, so as to distend them beyond their natural capacity. In this state the membrane is not only more vascular, but also much firmer and thicker than natural. The sep- tum lucidum is sometimes as thick as the dura mater, and very firm; but more commonly, those parts of the membrane which are thickened and rendered opaque, are also soft and pulpy. 35. Coagulated albumen is occasionally found on the surface of the ventricles. It is sometimes met with hi layers on the corpus striatum and the thalamus. I have found it of great thickness; and in one case, which recently occurred to me at the Children's Infirmary, it nearly filled both ventricles. Ulceration proceeding from inflam- mation is occasionally met with in this surface, particularly in the corpus striatum. It seems generally to arise from the formation of a small abscess or purulent collection under the mem- brane, which it ruptures, the fluid thus escaping into the ventricle. 36. D. Inflamed states of the pia mater, with ulceration, puriform secretion, are, as well as other lesions of this description in other parts of the brain, most frequently occasioned by external injuries. Inflammatory irritation, affecting the arachnoid and vascular membrane either of the periphery of the brain or of the cavities, is not an unusual consequence of injuries of a serious char- acter sustained in other parts of the body, as after compound fractures and contusions of the limbs and joints, severe burns, &c. In these cases, a similar state of the membranes, as well as a nearly similar kind of delirium to that which has been called delirium tremens, sometimes occur. In- flammatory states, either with dryness of the membranes, but more frequently with effusions of various kinds, often take place in the progress of acute diseases, particularly fevers, and the ex- anthemata; from drunkenness, accidents, concus- sions, or mental excitement; whilst congestions, 208 BRAIN — Morbid Anatomy of its Sinuses. effusions, and infiltrations of blood, proceed gen- erally from interrupted circulation through the heart and lungs, narcotic poisons, asphyxia, &c, and frequently are attended with convulsions, stupor, coma, paralysis, &c. The adventitious formations are usually the result of a cachectic habit of body, as scrofula, deficient vital power, and the vitiation of the. system by syphilis, and the cancerous or carcinomatous taint. 37. iii. Diseased States of the Sinuses of the Dura Mater. — Inflammation of the sinuses is sometimes observed, in its advanced stages and consequences, and but rarely at the early periods. In this latter case, they manifest chiefly increased vascularity, and redness of their internal lining, with slight thickening and friability, sometimes with softening, and occasionally with abrasion, and give rise to the following changes, seated immediately within the part of the vessel which is inflamed:—1st, To the coagulation of the blood in contact with, and its adhesion to, the inflamed surface of the vessel: 2d, Subsequent discolouration ofthe coagulum, and its conversion into a state nearly resembling that of coagulated lymph : and, 3d, The presence of pus, which is usually found in the middle of this coagulum, though not always. Thickening of the mem- branes forming the parietes of the sinuses is oc- casionally remarked, and is evidently a result of a slow state of inflammatory action, affecting cliiefly the fine cellular tissue connecting the serous lining to the fibrous membrane. Some- times their parietes are remarkably thick and dense, almost approaching to cartilage, this morbid change being chiefly seated in their connecting cellular substance. Firm fibrinous formations, or coagulated lymph, are also occasionally formed in these vessels; in some cases, conjointly with marks of inflammation in them ; the internal tissues of the vessels being red, injected, con- gested, and of a dark colour; and in others with- out any very marked appearance of such disease, but with evident thickening of their parietes. In several instances I have observed these formations disposed in the form of false membranes within the sinuses, and adherent to their serous lining. While the more exterior surface of these false membranes, or that next the vessel, is generally firm, the interior of the canal which it forms is soft, and contains a purulent like matter mixed with a concrete albuminous substance. 38. In other instances, no fibrous concretions are formed, nor is the vessel perceptibly inflamed, and yet pus is found in parts of the sinuses, either distinct and -in considerable quantity, or mixed with firm coagula, or with clots of blood, and in 6inall quantity. In these cases there is reason to suppose that pus has been carried by the veins into this situation from an adjoining part. In some cases it occurs accompanied with an albu- minous-like effusion, more or less concrete, or with firm fibrinous coagula, and an inflamed state ofthe internal membrane of the vessel. In many, the presence of pus is connected with an apparent abrasion, and even ulceration of the internal surface of the sinus; but in others, increased vas- cularity, with patches of deep redness, or of con- gestion, with a deep lividity, and, occasionally, slight thickening with diminished cohesion of the parietes of the vessel, are most remarkable. In all these, there can be no doubt that the puriform fluid is deposited in this situation from the sur- rounding inflamed parietes of the vessel. 39. The lesions now described are most fre- quently connected, in adults, with chronic disease of the bones of the cranium; and, in rarer in- stances, with disorganization of the brain itself and of its membranes. They are most frequent after fractures of the skull, and external injuries : and I believe that they are occasional consequences of the worst forms of erysipelas of the head; a case of this description having occurred to me, in which inflammation of the sinuses of the dura mater was found upon dissection. They are more common in children, according to my experience, than in any other class of patients; particularly from the age of one and a half or two years to ten or twelve. I have observed the appearances now described in several cases of cerebral disease ; or, at least, of cases terminating with the usual symptoms of pressure on the brain, following severe states of porrigo, ulcers of the scalp, and chronic diseases of this structure, particularly in scrofulous, weak, and ill-fed children. The ob- servations of M. Tonnelle and of M. Ribes fully agree with my experience as to the patholo- gical relations of these lesions of the sinuses. 40. The sinuses also present a vermilion colour of their internal membrane, like that which is sometimes found in the arterial system. This appearance is most probably caused by a morbid state of the blood; and it may be, on some oc- casions, a post mortem change, arising from the staining of the internal surface of the vessels by the colouring part of their contents. In respect of the state of the blood itself in the sinuses, much diversity exists: the quantify contained by them also varies greatly. More frequently they are empty, or nearly so. When they contain blood, it is in some cases dark, semifluid, or thick; in others, less dark, and more fluid; in the greater number, either altogether or partly coagulated. In a few, it is separated into a serous or sero- sanguineous fluid, and a fibrinous coagulum having no connection with the parietes of the vessel, the coagulum consisting entirely of the fibrine of the coagulated blood, and not of the albuminous fibrin, or coagulated lymph, already described (§ 36.). In some cases, one or more of the sinuses is filled with a dense, firm, and brown co- agulum, perfectly continuous throughout; branch- ing even into the veins which open into the sinuses; and not interrupted, soft, and forming variously sized clots, such as are often found after death. This state of the contents of the sinuses is seldom or never connected with inflammation of its parietes, unless the inflammation has occasioned, by means of the albuminous matter effused, a complete obstruction of the vessel, and, conse- quently, the accumulation and gradual coagulation of the blood beyond it; being a change in these fluids independent of organic lesions of the parietes of the sinus, unless such lesion occasion obstructed circulation through it. 41. The firm, dense, and continuous coagulum now described is evidently the result of a slow coagulation proceeding in the sinuses previous to death; and, in every instance in which I have observed it, has arisen from obstruction in the return of blood from the sinuses, owing to com- pression of the jugular veins, by tubercles, scro- fulous tumours, or other organic changes obliter- BRAIN—Alteration ating the canals of these vessels, or ofthe sinuses themselves; or from a stasis ofthe blood, follow- ed by coagulation in these vessels, arising in con- sequence of great cerebral congestion, joined with the utmost general adynamia. There is no doubt that the effusion of lymph, in any of its states, or even of purulent matter, will, while in connec- tion with the internal surface of an inflamed ves- sel, or mixing with the blood in it, dispose this fluid to coagulation; forming a nucleus around which coagulation will proceed, or a point from which it may depart. And such seems to be the source ofthe more or less extensive and continu- ous coagula, which we frequently find in connec- tion with inflammatory lesions and formations in the sinuses. But such is not the case here. In the course of an extended experience at the In- firmary for Children, I have observed, in several cases, that this state of dense coagulation of the blood in the sinuses manifestly supervenes before death, owing to the general and local conditions now stated, and gives rise to all the symptoms of more or less complete and sudden compression of the brain, owing to the consequences I am now to notice as arising from it, in common with other causes of obstruction in the sinuses. In cases of this description, if no effusion of blood have oc- curred, the veins are found generally engorged with dark blood. In some cases, the distension ofthe veins had given rise to an exudation of blood, or rupture of several of their minute distri- butions, with copious extravasation of this fluid; and in many, the distension of the veins was ac- companied with copious effusions of serum hi the ventricles, between the membranes, or in both situations. 42. The glandule Pacchioni are sometimes so much increased in number and size as to obstruct the passage of blood through the sinuses; give rise to the appearances now described; and thus, as the other changes in the sinuses, terminate in some one or other of the apoplectic states. Mr. Earle (Medico-Chirurg. Trans, vol. iii. p. 66.) has observed these glands changed to the appear- ance of grumous blood, in connection with fun- goid disease in the brain. They are more fre- quently enlarged and hardened; and, occasionally, they cause an absorption of the dura mater, with corresponding depressions in the superincumbent bone. 43. The bands which cross the longitudinal sinus are occasionally more numerous than natural; and they are sometimes thickened, particularly in connection with a similar change of the parietes of the sinus. 44. The veins on the surface of the brain some- times contain a few bubbles of air; but it is doubt- ful whether this is a morbid state or a post mortem change. They are occasionally filled with fibrine, particularly in those cases which presented a corresponding state of the sinuses. Pus has also been observed in them, especially in cases of inflammation, with secretion of pus under the ar- achnoid. 45. Ossification is detected only in the arteries; but it occurs in them very frequently, and to a very great extent, particularly in advanced life. The early stages of this change have also been discovered in youth, although rarely. The arteries most commonly found ossified are the internal carotids and the basilar; but the circle of Willis, 18* s of its Substance. qqq and the vessels departing from it, as well as the arterial ramifications which appear between the convolutions, and come out upon the surface, often participate more or less in this morbid state. Car- tilaginous degeneration is still more extensive, and seems to precede the ossific deposits. Car- tilaginous and ossific formations in the coats of the arteries of the brain occasion nregular dis- tributions of blood, and interrupted or imperfect supplies of this fluid to some parts of the organ; disposing to aneurismal dilatations, to rupture, and, consequently, to the production of apoplexy and paralysis. In most instances of extravasation of blood in the substance of the brain, this condi- tion ofthe arteries exists; and is, most probably, the cause of the extravasation, by disposing it to congestion, and rupture from increased action of the heart. 46. Aneurismal dilatations of the arteries of the encephalon are by no means very uncom- mon: they are most frequently met with in the carotids after they have entered the cranium, in the large branches, and in the basilar artery. They may derange the circulation of the brain, or may occasion effusions of either blood or serum, without themselves having been ruptured; but they more frequently break, occasioning apoplexy. The arteries, particularly those about the base of the brain, and some part ofthe branches forming the circle of Willis, are also occasionally obliter- ated and reduced to a thin cord. 47. II. Lesions of the Substance of the Brain.—The morbid states of the brain have been investigated in modern times with the great- est success and advantage to practical medicine. The labours of Reil, Serres, Lallemand, Wenzel, Gall, Rostan, Abercrombie, Hooper, Craigie, and Duncan, have chiefly tended to this advancement; whilst a number of other enquirers have added much of importance, as well as confirmed the observations of more original enquirers. 48. i. Inflammation of the Substance of the Brain,— Encephalitis, — Cerebritis. —A. Acute inflammation of the brain does not fre- quently occur as an idiopathic or primary and un- complicated malady. It is in consequence of pre- vious disease, as fevers, the exanthemata, inflam- mations of the ears, extravasated blood, tumours and tubercles ofthe brain, of poisons, and external injury, that it comes most frequently before the pa- thologist. Resulting from injury, it is generally limited in extent, although intense in degree. The whole brain is rarely or never affected at the same time, but only a part of it; and the disease is seated either in the vascular membrane, or in the cortical substance, or in the medullary matter of the interior parts, of the brain, or in them all simultaneously. The part affected first becomes vascular, and the injection of the vessels proceeds till the cerebral substance displays a red tint, deep- ening, as the disease advances, until it assumes a reddish brown, and, occasionally, even a brown- ish or green shade. With this increased intensity of disease, the part becomes softer than natural. The formation of matter, however, is not so fre- quent a consequence of this form of inflammation as of that of a sub-acute or chronic kind, occur- ring in persons of a scrofulous diathesis, and un- healthy habit of body, unless when a foreign sub- stance, or piece of bone, has been driven into the 210 BRAIN — Alterations of brain. Somewhat similar to inflammation, al- though decidedly different from it, is that state of morbid irritation frequently met with in fevers, especially typhus, eruptive diseases, epilepsy, de- lirium tremens, tetanus, convulsions, hydrophobia, nostalgia. In these diseases, vascular turgescence and red injection ofthe brain, are usually seen; but not the general red colouring, the spot-like effusion of blood, and the change of consistence, which characterise acute inflammation of this structure. 49. Acute cerebritis occasions violent headach, intolerance of light, acuteness of all the senses, delirium rapidly succeeded by convulsions, coma, and death. When it arises from morbid poisons affecting the system, as in gaol and camp fevers, purulent formations are more frequently met with, as stated by Pringle and others. In these cases the symptoms are somewhat varied; the prostra- tion of the powers of life being much greater, and the delirium of a much lower grade. In those diseases, the post mortem inspections, when nu- merous, will furnish examples of the various stages of lesion, from the first appearances of injection of the vessels to the formation of matter, or com- plete destruction of the part chiefly affected. 50. B. Suppuration of the brain,—Abscess of tlte brain, — Apostema cerebri. — Collections of purulent matter have been often found in the brain, generally as a consequence of inflammation of a sub-acute or chronic kind. Of this the writings of Bonet, Morgagni, Lieutaud, Baader, Stoll (Rat. Med. i. p. 285.). Frank (Acta Inst. Clin. Viln. Ann., 1. p. 75.), Prochaska (Anat. Acad. Fasc. part ii. sect. ii. cap. 2.), Schaeffer (Hufeland und Himly, Journ. der Pr.Heilk. 1809.), Portal (Mimoiresde I'Acad. des Sciences, 1780, p. 315.), Lallemand, Baillie,Brodie,Powell, Hooper, and Ab- ercrombie, furnish numerous examples. The situations of these abscesses vary considerably, as well as the kinds of abscesses formed, a. Some- times the purulent collection is lodged in an irregular cavity, and appears unsurrounded by any distinct cyst. These take place to a greater or less ex- tent, and consist most commonly of purulent mat- ter mixed with flakes of lymph, giving it a slight curdly appearance. They are most commonly found in the anterior lobe of the cerebrum, or in the centre of the hemisphere. Some of the ab- scesses of this kind seem to consist of several small cavities communicating with each other: these are usually found also in the anterior lobes, the centres of the hemispheres, or near the striated nucleus of Reil. b. The next species of abscess consists of a distinct, firm cyst, or even cysts, as observed by Lallemand, and seems to have been the result of a slower process of formation, and of a less acute form of inflammation: it con- tains purulent matter, and is most frequently found in the centre of the hemispheres, particularly just above the central oval of Vieussens, or at its margin. Abscess of the brain has also been met with immediately below the coi-nu ammonis; likewise near the parietes of the small posterior cornu of one of the lateral ventricles, and just below the unciform eminence which rises into the interior of this cavity. In one instance only (North Amer. Med. and Surg. Journ. 1818.), have the tubercula quadrigemina, and pineal gland, been the seat of abscess. 51. c. Purulent matter is also found in some part its Substance—Abscess. ofthe brain, infiltrated, as it were, into the cere- bral substance in the form of a number of minute drops, and occupying a considerable extent, but not lodged in any single distinct cavity: the parts surrounding the purulent infiltration presenting scarcely any other appearance of change, except- ing more or less softening, which is always pre- sent, and seldom any sign of augmented vascular action. This morbid state is frequently observed as the consequence of the transit of purulent matter into the circulation, which, in some cases, is secreted from the vessels in the substance of the brain, giving rise to the infiltration. This phenomenon takes place much more frequently in the parenchyma of other organs, as of the liver, lungs, and spleen, than in the brain. The infiltration, whether proceeding from this source or not, often passes into the condition of distinct collections, varying in number and size; and some- times they nearly or altogether communicate. In such cases, the cerebral substance separating these collections seems as if it were softened, or broken down into the purulent matter, and often processes of the cerebral structure, still adhering to the surfaces surrounding these collections, are floating in them, appearing as the debris of a portion of the disorganized brain. In these cases an approach is made to the formation of a regular cavity. In other instances, if the disease is less rapid, or does not destroy life before further local changes take place, a distinct cavity is effected, which, at first, consists of the cerebral substance merely, softened, discoloured, and vascular. M. Andral thinks that the following characters pre- sented by the cavities containing purulent matter are the result of subsequent changes which the sur- faces of these cavities undergo, and not the result of an original dissimilarity of structure. As to this point, I think his reasoning inconclusive, and his proofs insufficiently strong. It, however, should be admitted, that the purulent infiltrations, and collections in either ofthe forms now noticed, are those which take place most rapidly, and which are generally observed in post mortem researches, in cases of death taking place soon after the symp- toms of cerebral disease had supervened; whilst the encysted form, as I have already stated, are those which manifestly form most slowly. 52. d. The different kinds of parietes sur- rounding the collections of matter in the brain, according to this able pathologist, are, — 1st, The cerebral structure itself, which, in recent and acute cases, forms the only envelope of the purulent collection ; but which may assume the following appearances successively, according to the duration of the disease. 2d, A cellulo-vascu- lar substance, extending over the whole of the internal surface of the cavity, or merely in parts. 3d, A true membrane, which is as yet soft, and flocculent, but yet admitting of separation from the adjoining nervous substance. 4th, A fine membrane, presenting a distinct organization, and capable of being detached either in pieces or entire. Once arrived at this stage, their internal surface often has the appearance of villosities, whilst sometimes the cyst is composed of two or more distinct layers, which may be detached from each other. In these cases, the cysts are thick, as remarked by Professor Lallemand; the in- ternal layer, or cyst, being of a reddish white, and presenting the appearance of a mucous sur- BRAIN —Alterations of face slightly inflamed. In a case noticed by this author, in which three distinct layers, or cysts, were observed, the exterior was cellular, adhering to the cerebral substance; the middle, one thick and firm; the interior layer closely resembled a mucous surface. Meckel, however, espouses a different opinion from Andral, as to the form- ation of abscesses contained in distinct cysts. These are not, according to him, owing to ad- vanced changes in the organization of the walls of the purulent collection ; nor are they to be ascribed to suppuration of the cerebral texture itself; but to. inflammation and suppuration of an adventitious structure, developed in the cerebral substance. His reasons for this opinion, are, —■ 1st, That those cysts adhere but very loosely to the surrounding cerebral texture : 2dly, That this texture is not hardened, but, on the contrary, softened, immediately around them. 53. The cerebral substance in which the puru- lent infiltrations and collections of the first grade are found, is generally softened, and, excepting when they arise from the absorption of purulent matter into the circulation, more or less injected. In cases of purulent collections contained in more or less distinct cysts, or membranes, the surrounding structures are often but slightly alter- ed, and occasionally not even perceptibly so. But when the collection has much increased, or continued long, the nervous substance surround- ing the cyst becomes irritated, inflamed, dis- coloured, and softened; and then only supervene those symptoms which evince, unequivocally, the existence of abscess or serious organic lesion: for, up to this period, the abscess may have been proceeding, but so slowly as not to disturb the functions of the organ, until, owing to some de- termining cause, in conjunction with the changes taken place in the cyst, its contents, or with its size, the substance of the brain surrounding it becomes diseased. 54. Abscesses, whether immediately surround- ed by the cerebral structure, or contained in more or less distinct cysts, may vary in number from one to six or seven, each distinct from the other, and seated in various parts of the brain. They may present appearances of ulceration in their parietes; and they may be accompanied by a variety of other lesions ofthe brain and its mem- branes, generally in different subjects, but occa- sionally even in the same case. Inflammatory appearances of the membranes; effusions, serous or albuminous, in either the external or internal surfaces of the organ; softening of the structure, tumours, occasionally hardening, &e.; are their usual attendants. 55. e. In respect of appearance, the pus found in the brain differs in' no way from that formed in other textures of the body. M. Lallemand (Richerches Anatomico-Patholog. sur I'Enceph. &c. let iii. p. 361., let. iv. p. 41.), whose nume- rous observations of purulent collections in the brain have enabled him to give much interesting information on this topic, states, that he has ob- served it of a yellowish green tint, yellowish, yellowish white, greenish, grayish, yellowish gray, whitish gray, dirty white, and altogether white. He, as well as Abercrombie, has frequently found it extremely foetid. This foetor of the pus I have observed in sev.eral cases of abscess oc- curring in young subjects, from the extension of its Substance — Abscess. 211 inflammation of the ear to the brain. In a case of this description, reported in the Medico-Chi- rurgical Review for Dec. 1830, the fcetor of the purulent collection was extreme ; and the cerebral substance surrounding it greenish, dis- organized, and broken down into the contained matter. Abscesses formed within the substance of the brain occasionally make their way to some part either of the external or of the internal sur- face ofthe organ : thus they sometimes break into the ventricles, as in the case just now alluded to : when they open upon the periphery of the cere- brum, they occasionally destroy the bone and intervening membranes in its immediate vicinity, before death is occasioned. M. Andral says, that he has observed an abscess of the brain destroy the cribriform plate of the ethmoid bone, and escape externally tlirough the nasal fossae: and MM. Itard, Lallemand, and others have shown, that abscess of the brain, from an exten- sion of inflammation from the ear, may destroy the petrous portion of the temporal bone, so far as to admit of the evacuation of the abscess by the ear. In cases originating from this source the matter is frequently contained in no distinct cyst, the cerebral structure surrounding it being gene- rally discoloured, softened, and often appearing as broken down into it. Sometimes the meatus externus and interims are shut up by means of fungous granulations preventing the external exit of the purulent secretion, and hence probably, in some cases, diverting it internally. In some cases more than one abscess, in some instances four or five, seated in distinct parts of the brain, have been observed. 56. /. Collections of purulent matter have like- wise been found by Bianchi, Stoll, Weick- ard, J. Plancus, Frank (De Curand. Homin. Morb. lib. ii. p. 49.), Nannoni, Perrault (Journ. de Mid. t. vi. p. 389.), and Abercrom- bie , in the cerebellum, generally contained in more or less distinct cysts, "the walls of which were membranous and vascular." Matter, indistinctly defined, has been found also in the medulla oblon- gata, generally in small irregular cavities, " espe- cially in that part ofthe olivary body which contains the corpus dentatum." (Craigie, in opus. cit. p. 386.) Dr. Abercrombie mentions a case where it was met with at the junction of the protuberance. 57. g-. These collections are evidently the result of inflammation, but of a peculiar and slow cha- racter, probably owing to the constitution of those in whom they are most frequently found, and who are generally of the strumous diathesis. The en- cysted abscess seems to take place very slowly, and to be analogous to what has been commonly called chronic or cold abscess. The purulent infiltrations occasionally met with in the large nervous masses, as well as in other viscera, from the absorption of purulent matter into the circulation, evidently take place with great rapidity, and are a result rather of morbid secretion, than of inflammation. 58. h. Abscess of the brain is very frequently met with as a consequence of purulent discharge from the ear. This affection of the ear, when it has not apparently proceeded from inflammatory sore throat, and the extension of the inflammation along the Eustachian tube, is very generally con- nected with a sub-acute or chronic inflammation ofthe dura or pia mater of the brain; and is thus frequently extended to the substance of the brain 212 BRAIN —Alterations of itself, terminating at last in abscess in this situation. This has been satisfactorily shown by Morgagni, Itard, Powell, Lallemand, Dun can, Aber- crombie, Craigie, and others. Bonet, and, more recently, Mr. Brodie, supposed that the affection ofthe ear was consequent upon that of the brain, or at least coeval with it; and hence they ascribe the discharge from the ear to the in- flammation of the membranes having extended itself from the dura mater of the temporal bone to the tympanal cavities. When abscess of the brain takes place owing to the affection ofthe ear, they consider it an extension ofthe inflammation from the membranes internally to the substance of the brain, in consequence either of the unhealthy habit ofthe patient, or of improper treatment, by suddenly suppressing the discharge, "and con- verting a chronic external inflammation into an acute internal disease;" the external discharge having been, as it were, arrested and turned in upon the cerebral substance. The only question here is in respect of the particular parts in which the inflammation originates; as to the consecu- tive phenomena, there seems to be no difference of opinion : and this point can be decided by the symptoms only, and the order in which they occur. If the purulent discharge takes place without any previous internal and deep-seated pain, and the dangerous symptoms follow upon the suppression of the discharge, we may infer that the disease has commenced in the ear, and extended itself to the membranes and brain itself. This is, perhaps, the most frequent procession of the morbid phenomena. But, occasionally, a different course is manifest, especially in delicate children, and patients of a strumous diathesis. In these, symptoms of disease of the brain or its membranes are very manifest before the discharge takes place; and when it does take place, either the patient recovers under judicious management, or, upon the disappearance or suppression of the discharge, a sudden exacerbation of the symptoms are observed, with delirium, coma, convulsions, &c. followed by death. Such is the result of my experience in a very great number of cases which have come before me; so that I am led to con- clude that, whilst the opinion adopted by Mor- gagni and his followers, on this question, is often correct, that espoused by Bonet and Brodie is not wholly without foundation. 59. But it is not infrequently observed, (and I have met with several instances in grown up persons,) that patients have been occasionally liable, for years, to a puriform discharge from the ear, — occasionally from childhood, with little remission, and with little or no further ailment. This sometimes gradually diminishes, or sud- denly disappears; when either soon afterwards, or not until several months subsequently, or even after a year or two, dangerous symptoms of dis- eased brain supervene, and rapidly advance to a fatal termination; and upon dissection, inflam- mation of the membranes of the brain of the same side of the body with the affected ear is observed, and in the substance of the hemisphere is found a large purulent collection with inflam- mation and softening of the cerebral matter sur- rounding it, the cavity presenting an irregular soft surface. 60. The following cases strongly illustrate this : — 1st, A young gentleman had, from childhood, a its Substance — Abscess. slight purulent discharge from the right ear, until nearly the period of puberty; about which time it gradually disappeared. He had nearly lost the sense of hearing on that side. He went into the public service, in which he continued for several years, until, about the age of thirty, he was sud- denly seized with intense pain ofthe head, fever, followed by paralysis ofthe whole left side ofthe body, insensibility, involuntary motions, coma, shortly terminating in death. On examination, thickening of the membranes of the right side of the brain, with adhesions, softening of the cere- bral structure, and a purulent collection nearly in the centre of the middle lobe of the hemisphere, were found. I very recently witnessed a nearly similar case, to which I was called by a neigh- bouring practitioner; and a tliird case, in which I had ventured to predict similar lesions in a per- son advanced in life, but which we were not permitted to verify by a post mortem inspection. 61. Abscess of the brain consecutively on pu- rulent discharge from the ear, is most frequently observed in young subjects, particularly in those of a strumous diathesis. From what I have said, it must not be inferred that abscess of the brain is the only unfavourable consequence, or even the most frequent one, owing to an extension of the inflammatory action from the ear or cerebral membranes; for other lesions accompany it. But, whether the abscess proceed from a gradual ex- tension of disease, as now stated, or be a vicarious result of the suppression of the external discharge, — in which light it may sometimes be justly viewed, — there are generally found, upon exam- ination of the surrounding parts, increased vascu- larity, softening ofthe cerebral substance, and an irregular, soft, and vascular cavity, containing the purulent matter. Added to this, there are also inflammation, thickening, and suppuration of the membranes; the pia matter being injected, and covered with lymph; the dura matter thick, opaque, dark coloured, more readily torn, and detached from the bone underneath it, which is also discoloured, and sometimes carious. 62. Abscess of the brain is very often a conse- quence of external violence; but it is one which takes place at extremely indefinite periods from the receipt of injury, and which often has little or no relation to the extent of the_ external mis- chief. The period which elapses' from the ex- ternal violence to that full developement of the abscess which is incompatible with the duration of life, according to the observations of Pig ray, Morand, Prochaska, Thilenius, Home, Denmark, and others, varies from two or three months to as many years. A case which I had an opportunity of observing in a public institution, and in which the operation of trephining had been performed, presented a large abscess in the hemi- sphere, underneath the seat of injury, between three and four years from the time at which it had been sustained. The perforation made by the trephine was completely filled with ossific matter, which extended in a radiated manner from the edges of the perforation towards its centre. 63. Dr. Baillie says, that when suppuration of the brain takes place from internal causes, it is generally in the substance of the organ; but when it arises from external violence, it affects only the surface. But as Dr. Craigie has very BRAIN — Alterations of its Substance—Abscess. 213 justly remarked, this distinction does not always hold good, and requires modification.—1st, Where a long interval elapses after the infliction of the injury, the collection of purulent matter is almost invariably deep-seated. 2d, In like manner, when the injury operates in the manner of counter- stroke, the collection is also often within the sub- stance of the organ." 3d, In some instances of suppuration after injury, the collection does not take place at the part where the blow struck the skull, but either in the line of the force passing through the brain, or in some of the lines into which this force may be resolved. 4th, It is chief- ly when this force has been directly expended on the part, i. e. when the bone has been immediate- ly broken, and its membranes injured, that suppu- ration takes place on the surface of the brain : it is then the result rather of the injury of the mem- branes, especially of the pia mater, than of the cerebral substance itself. 64. Suppuration may occur in any part of the brain ; but it is most frequently met with in the hemispheres, as shown above (§50.). Its effects vary exceedingly, according to the situation and extent of the purulent collection ; but are not es- sentially different from those which follow upon the slow effusion of blood, the presence of tu- mours, or other morbid formations. I have al- ready hinted at the occurrence of suppuration in parts of the brain in the course of fevers, espe- cially those which are of a malignant character, or which are complicated with inflammatory ac- tion of the brain. Such occurrences have been observed by Pringle, Borsieri, Eisfield, Ploucquet, Clutterbuck,Marcus, Jack- son, and Mills, and many others. But this falls under the pathology of, and morbid appearances in fevers, where the subject has received due attention. 65. C. Ulceration.—To ulceration of the brain authors have attached no precise idea, they differ- ing widely as to what should constitute ulceration of the cerebral texture. According to the opin- ions of some, those solutions of continuity, some- times observed in the most advanced degrees of pulpy destruction of the brain, about to be de- scribed (§ 72.), are nothing else than ulceration ; and certainly, if there were appearance of any considerable loss of substance by absorption, the lesion would be legitimately ulceration. The case recorded byMoiiGAGNi (De Sed. et Caus. Morb. ep. xi. pars ii.), in which he described the corpus striatum ab reliquo cerebro omnino separatum in- ventum est, which is so singular, may be referred to ulceration. By ulceration of the brain, Dr. Craigie understands destruction of part of either of its surfaces, "so as to present a hollow or de- pressed surface, rough, irregular, and covered par- tially either with bloody or albuminous exudation." This seems sufficiently precise ; and excludes those doubtful cases of ulceration sometimes conse- quent upon effusions of blood, the advanced stages of softening of the organ, and the forma- tions of abscesses existing in the substance of the brain, where, although a breach of continuity of structure is produced, yet the removal of it by absorption cannot be demonstrated. Cases of this description are more legitimately examples of pulpy destruction, or suppurative disorganization, than of ulceration. With this limitation of ul- ceration and erosion to the various internal and external surfaces of the brain, M. Andral agrees with Dr. Craigie. This species of lesion, al- though not of frequent occurrence, is yet occasion- ally met with. Besides the case given by Mor- gagni, and already referred to, another is men- tioned by him in the same epistle. Instances of this disease have also been recorded by Bonet (Hist. Anat. Med. part iii. Ob. 108. 138.), Wep- fer (p. 212.), Morgagni (Epist. Jnat. Med. iv.), Lieutaud, (Hist. Anat. Med. let. iii.), Se- nac, Valsalva, Portal (Anat. Mid.t. iv. p. 98.), Howship (Med. and Phys. Journ. March, 1810.), Anderson (Transact, of Royal Soc. of Edinburgh, vol. ii.), Ridley, Haller, Stoll (Ratio Med. pars iii. p. 122.), Powell (Case 6. Transact, of College of Physicians, vol. v. p. 96.), andScouTETTEN (Archives Gin. t. vii. p. 31.), who have met with it on the convoluted surface of the brain, on the foliated surface of the cere- bellum, and in the surface of the ventricles,__ parts in which this morbid change is chiefly found. As shown by Haller (t. iv. p. 351.), Stoll, and Scoutetten, ulceration of any part of the brain's surfaces is always attended with an in- flamed, or otherwise unsound state ofthe pia ma- ter, and occasionally with softening of the parts underneath, sometimes limited to the gray sub- stance, but at others proceeding further. In the two cases recorded by M. Scoutetten, the ad- jacent brain was somewhat softened, and in one of them, of a wine lees colour. The ulceration in the first case existed on the inferior surface of the right anterior lobe, and presented a hard, dry, irregular, yellowish surface, thirteen lines long and eleven broad, with singularly indented edges. This patient died with symptoms of irritation of the digestive canal, and of the brain. He ex- perienced a constant acute pain at the bottom of the orbits. In the second case, the extremity of the posterior lobe presented two small ul- cerated patches, one much larger than the other, and of an oval form. They penetrated no deep- er than the cortical substance. This patient had been seized with gastro-intestinal irritation, and complained of no pain in the head. During tha latter stage of his disease, he became delirious!. In both these cases the surrounding pia mater was injected, and somewhat eroded ; so that we may infer from these, and other cases upon record, that ulceration of the brain is a consequence of cir- cumscribed inflammation of the pia mater. 66. The existence of ulceration of the brain is indicated by headach, partial convulsions, some- times epilepsy, palsy, loss of memory, hebetude, coma, and exhaustion. In some cases the head- ach is intermittent, and the palsy is generally on the side opposite to that in which the lesion ia found. In the case recorded by Dr. T. Ander- son, and in which most of the symptoms now noticed were present, there was a superficial, loss of substance from ulceration, two and a half inches long, one and a half broad, and nearly an inch in depth, situated on the upper part of the right hemisphere of the brain. In the bottom of this cavity were found some thin lamina? of a brownish matter, with stony concretions, some of which broke into sand upon the slightest touch. 67. D. Sphacelation or mortification of the cerebral substance is rarely met with, and chiefly as a result of external injury, when it has been 214 BRAIN — Alterations of its Substance—Softening. bruised and acutely inflamed. In this state of dis- organization, the cerebral substance is dissolved, of an orange brown colour, or of a grayish black, and foetid. This alteration seems to be rarely produced by internal causes, and is to be distin- guished from the pulpy softening of the organ. Dr. Abercrombie, however, considers this lat- ter change to be identical with gangrene. 68. ii. Softening of the Brain.—A. From serous infiltration,—(Edema of the brain. In- filtration of the substance of the brain with a watery fluid has been noticed by Guersent and Andral,—by the former in children, by the lat- ter also in adults. In these cases the serum may be diffused in the nervous substance, or contained in more or less distinct cavities. This change is most frequently observed in the white central parts of the organ. It has not generally been re- marked in connection with any particular symp- tom ; but it has, in a few instances, co-existed with dropsy of the ventricles ; and, in adult sub- jects, with general leucophlegmatia and cachexia. 69. B. Simple diminished consistence of the brain, without change of structure,—Mulakence- phalon (Craigie),—seems to be a different state of the organ from that which constitutes the ra- mollissement—softening, or pulpy destruction of the brain.' In this latter more or less disorganiza- tion is manifest, and generally some change in its colour; but the former is merely diminished con- sistence, greater flaccidity, and decrease of its natural firmness, toughness or tenacity, and of that clamminess or viscid feeling which it usually communicates to the touch. This state is com- monly attendant on low or malignant fever, and on chronic diseases, particularly pulmonary affec- tions, marasmus, diabetes, dropsies, mesenteric and visceral affections. It generally affects the whole organ, and, indeed, the whole cerebro- spinal axis ; whereas the pulpy destruction of the brain is more or less limited in extent, affecting parts of the organ in a particular manner. 70. In dropsies, the brain is often flaccid, more easily lacerated, and of diminished consistence throughout. This state proceeds either from di- minished nutrition of the organ, or from an inter- stitial deposit of serous fluid with its minute at- oms, and defective vital cohesion of its substance. The proper texture of the part is not otherwise changed. Diabetes sometimes occasions a simi- lar state, and most probably from diminished nu- trition added to a deficient vital cohesion of the structure. In pulmonary consumption, and in chronic bronchitis, the brain is very commonly found softer than natural throughout; and this softness is the more marked, the more chronic the pulmonary affection has been, and the more com- plete the emaciation. May not this state be con- sidered as analogous to emaciation of other parts ? the molecules of matter removed by interstitial absorption of the texture of this organ being re- placed by a serous effusion, owing to the cranium being a shut cavity, which must necessarily, dur- ing the life of the subject, always be in a state of repletion. In such a case, the density of the brain is actually diminished. Meckel states, that he found a cube of six lines, taken from the brain of a man dead of phthisis, 1^ grain lighter than the same bulk of a sound brain. Dr. Monro has found the brains of condemned felons ex- tremely soft, particularly internally, (The Mor- bid Anatomy of the Brain, vol. i. p. 35. and 100.). Littre, however, states, that the brain of a felon, who committed suicide, was extreme- ly dense and firm, (Histoire de I'Acadimie Roy- ale des Sciences, Ann. 1705.) Tulpius, Kf.rk- ringius, King,Scheide, Morgagni, Gred- ing, &c. have found the brain frequently soft and flaccid in fatuous persons, as well as in epileptics, and epileptic maniacs. Greding (OnLudwig'a Adversaria, t. ii. part iii. p. 533.) found in about one half of the last named class of subjects, the brain very soft throughout, particularly in its cen- tral parts; and Dr. Haslam's observations (06- servations on Madness and Melancholy, 2d. edit. Cases, 4. 10. 18. 25. 28. 30. 37.) in some degree confirm these statements. But it should not be overlooked, that the brain of epileptics and ma- niacs is found also more than usually firm. The diminished consistence of the brain of condemned felons has been attributed to confinement, inac- tivity, and low diet. Whether these may have a greater influence in causing it than the mental dis- tress to which these persons are reduced, it may be difficult to determine ; but if the former be the cause of this state of the organ in felons, it may be equally so in maniacs, who are generally also subjected to confinement and low diet. The diminished consistence now described, is more or less universal, although more remarkable in par- ticular parts, and it generally affects the whole cerebro-spinal axis. Whereas the morbid soften- ing, or pulpy destruction, about to be described, is generally limited in extent. The former also seldom presents any very sensible change from the natural colour of the part ; whereas vrith pulpy destruction there is a more or less evident discoloration. 71. C. Pulpy destruction,—Softening,— Ra- mollissement,—Encephalitis sub-acutus,— Cere- britis sub-acutus et chronicus.—Softening of the substance of the brain has generally been ascribed to a sub-acute inflammatory action, especially by .Morgagni, Rostan, Lallemand, Bouil- laud, Pinel, Olivier, and Velpeau, to whom we are chiefly indebted for having direct- ed attention to this particular lesion. There are others, however, ssRecamier, who consider this change as the effect of a morbid nutrition of the part, rather than as a result of inflammatory ac- tion. By softening of the brain, must not be un- derstood that soft state of the organ which is al- ways present in early infancy, nor the less con- sistent state of the organ sometimes observed in some chronic diseases, and in certain forms of fever, and already described. It should also be recollected, that all parts of the brain possess not the same degree of firmness ; for, if the mesoce- phalon be as soft as a lobe of the cerebellum, it is undoubtedly in a morbid state. 72. Softening of the brain presents various de- grees. The least change of consistence of the part can be recognised only when it is touched. In a more advanced degree, the softening is ob- vious to the sight. In a still farther advanced grade, the cerebral substance is nearly liquid, and has almost entirely lost its organization ; and in its place there is a mere loose cellular substance, soft and gelatinous, appearing as the original matrix of the structure ; and in the last and most advanced stage of all, there is a perfect disso- | lution of the part, and breach of continuity. BRAIN — Alterations of its Substance — Softening. 215 In the cases of this description published by MM. Rullier and Velpeau, the disorganization was bo complete, that the filaments of the delicate cel- lular substance, forming, as it were, the matrix of the structure, were suspended in the middle of the diffluent matter into which the cerebral substance was changed. In the case observed by M. Vel- peau, the solution of continuity was still more complete. From the inferior margin of the meso- cephalon to the base of the pyramidal bodies, a substance entirely liquid, which no longer retained the appearance of nervous substance, occupied the place ofthe bulb of the cord; and through the whole of this space there existed neither arachnoid nor pia mater. 73. The softened portion of brain presents va- rious shades of colour. 1st, It may be of the natural or healthy colour of the part,—even al- though the softening has advanced to such a degree as to form a diffluent pulp, (Andral, Lalle- mand). 2d, It may be perfectly colourless; of a dull white resembling milk; and occasionally the whiteness of the part assumes a clear, or bril- liant hue. 3d, The shades of colour sometimes are the following:—a rose tint, an amaranthine red, reddish brown, the colour of wine lees, violet, yellowish, greenish yellow, light gray, and dark gray. Besides the above appearances, the softened part of the brain may be,—1st, The seat of effu- sions of blood, which are sometimes small, rela- tively to the degree of softening, or to its extent; at other times very considerable compared with the softening itself: 2d, Pus may be infiltrated throughout the part which is softened; or the pus may exist in it in the form of one or more distinct collections. M. Lallemand considers, that in all softenings of the brain of a white colour, this •appearance is owing to the infiltration of purulent matter through the softened structure. MM. Ros- tan and Andral espouse an opposite opinion, on the grounds that, in many softened portions of the brain of this shade, no pus could be detected. The softened part of the brain is generally inodo- rous; but M. Billard has remarked, in the case of an infant, the smell of sulphuretted hydro- gen. Softening, attended with the odour observ- ed by this author, seems to have constituted what was called, by the older writers, gangrene of the brain. 74. There is no part of the brain or cerebellum in which softening has not at some time or other been detected. Generally those parts which are most obnoxious to haemorrhage are most liable to softening, such as the optic thalami, and the cor- pora striata, and the parts in their vicinity. It also as frequently affects the cortical substance, as the medullary texture. In the cerebral hemi- spheres, the softening may be seated in the corti- cal substance of the convolutions, the white me- dullary structure remaining unchanged, where it may often escape detection, owing to such limit- ation; and it is usually an attendant upon active inflammation of the membranes of the brain. When the gray part is softened, it generally sepa- rates along with the pia mater, on attempting to raise this membrane. When softened, this por- tion is commonly also redder than natural; some- times, on the contrary, it is paler than common. The medullary structure situated above the lateral ventricles is very often the seat of this species of lesion. This mass may be altogether softened, or in a few small points merely, each point being quite isolated from the other. The symptoms, however, resulting from this smaller extent of morbid change may be as severe as those arising from the more extensive and more intense lesion. When one of the hemispheres is softened near to its external surface, the circumvolutions are flat- tened, and often evince a species of fluctuation. M. Andral has remarked, in some cases, the existence of softening of the parietes of the ven- tricles, with the presence of a turbid fluid effused into them. (Anat. Pathol, t. ii. p. 802.) 75. The optic thalami, the striated bodies, and parts in the vicinity of these; the cornu ammonis, and the eminences in the interior of the digitated cavities of the lateral ventricles, the commissures of the hemispheres (corpora callosum, septum lucidum, See), have all been observed the fre- quent seats of softening; sometimes limited to one or other of them only, at other times extending to two or more, and occasionally co-existing with signs of inflammatory action, or with effusion of a serous fluid into the ventricles. Softening of the other parts of the encephalon is not so often met with, as of those now enumerated; yet has it been seen in the mesocephalon, in the various parts ofthe cerebellum, in the medulla oblongata, and spinal cord. 76. Softening of the brain may be limited to one part, or it may exist in several parts, even in both hemispheres, in the same case; and it may affect these different parts at the same time, or successively, either as respects the brain merely, or as regards the whole cerebro-spinal axis. In- stead of being partial, which is its usual form, the softening may be so general, and to so intense a degree, that the brain is almost reduced to a pulpy matter, evincing scarcely any appearance of or- ganization. So general and great a change is very rarely met with in the adult; but it is occasionally observed in infants. M. Billard has met with ten instances of it, and I have also found it in some cases of young children: the odour of sul- phuretted hydrogen, first noticed by M. Billard, was sensible in these; and he found it present in all his cases, which were chiefly of infants only a few days old. 77. Softening of the cerebro-spinal axis is met with in patients of all ages. According to M. Rostan (Richerches sur Ramollissement du Cer- veau, 2d edit. p. 155.), whose attention has been directed, at the Salpetriere, to this lesion in a special manner, it is very common in old subjects; even more so than sanguineous apoplexy. The researches of Lallemand, Andral, and others go to confirm this opinion, and to show that it is also common during early and middle age, al- though less so than in old age. And I perfectly agree with M. Billard in considering it common in children, especially infants. He believes, and I think with justice, that it commences in some cases even before birth. 78. There still remains an important question to be discussed, namely, what is the origin and nature of the softening which has now been de- scribed ? M. Lallemand conceives that it is a constant and necessary result of an acute, sub- acute, or chronic inflammatory irritation of the part. M. Rostan, who has examined this sub- ject with great care, and viewed it in various lights, as respects both the morbid appearances 216 BRAIN — Alterations of its Substance—Hemorrhage. and the symptoms accompanying them, concludes at last by confessing its difficulty, and considering this change as analogous to senile gangrene. Be- fore the question can be entertained with precision, we should previously enquire with what other morbid states of the system generally, and of the brain in particular, has softening been found al- lied? 1st, It has been observed by Jemina, Black, myself, and others, to supervene during fevers, especially those of an epidemic and malig- nant character. 2d, It has been seen connected with puerperal disease of a malignant nature; and with epidemic and infectious erysipelas. 3d, It has been found in cases of scorbutus, and to occur in persons of an unhealthy and cachectic habit; also in those whose powers of life have been ex- hausted by bad living and excesses. 79. As to its relation to other lesions of the brain, I may state that it is often found surround- ing extravasated blood in the brain, and intimately connected with this effusion. The softened part is then generally of the color of wine lees, of a brownish hue, sometimes tending to green, or of a gray or ash tint. But what is the nature of this connection ? M. Rostan contends, that the soft- ening precedes and is always the cause of the ef- fusion, owing to the destruction of the minute capillaries at the point where the softening is greatest; whilst Dr. Craigie and others consider the softening surrounding the effused blood as the consequences of such effusion; and chiefly be- cause, " in cases hi which death takes place early, the pulpy disorganization is less complete than those in which it takes place at a later period. In short, the extent of the disorganiza- tion is proportionate to the interval which elapses between the effusion of the blood and the period of death." But is this the fact? It certainly is not in accordance with my experience, for I have observed no such relation; but have found recent effusions surrounded by as great, and even a greater, extent of softening as effusions of an older date. 80. Pulpy softening may be the attendant upon a coup de sang, or sudden congestion of the ve- nous capillaries of some part of the brain. This is considered to be the case in softenings with the reddish, amaranthine, crimson, or reddish brown shades of colour. But is the softening a consequence, or a cause of the injection ? May it not be a state of the vessels preceding that of effusion? These are questions which large ex- perience and deep thought will not readily de- cide. Dr. Craigie thinks that the softening is a consequence of the blood-stroke; but I cannot agree with him, merely because the reasons for a contrary opinion are quite as strong as those which may be urged in its favour. It has been often found accompanying hydrocephalic effu- sions, by Rostan, Lallemand, Billard, Otto, Andral, and by the author. It is then generally of the lighter shades of colour, and not great in degree. Is it here a consequence or a cause of the serous effusion ? It may be either. I am more inclined to consider both lesions as being often coeval, and, whether consecutive or not, depending upon a similar state of the vessels and vital manifestations of the organ and system generally. 81. Softening, or pulpy destruction of a portion ofthe brain, has likewise been found surrounding tumours and abscesses, by Morgagni, Sandi- fort, Meckel, Lallemand, Blane, Vel- lowi.ey, Powell, &c, and presenting almost every variety and depth of shade already noticed. In these cases, especially in those where purulent matter is lodged in the substance of the brain, without any intervening cyst or membrane, the softening often amounts to disorganization, and is more clearly attributable to inflammatory irrita- tion. When it is found subsequently to injury of the brain, external violence, and inflammation of the brain and its membranes, its nature and origin are most manifest. That it does supervene in this way, is shown by Fantoni, Morgagni, Le Dran, Schmucker, OTIalloran, Dease, Abernethy, Thomson, IIennen, Aber- crombie, and others. The apparently unequiv- ocal origin of this lesion in inflammation, under these latler circumstances, induced Morgagni, Lieutaud, Jemina, and more recently Baillie and Abercrombie, to consider it as analogous to gangrene in other structures. 82. But it should be kept in recollection that this state of the cerebral structure, although often preceded by signs of inflammation, and exhibiting in the parts surrounding it inflammatory appear- ances, is often neither preceded by the one, nor accompanied by the other, but, on the contrary, with a directly opposite train of phenomena and state of parts. In these opposing cases, what is the origin of the disease ? Are we to infer, with Rf.camier, an entirely opposite origin to that of inflammatory action, and that, as the softenings observed in the brain betray a variety of charac- ters, therefore they ought not strictly to be refer- red to a single unvarying source ? 83. From what I have seen of, or read concern- ing this lesion, I should infer, in respect of either of its most manifest conditions, that it is an effect of different states of morbid action, but most fre- quently of a form of sub-acute inflammation, cha- racterised by deficient power and loss of the vital tone and cohesion of both the vessels and the substance of the brain,—that it is the result of deficient vitality of the extreme capillaries and cerebral structure, occurring either primarily, or in consequence of previously excited action. The circumstances in which it is observed; its occur- rence after injuries and bruises, from the pressure of tumours, &c, and during the progress of ma- lignant diseases, show that it is not produced by a sthenic or healthy form of inflammatory action; but by that unhealthy, disorganizing and diffusive kind observed in cachectic habits, or in persons whose vital powers are much reduced. At the same time, I think it cannot be denied, that it sometimes originates in a diflerent way, being preceded by no signs of inflammatory irritation, nor attended with inflammatory appearances, and is a simple consequence of diminished, or alto- gether lost, vital power and cohesion of the part affected. 84. iii. Hemorrhage. — Sanguineous effu- sion may occur in a primary form, but more com- monly from some morbid state of the vessels, or of the substance of the brain itself. It may take place in any part of the organ, but much more frequently in some situations than in others, a. Blood is effused on the external surface of the brain, either in small quantities, beneath the pia mater, in one or two anfractuosities; or in an BRAIN — Alterations of its Substance—Hypertrophy. 217 uniform layer, even extending over the whole of an hemisphere in rare cases, b. It is sometimes found in large quantities in the ventricles; but it generally has escaped into them, owing to lacer- ation of the cerebral substance in which the ex- travasation takes place, c. The haemorrhage most frequently is in this substance. M. Andral states, that in 392 cases of haemorrhage in the brain, its actual seat was in some part of the cer- ebral substance in as many as 386. Of these, 202 occurred in the corpora striata, and thalami optici, and parts in the hemispheres, on a level with these places. The cavities formed by the extravasated blood Vary in size, from that of a small pea, to the greater part of the extent of a whole hemisphere. When the effusion is very large, it generally ruptures the parietes of the lateral ventricles, sometimes tearing the septum lucid um, and destroying the fornix. In other cases it may make its way to the exterior of the brain, and spread itself over the cavity of the arachnoid. 85. The number of hoemorrhagic cavities found in the brain vary from one to many. When several are found in the same brain, they gener- ally present different appearances, owing to their having been formed at different periods. This is generally the case when the patient has experi- enced several attacks of apoplexy or palsy. M. Andral remarks that effusion of blood sel- dom occurs in the cerebellum without appearing also in the cerebrum, whereas it may take place in any part of the cerebral hemispheres without occurring elsewhere. I have stated in the article on Apoplexy, the periods of life at which haemor- rh;ige in the brain is most frequently met with. Instances have occurred to MM. Rochoux, Bil- lard, Serres, Guersent, and myself, in which it has taken place at the unusual periods of infancy and childhood. The changes that take place in the effused blood, in the cavity contain- ing it, and in the substance of the brain after haemorrhage, comprising the reparative processes consequent upon it, are fully described in the ar- ticle Apoplexy (§ 35—39.). I have there shown that the cysts remaining after the coagula have been absorbed, sometimes disappear altogether by adhesion of their parietes. Some pathologists suppose that the cerebral fibres in those cases are directly united, and refer to the experiments of Fontana, Haighton, Michaelis, and May- er, who had shown, in opposition to Arnemann, that the filaments of divided nerves are, after a time, directly produced in the direction of their axis across the cicatrix. But intimate examination ofthe cicatrix of a lacerated portion of brain, or of a hasmorrhagic cyst, shows that this does not take place in the medullary structure of the brain. (See Apoplexy, § 53.) 86. iv. Hypertrophy and Atrophy of the Brain.—A. The brain occasionally presents lesions evidently connected with a modification of the nutritive process. In such cases, the con- sistence and size, either of the whole, or of cer- tain of its parts merely, are altered. Changes of its consistence are more frequent than of its size, and both are occasionally conjoined. It should not be overlooked, however, that the consistence and size of the organ are modified from the usual standard of middle age, at both the earliest and most advanced epochs of life; and that these 19 modifications, as being its natural conditions at those terms, are to be distinguished from the al- terations occasioned by disease. One hemisphere may also differ from the other, in respect both of its volume, and the form and size of its convo- lutions, owing to original conformation, without occasioning any appreciable disorder of function. 87. The brain continues to increase in size until manhood; from this period until old age its volume continues the same ; but with extreme age it somewhat diminishes in bulk. This is, however, not an uniform occurrence, for disease may have cut short existence before the period had arrived at which the organ would have un- dergone this change. According to Cazan- vieilh, the longitudinal diameter ofthe brain of an old man, compared with that of one in early life, is 6 inches 1 line French measure for the former, and 6 inches 4 lines for the latter; whilst the transverse diameter is 4 inches 10 lines, and 5 inches, respectively. M. Desmoulins (Anat. des Syst. Nerv. fyc. t. ii. p. 620.) found, that in persons above seventy years of age, the specific gravity of the brain was from one twentieth to one fifteenth less than that of the brain of persons just arrived at manhood. 88. The convolutions of the brain are scarcely developed at birth, or even until the expiration of the first year. In old age they again become less distinct and prominent. In the brain of the full grown young subject, they vary in thickness from three to five lines, whilst they are usually about two or three lines in old persons. They present the greatest diversity in respect to their number and length, and the depth of their an- fractuosities in the adult: in general they are the most marked and developed in the largest brains. Several physiologists in France are of opinion that the developement of the faculties of the mind has a very ultimate relation with the extent and number of the convolutions of the hemispheres, and the depth of their anfractuosities. 89. But it is important for the physician to know that not only may the whole encephalon experience a diminution of its bulk and specific gravity with old age, but that this diminution may be particularly apparent in certain parts of it in preference to others; and it is presumed, that this change may sometimes commence in one portion previously to others, or may affect it alone, so as to disturb its functions without being so evident upon dissection as to attract notice. The com- parative length ofthe following parts ofthe ence- phalon of subjects just arrived at puberty, of those in the prime of life, and of aged persons, is here given, as furnished by M. Cazanvieilh in French measure:— Persons at Puberty. 2 3 length 0 breadth 1 length 2 breadth 3 in. lines. 1 5h 6" Thai, optici Corp. striata - Corp. callosum Mesocephalon < Cerebellum 5 90. From these data it will appear, that the cerebellum is the only part of the encephalon which is not diminished by old age. But it may be asked, do the large nervous masses experience In the Prime of Life. in. "lines. 1 6 2 6 3 5 0 11 In Old in. lines. 1 4»- 7 101 0" 3 9 218 BRAIN—Alterations of its Substance—Atrophy. any diminution of volume analogous to that which the muscular textures and other parts experience in chronic diseases ? In answer to this, M. Des- moulins states that the brain, although atrophied in the manner stated above by old age, suffers no diminution of its bulk, whatever may be the de- gree of marasmus to which the individual may have been reduced. In all such cases he has also found the brain of the same specific gravity; and, to this predominancy of developement which the brain thus has acquired over all other organs, he is inclined partly to impute that nervous sus- ceptibility and excitation, which are common to the last stages of those maladies. It ought, however, to be borne in recollection, that, al- though the nervous centres may not undergo any change in bulk or specific gravity in consequence of those diseases, they often experience a very marked diminution of their consistence, as we shall have to show in the sequel. Having been made acquainted with these modifications of the nutrition of the encephalon which it undergoes at the different epochs of life, we are the better able to recognise those which are the result of disease. 91. B. Hypertrophy, or morbidly increased bulk ofthe brain, is very rarely met with. This state of the organ is to be distinguished from the apparently augmented bulk, arising either from in- creased vascular action, or congestion of the ves- sels. It appears to consist of an actual increase of the molecules of matter composing the proper tissue ofthe organ, and not of an injection of the minute vessels distending its structure. Although this condition of the brain seems to have been known to Morgagni, it is to Laennec that we are indebted for precise information respecting it. He stated (Journ. de Corvisat^t, fyc. t. ii. p. 669.), that, upon opening the heads of patients who had been thought to have died of hydrocephalus, he found no fluid effused; but the brain presented appearances of great compression, which he could attribute to no other cause, than to a too active nutrition of its structure, giving it a bulk too great for the bony case containing it. In children es- pecially, who had died in convulsions, or who had been subject to epilepsy, this disproportion between the capacity of the cranium and the bulk of the encephalon has been witnessed by him on several occasions, the convolutions of the hem- ispheres being flattened, and apparently squeezed against each other. M. Dance has also describ- ed this state of the brain (Repertoire d'Anato- mie, t. v. 1828.), and furnished some cases in which it was observed. It is chiefly met with in children or young subjects, and is, I conceive, of very rare occurrence, since, from amongst the great many thousand cases of children's diseases which have come before me, I have only remark- ed three cases in which it was unequivocally pre- sent. In these it presented the following charac- ters:—The convolutions of the hemispheres were extremely flat, and closely pressed against each other, so that the separations between them were scarcely apparent. The cerebral structure was firm, and, when incised, was dry, and more than commonly destitute of blood. The ventricles seemed small, were closely pressed together, and almost dry. The bones ofthe cranium were either natural or thicker than usual, as if they had parti- cipated, as regarded their thickness, in the increas- ed nutrition of their contents: the dura mater ad- hered closely to the cranium. A similar augmen- tation ofthe thickness ofthe cranial bones, but to a greater degree than I have remarked it, has been recorded by M. Scoutetten, who met with it in a girl five years of age, who died of ab- dominal disease, and who had never complained of any disorder of the head, or of disturbance of the mental faculties, which were those common to children at her age. 92. Rickety hypertrophy of the brain is more frequent. It commences soon after birth, and often attains a great extent. Otto supposes that brains which have been much expanded by dropsy in youth, become subsequently, in rare instances, cured by increased deposition of cerebral matter; and thus retain their size and weight. The dis- tension of the cerebral substance by the accumu- lation of fluid in the ventricles, cannot be compre- hended under hypertrophy of the organ. 93. M. Andral (Anat. Path. t. ii. p. 776.) says, that, although hypertrophy of the brain is usually general, and extends to the whole of both hemispheres, it is sometimes also partial: thus he has seen the thalamus opticus of one side of its natural dimensions, whilst that of the opposite side was one fourth larger. This extraordinary developement of the thalamus of one side was not attended with any particular symptom during the patient's life. Otto refers to a number of cases of hypertrophy confined to a single part of the brain, chiefly to the thalami and the corpora qua- drigemina. I am not aware that any well authen- ticated cases of marked hypertrophy of the cere- bellum are upon record. The spinal cord, how- ever, is not infrequently subjected to this change. 94. Morbid enlargement of the pineal gland has been observed by Drelincourt, Morgag- ni, LlEUTAUD, DESPORTES, SOEMMERING, An- geli, Greding, Meckel, and Blane. The pituitary gland has also been found enlarged, in- flamed, and otherwise changed, by Greding, Baillie, Chaussier, Oppert, Ward, Rul- lier, De Haen, Rayer, Neumann, Aber- crombie, Otto, the Wenzel's, and Meckel. 95. C. Imperfect developement and atrophy of the brain,—Agenisie cerebrate (Cazanvieilh), —is met with in every degree, from a slight dim- inution of the usual bulk of the whole organ, or of any of its parts, to their almost entire disappear- ance. Atrophy, although occurring in all situa- tions ofthe cerebro-spinal axis, is most frequently observed in those which are the last formed: thus the spinal cord is formed before the brain, and atrophy of it is much rarer than that of the ence- phalon. Of the brain, the convolutions are the last developed, and they are most frequently atro- phied. It should, however, be noticed, that the majority of those cases which are denominated atrophy ofthe brain by Andral, and other French pathologists, are, strictly speaking, imperfect or arrested developement of the organ. The hemi- spheres are most frequently the seat of atrophy and imperfect developement; and they may be thus affected, either partially, or altogether. Im- perfect growth of particular lobes, especially the anterior, is common in idiots, and may exist even although the cranium is well formed, the void being filled up with water, the congenital effusion of which is the probable cause of the arrest of developement. When the hemispheres are par- BRAIN — Alterations of its Substance — Induration. 219 tially affected, the lesion is most commonly ob- served in the convolutions. 96. a. Atrophy of the convolutions.—These parts are sometimes only smaller and less numer- ous than usual, either in respect of one or both hemispheres, or in a portion of a hemisphere merely ; and they may be altogether wanting in one, or in both. M. Jadelot lately found the hemispheres of the brain of an idiotic child, aged six years, without convolutions, and consisting of an uniform layer of medullary substance covered by a thin coat of cineritious matter. 97. 6. Sometimes the greater part ofthe hemi- spheres ofthe brain, especially their superior por- tions, from the vault of the ventricles upwards, are found in a state of atrophy, or altogether wanting. Most of the cases of this description, which have been adduced by the French patholo- gists, as well as the case of Jadelot, are merely instances of imperfect developement of the part. Sometimes this portion of the encephalon is re- placed by a sac containing a serous fluid, having no communication with the ventricles. In other cases, no such body replaces the deficient hemi- spheres ; but the different parts of the anterior and superior aspects of the ventricles, as the thalami optici, corpora striata, &c, may be seen through the membranes, no substance intervening between tliem and those portions of the floors of the ven- tricles. These occurrences are, however, not cases of atrophy, but of arrest of the formative process as respects the hemispheres of the brain. Cases of diminished size merely, of one or both hemispheres, are more common than those now instanced ; and are generally to be considered as being congenital ; or, at least, the result of a di- minished nutrition of the part, in the process of the growth of the organs. Instances of extreme smallness, or an entire absence of a part of the hemisphere, are most frequently met with in its posterior or anterior lobes : either of which may be altogether wanting, in one or both sides ofthe brain. Diminished size of the anterior or pos- terior lobes are a much more frequent occurrence than their entire absence. 98. c. The thalami optici, and corpora striata, may be also much diminished in volume, either singly or together. The diminution may proceed from a defect either of the gray matter, or ofthe white substance ; and from this cause of diminish- ed bulk, the accompanying symptoms will derive their chief characters. Not only may those bodies be simply diminished in volume, they may be even altogether wanting, either being replaced by a serous cyst, or having no other body as a sub- stitute : in the former case, the hemisphere of that side may be, or not, also entirely wanting ; in the latter it is always absent, and, from the cerebral peduncles, nothing more is found than a few scat- tered fibres, which are spread out into a mem- branous tissue, resembling that which, at the earliest epochs of foetal existence, forms the ru- diments of the hemispheres. It is evident, that in such cases, the white central portions of the brain being absent, and both sides of the cere- brum being thus circumstanced, there can scarce- ly be said to be any brain in existence. This, however, does not prevent the other parts con- tained within the cranium, as the mesocephalon, cerebellum, &c, from being fully formed. 99. d. The central white parts of the brain may be imperfectly developed, even when no al- teration is remarked in the hemispheres. In some such cases the corpus callosum is so small as to form merely a thin membrane. Reil remarked its entire absence in a female idiot, who died at thirty : the two hemispheres communicated only through the medium of the anterior and posterior commissures. It is remarkable, that when the cerebral lobes are wanting, two small masses of nervous substance, whence the olfactory nerves arise, are sometimes found in the anterior part of the cranium ; thus displaying in man, in the mor- bid state, the independent existence of the olfac- tory lobes, naturally shown in animals. 100. It will be seen from the above, that all the parts of the brain may present a state of im- perfect developement to a greater or less extent; that either of them may be entirely wanting, while the others remain : and that all of them may be absent, so that there exists no brain: a circumstance not infrequently observed in foetuses, and evidently owing to the process of develope- ment having been suddenly arrested. 101. But not only may the brain be in part, or entirely, deficient at birth; it may be also remark- ably small at advanced age, particularly in idiots. It may be generally, but more frequently only locally, diminished by external pressure, as in meningeal hydrocephalus. Although the brain, as well as the other parts of the nervous system, wastes so little in general consumption, it is, how- ever, somewhat diminished, although rarely, in the course of certain diseases : Savaresy states, that he has found it atrophied in yellow fever. Horn remarked a similar state in diabetes ; and O tto, after venereal excesses. Atrophy, is, how- ever, more frequently observed in particular parts of the brain. The lateral lobes of the cerebellum have been occasionally found atrophied. M. Hu- tin observed the medullary centre of the cerebel- lum reduced one third of its natural size. Mor gagni, Wenzel, and Biermayer have de- scribed atrophy of the corpora striata. The op- tic beds have been found greatly reduced in size after blindness, by Soemmering, Michaelis, Rudolphi, &c.; and in idiots, by Otto, Ram- say, and Romberg. The quadrigeminal bodies, and the tubercles of the brain, have likewise been severally found atrophied. The pressure occa- sioned by tumours, collections of lymph, pus, or blood, or even dropsy of the ventricles, may give rise to atrophy, interstitial absorption, or destruc- tion of particular parts of the brain. The want of exercise of the functions of the nervous system may also occasion atrophy, by diminishing nu- trition, as an unexercised muscle soon wastes. Thus, the wasting of the brain so generally ob- served in idiots, may be the effect and not the cause of idiotcy. The pineal gland, and the pituitary gland or appendage of the brain, have both been seen remarkably atrophied, particular- ly the latter. According to Otto, this change has been most frequently remarked in idiots, and in hydrocephalic cases. 102. v. Induration, or Hardening of the Brain, — Sclerencephalia (Craigie).— The cerebro spinal axis sometimes presents, eith- er throughout its extent, or in particular parts, a remarkable increase of consistence. This increase varies in grade. In its first degree, it is nearly of the consistence of a brain which has been kept 220 BRAIN — Alterations of r some time in dilute nitric acid. The second de- gree of increased hardness resembles the con- sistence of cheese. In this state, the cerebral substance, when exposed to the action of fire, in- stead of swelling up, without emitting any mark- ed odour, and leaving a brownish light residue, assumes a horny hardness, emits a strong heavy smell, and leaves a compact blackish residue. Nitrous acid also imparts to it a horny hardness, —circumstances evincing a great increase of the albuminous constituent of the structure. The third degree of hardening equals the firmness of wax, frequently also conjoined with elasticity, so that the indurated portion resembles fibro-cartilage. 103. a. The first grade of induration may affect the whole or the greater part of the cerebro-spinal axis. The two greater degrees of this change are commonly of more or less limited extent. Gen- eral hardening of the brain is usually attended with augmented vascularity, numerous drops of blood becoming effused when the cerebral struc- ture is incised. This increased vascularity, al- though general, is not constant; for, in some few instances, little or no injection of the capillaries is observed, the brain being rather exsanguineous than vascular. Even in the general induration of the brain, the hardening is not equal throughout every part. It is least remarkable in the cortical structure and convolutions ; and more manifest in the white, particularly the central medullary parts, than in the gray substance. 104. b. Partial induration of the brain is most frequently found in its central parts, and some- times in the convolutions. M. Andral has ob- served it in this latter situation, at as early an age as three years, which is extremely unusual. Sometimes the convolutions of the convexity of the hemispheres are unaltered, whilst those ofthe base are hardened ; occasionally, in such cases, especially when the induration is considerable, the cortical can scarcely be distinguished from the medullary structure. In a case recorded by Lallemand, the induration was limited to a cir- cumscribed portion of cortical substance, and, under it, the medullary texture was manifestly softened. M. Pinel found, in one of the hemi- spheres of a female who had died in a state of idiotcy, a portion of the medullary structure ex- tremely hardened; and, in the same individual, there existed, in the whole posterior and inferior border ofthe cerebellum, an induration of a fibro- cartilaginous description. The hardened por- tion was yellowish, elastic, resembling a piece of whitish-yellow leather. Mr. Pa yen found, in a girl six years of age, near the posterior third por- tion of the left hemisphere of the brain, a de- pression, owing to hardening of one of the con- volutions, which seemed externally as if it were shrivelled. It was rose-coloured on its surface, slightly yellowish in its substance, and almost concealed from view by two convolutions, which were healthy. The membranes covering this hardened convolution were white and thickened. Hardening was here joined to diminution of vol- ume ; or, perhaps, the disease of this portion of the brain was congenital, and, whilst the growth of the rest of the organ had proceeded, the de- velopement of this was interrupted. The intel- ligence of this child was well advanced ; but she had, from birth, a contraction of the right wrist and foot, with slight atrophy, and incomplete s Substance.— Induration. hemiplegia of this side. Similar cases of harden- ing of portions of the lobes of the brain are de- scribed by Monro, Lallemand, and Hutchin- son. In a case recorded by Joeger, the indu- ration was limited to the parietes of the posterior cornua of both lateral ventricles, and amounted al- most to that of cartilage. Bergman found both optic beds hardened hi a paralytic and squinting girl: and Castf.llier and Anderson observed excessive hardening of the lobes of the cerebel- lum. Partial induration of the nervous centres frequently co-exist with other lesions of those or- gans, especially around old sanguineous effusions and morbid productions formed in the cerebral substance : they are also occasionally found ac- cornpanving the usual results of chronic inflam- mation ofthe membranes ; these being firmly ag- glutinated together, to an extent of surface more or less considerable, and closely adherent to a subjacent hardened portion of brain. (Portal, Anatomie Mid. t. iv. p. 91.) 105. Cause of hardening of the brain.—The first degree of induration has been frequently found in persons who have died of fevers, gener- ally of an ataxic or typhoid type, and in maniacs. M. Andral observed it in two patients afflicted with convulsions from working in lead. MM. Gaudet (Recherches sur VEndurcissement gen. de I'Enciph. comme une des Causes des Fitvrcs Ataxiques. Paris, 1825.) and Bouillaud (Ar- chives Ginir. t. iii. p. 477.) consider it as the consequence of acute inflammatory action of the brain and its membranes, they having found it in persons who have died of encephalitis occurring either primarily, or as a complication in fevers ; and M. Andral (Anat. Path. t. ii. p. 810.) seems to coincide with this opinion. Rudolphi ob- served it in thirty cases of typhus : and Otto found, during the epidemic typhus of 1809 and 1812-13, hardening ofthe brain frequent in those who died within the first week ; and softening in many who died at a later period. But, in these cases, granting the induration to have been the consequence of the disease which destroyed life, it must have taken place in the short space of a very few days ; whereas, I am much more inclin- ed to impute it to inflammatory action of a lower grade and of a much slower progress. M. Brous- sais regards it as the result of meningo-encephalic inflammation, of a sub-acute or chronic nature. As being generally found in connection with in- creased vascularity of the substance ofthe organ, and with this and other signs of inflammatory ac- tion of the membranes, the relation of this change to inflammation seems established ; but I am in- clined to adopt the inference of Dr. Craigie, in respect of the opinions of MM. Gaudet and Bouillaud, that, in those cases in which they observed this lesion, it had existed previous to the acute disease which occasioned death. 106. Induration of the brain has been long fa- miliar to pathologists, in relation to mental derange- ment. The writings of Littre, Geoffroy, Bo- erhaave, Lancisi, Morgagni (Epist. Anat. Mid. viii. 4—IS.), J. F. Meckel (Mem. de I' Acad. Roy. de Berlin, t. vii. p. 306.) Lifutaud, Santorini, Greding (Ludwig's Advers. Med. Pract. t. ii. pars 3. p. 533.), Portal, Mar- shall (Morbid Anat. of the Brain, fyc. Lond. 1S15.), Haslam (Observ. on Madness and Me- lancholy. Lond. 1809.), Serres (Ann. Medico- BRAIN — Alterations of Chirurg. Paris, 1819.), Lallemand (Recherches Anat. Path. let. ii.), Lerminier, Bouillaud (Traite Clinique de iEnciphalite. Paris, 1825.), Pinel, jun. (Rev. Mid. t. vi.), Foville, and Pinel-Grandchamp, furnish numerous instances of it, thus related: and, from the history of the cases, as well as the generally augmented vascu- larity of the membranes and of the indurated brain itself, I infer that it is a consequence of chronic inflammatory action, conjoined with some change in the nutrition of the cerebral substance; and that it proceeds from a less intense and more chronic state of the vascular action than that which occasions softening, or pulpy destruction of the cerebral texture. That such is the case, is proved, not only by my own experience, but also by the observations of the authors enumerated above; for, in the majority of those cases, even when presenting the appearances and conse- quences of cephalo-meningeal congestion and inflammation, the symptoms of cerebral disease were of much longer duration, than those depend- ing upon morbid softening of the organ. 107. It has already been stated, that induration of the cerebral substances, amounting to either the second or the third degree, is generally cir- cumscribed in extent. Whatever doubts may be entertained of the first degree of hardening being the result of chronic rather than of acute disease, there can be no doubt of the second and third being always a chronic affection — perhaps, of a still more chronic state of capillary action than that giving rise to the first form of increased hard- ness; the morbid action, affecting in the former cases a portion of the brain only, may be com- patible with a longer duration of life, and hence give rise to ulterior or more advanced stages of change than those presented when the whole or- gan is affected, and all its functions and energies thereby involved. That this change is one of the consequences of chronic irritation, or inflamma- tory action, may be conceded, as well as the sup- position entertained by Andral and Craigie, that the morbid irritation is connected with a perversion of the nutritive action. Indeed, the numerous cases detailed by Portal, Serres, Lallemand, Bouillaud, Pinel, and others, furnish satisfactory evidence, both in the symp- toms during life, and in the co-existent lesions in the membranes and other parts of the brain, of the existence of a chronic inflammatory action, or of a state of irritative erythism of its capillaries. But to say that this state is in such cases accom- panied by a perversion of its nutritive actions, is ascribing to it what always is an attendant upon inflammatory action, of whatever grade, or in whatever texture it may be seated. It should, however, be mentioned, that M. Lallemand considers partial induration to occur occasionally as a favourable termination of morbid softening ofthe brain; but this is a mere supposition. 108. As to the phenomena to which induration of the brain gives rise, every practical man must feel considerable interest. The first and more general induration of the brain generally occa- sions loss of memory, confusion of thought, and derangement of the mental manifestations—caus- ing insanity without lucid intervals. When the induration is advanced in degree, or considerable as to its extent, or both, and especially when its long duration has been indicated by continued 19* its Substance—Tumour's. 221 mental derangement, a complete obliteration of the mental faculties, or fatuity, is frequently its attendant towards the last periods of life, and may therefore be considered as the consequence of the most advanced degrees of this lesion. . The signs of partial induration of the brain, in any of the grades to which I have referred, will vary accord- ing to the extent and seat of the lesion. They consist chiefly of a progressive defect of memory, inattention, or an inability to pursue a long train of ideas, indifference to momentary impressions, and to present or future occurrences, difficulty of articulation, derangement of ideas, with partial or total loss of the affections, appetites, and de- sires ; and ultimately increased loss of speech, palsy, convulsions, or want of power over the muscles, futuity, general or partial wasting, and death. 109. Lallemand found, in a patient who had complained of fixed pain of the forehead, palsy ofthe face, and confusion of memory; the mem- branes firmly matted together, for the extent of a thirty sous piece, at the anterior extremity of the left hemisphere; the subjacent cerebral substance hardened to a scirrhous or cartilaginous firmness, and adhering closely to the membranes. Bouil- laud states, that of a man, aged sixty-eight, who, after symptoms of cerebral disease, had un- paired memory, headach, difficulty of expressing his ideas, followed by muscular weakness and convulsions. The cerebral substance was found injected, and induration was seen " passing from the striated body of the left hemisphere, through the nucleus, at the upper region of which it formed a cavity with hard yellow walls; a similar hard- ened portion also existed in the posterior lobe. According to M. Pinel, induration confined to the brain causes fatuity, with more or less of palsy; but, if it extend to the annular protuber- ance, the crura cerebri, the corpora olivaria, or cord itself, epilepsy, followed by palsy, and death by marasmus, are generally superadded. In these advanced degrees of hardening, which are some- times attended with a shrunk, depressed, and con- densed appearance,—a species of atrophic hard- ening of the part, — there are usually remarked palsy and idiotcy, which are either congenital, or occurring subsequently to birth. 110. vi. Morbid Growths.—Tumours ofthe brain. Tumours of various kinds have been found to originate in the substance of the brain; but as Dr. Craigie (Anat. p. 447.) has observed, they have not been distinguished with sufficient precision by authors, from those which, originat- ing in the membranes, affect the brain only secon- darily. The first form of tumour which he has described, and denominated " cerebral tumour," entirely agrees with those partial indurations al- ready considered; differing from them in no re- spect, but in the extreme degree of firmness it presents, which is similar to the second and third (the latter particularly) degrees of hardening, arising in the manner I have endeavoured to ex- plain (§104.), and affecting all parts of the ner- vous masses, — the cerebellum and medullary cord, as well as the various parts of the brain itself. (See Hardening, &c.) 111. A. Tubercular secretion,— Tyroma (Craigie).—Tubercles of the brain have been described in recent times with much accuracy by Gendrin, Leveille, Ollivier, Abercrom- 222 BRAIN—Alterations of bie, Andral, and Craigie. They are formed of a white, or pale yellow, opaque, firm, cheese- like, sometimes granular and friable substance, consisting of a large proportion of albuminous matter, and varying in size, from that of a millet seed to the bulk of a hen's egg. Tins substance is deposited in various forms in the brain, but usually as follows:—1st, One, two, or more, homogeneous, distinct masses, of considerable size ; 2d, Several, or many, separate, minute, spherical, or spheroidal masses. Cases of the first form of tubercular formations are to be found in the writings of Manget, Rochoux (Richerches sur VApoplexie, p. 151.), Powell (Trans, of Coll. of Phys. vol. v. p. 222.), Blane (Trans, of a Society, Sj-c. vol. ii.), Baillie (Fasc. of Eng. No. 10. plate vii.), Coindet (Mem. sur VHydrociph. p. 106.), Bouillaud (Traite, fyc. p. 161.), Abercrombie, (Dis. of the Brain, fyc. p. 428.); Chambers (Med. and Phys. Journ. vol. Iv. 1826, p. 5.), Piedagnel (Journ. de Phys. t. iii. p. 247.), Berard (Ibid. t. v. p. 17.), and Hooper (Morbid Anat. ofthe Brain, p. xi. and xii. fig. 1.). Tubercles of this class vary in number from one to five or six, and in size from that of a pea to the bulk of a hen's egg. In form they closely resemble tubercles in other parts of the body. According to Le veille, they are often of an unequal surface, so as to ap- pear tabulated, particularly when they are very large. If only one or two are present, their size is generally considerable. M. Andral mentions their existence in the cerebellum, of so large a volume as to destroy nearly the whole of one of its hemispheres. Even when of this bulk, they consist of the opaque, cheese-like substance already described, and are always destitute of vessels, or any trace of organic structure. They are albuminous, friable, and generally surrounded by a cyst. MM. Gendrin and Llveille are of opinion that they always have cysts, but of variable thickness, which are sometimes remark- ably thin, at other times, especially in old tuber- cles, thick and fibrous. The cyst adheres exter- ally to the surrounding cerebral structure; and its internal surface sends off delicate filaments, which traverse the continued tubercular matter, and, in the large and old tubercles with thick cysts, seem like small fibres or partitions passing between the lobules of the contained substance, which is disposed in cellules formed by these fila- ments. In some large and old tubercles, the cyst is fibrous,cartilaginous,or even osseous (Gendrin), and is sometimes partially separated from the sur- rounding cerebral structure by a minute quantity of serous fluid. In proportion as the tubercle softens, the cyst becomes more apparent. 112. The surrounding cerebral substance is often perfectly natural, and sometimes variously altered; — occasionally inflamed, or softened, or atrophied, or even destroyed, especially when the tubercles are very large. Upon these lesions, the symptoms during life are often chiefly dependent. Very frequently, especially hi children, tubercles varying as to number and size may exist in the brain, without occasioning any symptoms suffi- cient to lead to the suspicion of cerebral disease : but this seems to be the case only when the nervous substance around them has been but little changed from the healthy state. When nervous symptoms have appeared without such change, its Substance—Tumours. they have generally assumed an intermittent character. 113. It is very probable that tubercles are formed in the brain, as elsewhere, at first in a fluid state; and that they afterwards either un- dergo a slow coagulation, or have their aqueous portions partly absorbed, the albuminous and other more solid constituents forming the tuber- cular substance. M. Bouillaud believes that they are the product of an inflammatory process; and the tendency of inflammation to produce an albuminous secretion certainly countenances this opinion. Whatever may be the origin, they ap- pear to experience in the brain a similar softening to that which they undergo when formed in other organs. When this is advanced to more or less partial fluidity, tubercles may be mistaken for other formations; and when amounting to lique- faction, the tubercular production can, with diffi- culty, be distinguished from a small encysted abscess. (See art. Tubercles.) 114. The second form in which tubercular productions are found in the brain, is that of spheroidal bodies, disseminated through its sub- stance. Professor Reil (Memorab. Clinica,t. ii. fas. iii. No. 2. p. 39.) describes them, in a case which occurred to him, to have consisted of about two hundred spheroidal bodies lodged in the gray matter of the brain and cerebellum. They were a little firmer than the brain itself, mostly of a pale yellow, some of a pale blue, of the size of a lentil or pea, and consisting of an adipose-like substance. From some, which were marked in the centre with a dark point, and seemed covered by a thin cyst, a slight incision discharged a mat- ter like vermicelli. These bodies were confined entirely to the cortical substance of the brain, chiefly near the deep anfractuosities, and but very few were in the prominent parts of the convolu- tions. They were most numerous in the superior aspect of the hemispheres, less so in the cerebel- lum, and least numerous in the base of the cere- brum. The pia mater was remarkably injected with blood, and the ventricles contained verv much fluid. This patient had never complained of pain in his head, although long afflicted with scrofulous sores, until eight days previous to death. In a case recorded by M. Chomel (Nouv. Journ. de Mid. t. i. p. 191.), similar bodies were found disseminated through the brain of a woman aged thirty, who died with symptoms of cerebral disease. Two such productions were also found in the cerebellum, and one in the spinal cord. Cases similar to the above have likewise been recorded by other writers. Tubercles, even in the form now being considered, are seldom or ever found in greater number than in the case just quoted from Rf.il; and, as Gendrin has remarked, they are never found in the brain in 60 very great numbers as in the lungs; nor, in my opinion, do they assume, in the cerebral struc- ture, the agglomerated form, in which they are so often met with in other viscera, and in the lungs especially. 115. Tubercles are often met with in the brains of children, and those especially of a strumous diathesis, and upwards of one or two years of age. They occur most frequently from this age to puberty; after which they are rarely met with, even in scrofulous and phthisical subjects, where tubercles exist not only hi the lungs, but BRAIN — Alterations of its Substance—Tumours. 223 also in other organs. They are most common in the hemispheres of the brain, and there occupy indifferently either the cortical or the medullary texture: sometimes they appear, as it were, placed between both. In some cases in which they have been found in the more exterior layer of the cineritious structure, they seem not to have been originally formed in it, but to have sprung from the internal surface of the pia mater, and to have pressed inwards the cerebral tissue as they in- creased in size, forming, as it were, a superficial cavity in it, without any intimate union with it beyond that of close contact. The parts of the brain, after the hemispheres, where tubercles are most commonly found, are, according to M. An- dral, the cerebellum, the mesocephalon, the medulla oblongata, various parts of the spinal cord, the peduncles of the cerebrum and cere- bellum, the thalami optici, corpora striata, the commissures of the thalami,- and pituitary body. According to the order of frequency here indicated, it will be observed, that those parts of the cerebro- spinal axis which are most frequently the seats of inflammation, softening, or haemorrhage, are not those which are oftenest the seat of tubercles. 116. B. Adipose tumour (Wenzel),—Fatty productions (Andral),—Lardaceous degenera- tion (Hf.breAKT,AnnuaireMid. Chirurg.Paris, 1S29. p. 579.), — Ceroma (Craigie).—This morbid formation has been noticed, under the above designations, by the authors whose names are respectively noticed, and also by Rudolphi, Braun, Cruveilhier,Merat,Leprestre (Archives Gener. de Mid. t. xviii. p. 19.), and Dalmas (Journ. Hebdom. de Mid. t. i. p. 332.). Borelli states that he has found, behind the upper part of the medulla oblongata, a fatty, ho- mogeneous, reddish, or rose-coloured substance, the size of a nut, apparently traversed by reddish lines, and contained within a thin envelope. A similar tumour, though smaller, was found in the left cerebellic hemisphere. Amongst the great number of brains examined by the Wenzels, only two presented this change; which they de- scribe as having been smooth, of a yellow colour, and consisting of a solid, adipose, ash-coloured substance; and, although found near the exterior surface of the hemisphere, penetrating deep into the substance of the organ. 117. According to M Hebreart, this disease is not so rare as the Wenzels lead us to suppose. He had met with four cases of it; two in which the tumour was seated in the brain, and two in the cerebellum. " In the first of the former, a distinct tumour, consisting of matter of a yellow colour, and lard-like consistence, the size of a nut, in the auterior part of the anterior lobe of the right hemisphere, gave rise to idiotcy. In the second, a square inch of the posterior lobe of the left hemisphere was converted into a yellowish pulpy matter, which was separated from the con- tiguous sound brain by hardened cerebral sub- stance. This, in a man aged forty, caused epi- leptic paroxysms, occurring once or twice a month, which at last proved fatal, by causing asphyxia. In the first of the cerebellic cases, in a young man who had been idiotic for six years, the cere- bral substance, forming the walls of the fourth ventricle, had been converted into a yellowish lardaceous matter. In the second, that of an incurable maniac, a space, six lines in diameter, of the lower part of the right hemisphere of the cerebellum, had become hard, yellowish, and lardaceous, both in the gray substance, and also in the white." The membranes also participated in this change. M. Hebreart considers that this lesion may occur in two forms, — 1st, As a de- generation of the cerebral structure into a matter of a yellowish colour and lardaceous consistence; and, 2d, In the shape of a distinct tumour situated in the cerebral substance. 118. Closely allied to the above, although materially different in some respects, yet still more strictly deserving the term adipose, are the tu- mours described by Leprestre and Dalmas. M. Leprestre found, in the left side ofthe me- socephalon of an adult subject, a large tumour, with a brilliant tabulated surface, consisting of concentric layers, "united by means of fine cellular tissue, but without any trace of blood-vessels. It was denser in its structure than the brain, and closely resembled a mass of adipocire. This resemblance is remarkable, inasmuch as MM. Barruel and Gmelin have demonstrated, in the healthy human brain, a certain quantity of fatty matter and cholesterine. The tumour found by M. Dalmas nearly resembled the foregoing. It was situated in the base of the brain, and was as large as a hen's egg. It rose upwards into the third ventricle, separated the parts which contri- bute to the formation of this cavity, and disap- peared in the medullary substance of the striated bodies, the thalami optici, the anterior commis- sure, &c. Its superior surface closely resembled spermaceti. Its inferior surface was transparent, polished, and studded with a number of pearl- like granulations, from a line to a line and a half in diameter, which were, like the whole of the mass, perfectly homogeneous, and devoid of every trace of organization. When analyzed by M. Barruel, this tumour was found to contain a very large portion of fatty matter, and a substance which seemed to be cholesterine. The description of a similar tumour is recorded in the first volume of the Journal Clinique des Hbpitaux. Otto also found a fatty tumour, which contained hair, pro- truding through an aperture in the hemisphere into the ventricle, its cyst shining like mother-of-pearL 119. C. Flesh-like tumour,—Adenoidea (Crai- gie).— This production has been described by the vague names of scirrhous and scrofulous tu- mour; but it cannot be admitted to possess un- equivocal characters of either. It is generally stated to be similar to a mass of flesh, or an en- larged absorbent gland. Its colour is light pink, or pale flesh-colour; its firmness is considerable; and, in some instances, it is compared to the kidney. Cases of this description of lesion may be found in the writings of Plater (Obser. 1. L p. 13.), T. Bonet (Sepulchetum, t. i. p. 283.), Rhodius (Cent. Obs. I. No. 55.), J.J. Wagner (Miscell. Curios. Dec. II. Ann. 10.), J. G. Zinn (Comment. Soc. Reg. Scient. Gott. t. ii. 1752.), J. J. Huber (Nova Acta Physico-Medico Acad. Ces. Leop. Cur. t. iii. p. 533.; et Comment, de Rcbusin Scient. Nat. t. xviii. p. 335.), Haller (Opusc.Path. Obs. i.), J. E. Greding (Ludwig's Advers. Med. Prac. t. ii. part ii. p. 492.), H. Earle (Med. Chirurg. Trans, vol. iii. p. 59.), Powell (Trans, of Coll. of Phys. vol. v. p. 241.), &c. Most of those cases appear to have occurred in strumous habits; and, besides signs of 224 BRAIN—Alterations of glandular disease, many of them were affected with palsy, apoplexy, or mental derangement; and others with convulsions and epilepsy, shortly before death. M. Andral (Anat. Patholog. t. ii. p. 848.) mentions his having found, in the middle of one of the hemispheres of the brain of a person who had died of apoplexy, a fleshy fibrous tumour ofthe size of a walnut. 120. D. Fibrocartilaginous tumour, — Scirr- hus, Chondroma (Hooper and Craigie), — is probably, in its slighter grades of change, merely an advanced state of the third variety of partial induration ofthe brain (§ 103.). It is distinguish- ed from the surrounding cerebral substance by its great firmness ; its irregular and tabulated form ; its yellowish, hard, and fibrous structure; and, in its advanced stages, by the presence of a semi- fluid, gelatinous matter, occasionally tinged with blood, contained in small cavities, disseminated through it; and by a tendency to softening; death, however, generally taking place before complete softening, or cancerous ulceration, has supervened. This tumour is not often met with in the substance of the brain, and very seldom as a primary affec- tion. It seems to consist of a change in the structure of the part affected, rather than of a deposition of adventitious matter; and it is not enveloped by any cyst; but gradually disappears in the surrounding substance, which is sometimes softened. All the cases which have been recorded of scirrhus of the brain, are not in every respect similar to the above description, but an approx- imation to it merely; some, according to the loose accounts given of them, being intermediate be- tween this and the cartilaginous conditions. The best illustrations of this form of tumour have been furnished by Cruveilhier (Anat. Pathol, t. ii. p. 80.), Rostan (Recherches sur le Ramol- lissement du Cerveau, fyc. Ire. ed. p. 80.), Andral ( Journ. de Physiol, t. ii. p. 105.), Bouillaud (Traite CUnique de VEndphalite, §-c. 1S25.), Lerminier (Ann. Mid.-Chirurg. 1819, p. 225.), Monro (Morb. Anat. of the Brain, p. 55.), Wade (Medic, and Phys. Journ. vol. Iv. p. 369.), Bayle (Rich, sur la Phthisie Pulmonic, p. 305.),and Copland Hutchison (Trans, of Med. and Chir. Soc. vol. ii. and iv.). All these cases were characterised by acute pain in the head, stupor, palsy, idiotcy, convulsive movements, and, at last, insensibility, coma, or complete apoplexy, and death; or by one or more of these symptoms; and several of them seemed to originate in external injury received at a more or less remote period. 121. E. Bony tumours and calcareous con- cretions,—Osteoma (Hooper), — are rarely ob- served in the substance ofthe brain. Cases have, however, been furnished of their formation, in more or less considerable masses,—near the right ventricle, in an idiot, by Kerkringius (Obs. Anat.p.l 35.); in the corpus striatum, by Deidi er (Des Tumeurs, fyc. p. 351.), and Kentmann (De Calc. in Hominib.T'ig. 1536.); in one ofthe corpora quadrigemina, by Tyson (Phil. Trans. No. 228.); in the union of the optic nerves, by Blegny (Zodiac. Gall. Obs. xiv. p. 81.); where they were attended by violent pain in the occiput, by Boy er (Cruveilhier's Anat. Path. i. ii. p. 84.) ; in the cerebellum, by Littre (Mim. de VAcad, de Paris, 1705, p. 55.); in the cerebellum of an epileptic, by Lieutaud its Substance — Tumours. (Hist. Anat. Med. 1. iii. Obs. 179.); in the pons varolii, by Mf.tzger (Obs. Anat. Reg. 1792, p. 3.); in the optic beds, by Caldani (Opusc. Anat. Path. 1803, p. 51.); in one hemisphere of an epileptic, by Otto (Comp. Anat. Path. p. 415.); in the cerebellic peduncles and protuberance of an idiot, by Home (Phil. Trans. 1814.); in the left hemisphere, by Andral (Journ. de Physiol, t ii. p. 110.); in the cerebellum, with violent pain at a determinate part of the occiput, by Nasse (Abercrombie on Dis. of the Brain, p. 426.); in the centre of the medullary substance of the anterior lobe, with pulpy destruction of the sur- rounding part in one case, and in the cerebellum in another, by Dr. Hooper (Morb. Anat. ofthe Brain, p. 39.). Besides these, other instances are referred to hi the Repertorium of Ploucquet, and the Compendium of Otto. In more numer- ous cases, the chalky, calcareous, or bony matter, is disseminated like sand in a diseased portion of brain, and can be detected only by squeezing or rubbing the part between the fingers. In some cases, the bony matter appears like minute spi- cules, or particles; and Dr. Hooper states that he has found each of them attached to a filament- ous vessel. 122. Sabulous concretions are so constantly found in the pineal gland, or its peduncles, even of those whose cerebral functions were most healthy, that Soemmering conceived them to form a part of its natural structure in adults. But this part may be greatly enlarged, and contain calcareous matter to an excessive amount. A case of this description is given by Manget (Theat. Anat. 1. iv. c. ii. p. 309.) and Salzmann (De Gland. Pineal. Lapid. Arg. 1733.). 123. F. Hygromatous tumours, or cysts, con- taining a serous or albuminous fluid,—Hygroma of Hooper),—are not infrequently found in some part or other of the brain. Dr. Hooper has de- scribed four varieties of these cysts: — a. That consisting of a simple cell, or cavity, containing a transparent, yellowish, or yellowish red, serous fluid. Their sides are somewhat harder than healthy brain, occasionally rough, and of a brown- ish hue internally, but mostly smooth and shining. They present no appearance of membrane lining the cell, nor of vascularity; are of the size of peas or nuts, and are most frequently met with near the external surface of the brain. They appear to be the remains of cavities formed by extravasated blood. 6. Another variety is a dis- tinctly encysted tumour, consisting of a membran- ous cyst, or vesicle, filled with a serous fluid. This cyst is delicate, is formed of a single mem- brane, and is provided with vessels coming from the surrounding brain, and which may sometimes be seen ramified over it. The fluid which fills it is colourless and limpid. This variety varies from a very small size to that of a small orange. It is sometimes solitary; but occasionally two or more may be embedded close together, c. Dr. Hooper describes two other varieties, one of which is formed of a cyst, which is opaque in some parts, and transparent in others, and distended with a sero-albuminous fluid. The cyst is not apparently vascular, but is much thicker than the preceding; and its contents coagulate by heat: d. The other is characterised by the remarkable thickness of its cyst, and the thick albuminous nature of its contents. It is generally found BRAIN— Alterations of its Substance—Rupture. 225 embedded in the medullary substance of the brain. 124. G. Hydatids.—The existence of true hy- datids,—both the acephalocyst, or headless hyda- tid, and the cysticercus, or bladder-tailed hydatid, —in the substance of the brain, has been doubt- ed. Several cases of hydatids in this part have been adduced by authors; and instances have oc- curred to Andral and Calmeil (Anat. Pathol. t. ii. p. 779.), which they considered to belong to the latter of the above species of entozoa; but whether they actually were such, or some one of the cysts described above, rests upon the patholo- gical reputation of these physicians. Those ad- duced by Home, Headington, Morrah, and Rostan, seem to have been merely varieties of hygroma. Dr. Hooper never met with hyda- tids in this situation, in his numerous dissections. Brera states that he has found them in the cho- roid plexus; and Dr. Monro relates a case, where a cyst, which he considered as a true hydatid, was found in one of the ventricles. But their con- nection with the membranes of the brain (§ 31.) has already been shown. 125. H. The Hematomatous tumour, — the Hematoma of Hooper,—is not common. It is mostly fungous, arising from a small base, sepa- rating the convolutions and cerebral substance about it, as it enlarges and rises towards the sur- face of the brain. It is soft to the touch; is elas- tic, and covered with a vascular and shaggy mem- branous tissue. When divided, its inner structure is vascular, mottled, of a whity brown, and, in some parts, of a bloody colour; and a humid sub- stance adheres to the knife like cream. Interest- ing cases have been detailed by Rochoux (Rich. sur I'Apoplexie, Ob. 38. p. 149.), Hooper (Op. Cit. pi. x.), Monro (Op. Cit. p. 56.), and G. Gregory (Med. and Phys. Journ. vol. liv. p. 462.), in which these tumours were, exteriorly, of a reddish or reddish brown colour, tabulated, and surrounded by pulpy destruction of the cere- bral substance. In two of the patients, violent headach and epilepsy, and, in one, palsy, follow- ed by coma, preceded dissolution. This tumour must not be confounded with the solid nodules of extravasated blood, often found after apoplectic seizures. 126. I. Encephaloid or cerebriform tumours, — Medullary sarcom,—Fungus hematoides, — Cephaloma, Hooper.—These tumours are not frequent. Delineations of them have been given in Dr. Baillie's and Dr. Hooper's illustrations. They occur chiefly in young subjects; and are en- cysted, soft, compressible, and spongy, resembling the gray cerebral substance, with a tinge of red, and of the consistence of the foetal brain. They are frequently divided into tabulated masses. When cut with a knife, the surface is smooth, and the knife is covered with an unctuous substance. I have met with one case in a boy of eleven years of age. M. Bayle found it in the cerebellum of a middle-aged man. (Riv. Mid. Avr. 1824, p. 77.) 127. K. The Melanoid tumour,—Melanosis,— Melanoma, of Hooper.—Melanosis has rarely been found in the brain. Dr. Hooper has, how- ever, observed it in a tuberculous form, both in the cineritious and medullary structure. These rumours were of a jet-black colour, soft, distinctly circumscribed, and closely surrounded by healthy brain. Dr. H. has found them of all sizes, from that of a mustard seed to that of a walnut. " They are so soft as to require a very sharp knife to cut them, which they soil. They are easily taken out of the brain with a forceps, and leave a clean cavity, without any cyst apparent to the naked eye; and if shaken in water, they colour it black, and a flocculent substance remains. In one ins- stance, in which there were several of these tu- mours, some of them were of a blood or liver color, and resembled haematoma (§ 125.); others were perfectly melanomatous; and several were of an intermediate colour, — a circumstance which is very much in favour of the hsematoma and melanoma having an intimate connection, if they be not one and the same disease, modified by particular circumstances." (p. 41.) 128. All the tumours now described occasion alterations, generally of an inflammatory nature, with softening in the substance ofthe brain conti- guous to them; and until those alterations have been in some measure produced, they often give rise to but little disturbance of the functions of the organ. However, when these changes be>- come developed, the usual symptoms of circum- scribed inflammation of the substance ofthe brain, with softening; epilepsy; loss, or perversion of one or more of the mental faculties—amounting often to insanity; idiotcy; palsy; coma, and apo- plexy; are the usual effects. (See the Articles on these diseases.) 129. vii. Rupture of the Brain.—Hernia cerebri,—Encephalocele, — is occasionally met with. It consists of the protrusion externally of a portion of the brain through openings in the cranial bones. This lesion either may be congenital, or may arise subsequently to birth. In the former case it is generally connected with effusion of fluid in the ventricles. The protrusion of brain varies with the size of the aperture in the skull, and the quantity of effusion causing it. In some cases a large portion of the skull is wanting, and the protruding part of the brain has a wide base : in other cases, the opening in the cranium is small, and the protrusion is either very small, or attach- ed to a narrow neck. Otto states, that in every case which he has observed, the lesion was owing to effusion, and not to hypertrophy of the sub- stance of the brain; and that the aperture arising from deficient developement of the bones of the cranium was one ofthe consequences ofthe effu- sion. This agrees with my experience, and con- stitutes hydrencephalocele or watery rupture of the brain. In some cases large portions of the brain are protruded, in others but small. Fre- quently the protrusion consists only of the mem- branes forming hydr encephalocele meningea, and the water which they contain. Otto describes this as a rare occurrence. I have met with seve- ral cases at the Infirmary for Children, and in unusual situations, namely, through clefts in the parietal bones. In rare cases of hernia cerebri, the water is found both within the ventricles and between the membranes. 130. Congenital rupture of the brain occurs most frequently on the back of the head, through the enlarged occipital foramen, and the cleft upper cervical vertebra, or through a cleft in the upper part of the occipital bone, or in the lambdoidal suture. It is not frequent at the top of the head, especially at the great fontanel; and Otto says it is still more rare in the sides of the skull and 226 BRAIN — Cerebral Plethora. forehead, and the rarest of all in the orbits and sphenoidal sinuses. Two cases, however, of its occurrence at the sides of the skull have come before me. Rupture of the brain, occurring after birth, arises from the expansion of the brain by its own elasticity, or by increased determinations of blood, and its consequent detrusion through apertures naturally or artificially made in the cra- nium. I have met with cases, however, in which no protrusion of the brain had been observed af- ter birth; and yet apertures, through which it might have occurred, were found in the middle or squamous parts of the bones, and must have been congenital. The inference is, in these cases, that a watery tumour of the brain had arrested the formation of the bone immediately over it, and that this tumour had subsequently disappear- ed, probably from the absorption of the aqueous effusion; but that the bone had not yet been form- ed in the situation where the ossific process had been interrupted. 131. viii. Laceration.—The continuity ofthe brain may be destroyed by external violence, or injuries penetrating the cranium, either with or without loss of substance. Concussions also will lacerate the brain, without the skull being pene- trated or even fractured. The substance of the organ, particularly the septum and fornix, may be torn by large collections of water in the ventricles. There is every reason to suppose that, when the solution of continuity Is simple, adhesions will take place. When there is loss of substance, the injury can be repaired only by granulation. If the laceruHon he accompanied with the efiusion of blood, so as to form a large coagulum, requir- ing to be absorbed, the reunion of the opposite sides of the lacerated brain is effected by means of a fine cellular tissue; permanent paralysis being the usual consequence. When the granulations of the lacerated brain protrude through the frac- tured skull, owing to their luxuriance, or rather to the elasticity of the brain; and when the pro- trusion proceeds from the distension arising from the fulness of its vessels, the morbid condition has been improperly called fungus cerebri,—impro- perly, inasmuch as the term fungus is applied to a malignant and constitutional malady. 132. ix. Ecchymoses, and Alterations of Colour.—Besides the lesions now described, there are others of a less remarkable kind, of which a brief notice may be taken, a. The cine- ritious substance may be extremely pale, and even approximating to white; and it may also be of a very deep colour, and almost approaching to black, particularly in some cases of asphyxia and fevers, owing probably to the dark and imperfectly de- carbonised state of the blood. The different layers composing this substance are sometimes also more than usually distinct, and separate easily from each other (M. Foville and Dr. Bright). In other cases they are very thin, as if in a great measure absorbed. This part of the cerebral substance likewise, in some instances, presents numerous ecchymosed spots of various sizes and depth of colour, b. The medullary structure is also sometimes ecchymosed, particularly after concussion; and variously marbled, and present- ing blotches of a pink,- purplish, grayish, or of a grayish yellow. These changes seem to proceed from excessive injection of the minute capillaries of the organs, and probably from partial extrava- sation of their contents, owing to over-distension, or a morbid state of the blood which had circu- lated in them shortly before death, and are most commonly observed after death from convulsions and malignant diseases. 133. As respects the colour of the brain gene- rally, I may state that it is sometimes found un- usually pale from deficiency of blood, in cases of anaemia and cachexia. But it is more commonly of a deep or pink colour, particularly in those who have died from apoplexy, strangulation, narcotic poisons, asphyxia; and in the insane, or those given to drunkenness. In some cases resulting from those diseases, or attended with cerebral congestion, dark red, bluish, or purple coloured spots, or even streaks, have been found in both the cortical and medullary structure. In cases of inflammatory irritation, a reddish or pink hue is observed. A red colour is rarely met with, but more commonly a pale rose tint, unless effu- sion of blood have occurred. I may also state, at this place, that if, in severe diseases of the brain, the blood be decomposed, or if the colour- ing particles be secreted in various proportions, the brain will present different shades of colour, both in its cineritious and hi its medullary sub- stance : it will thus be either a pale or dusky yellow, an orange, a brown, grayish green, a slate colour, and even here and there soot-coloured. Occasionally, also, in different changes of texture, although even without these, a deposition of a melanotic pigment takes place, chiefly in the course of the larger vessels, independently of the melanoid tumour (§ 127.). Otto never observ- ed the brain generally tinged yellow in cases of jaundice, and doubts it having ever occurred, although Stoll says that he has seen it. I should add, that the above changes of colour are independent of marked softening or pulpy des- truction of the cerebral substance. Brain.—Anaemia of the.—See § 132., and art. Convulsions. Brain.—Cerebral Plethora.—Deter- mination of Blood to the Head. Classif. II. Class, I. Order (Author). 134. When the blood is determined in too great quantity to the brain, although the patient may not be altogether incapable of his usual avo- cations, yet much disorder may be present, which, if neglected, may lead to serious diseases, more especially to those which will be considered in the sequel of this article. 135. Causes.—The causes of general vascular plethora likewise occasion this affection. Those which are more peculiar to it, are inactivity ofthe secreting and excreting functions, mental exertion, retention of accustomed evacuations and dis- charges, full living, sedentary occupations, and want of exercise in the open air; organic diseases of the heart, particularly hypertrophy of the left ventricle, and those causes which are enumerated under the article Apoplexy. 136. Symptoms.—Cerebral plethora, and de- termination of blood to the head, differ in many respects from cerebral congestion, or coup de sang (§ 133.), but the symptoms accompanying them vary chiefly in degree. Where the disorder consists merely of plethora from local determination, som- nolency, cephalalgia attended with scintillations, and objects appearing of a red colour, vertigo, noises | in the ears, sometimes sleeplessness, moral and BRAIN — Congestion of the. 227 physical excitation, intellectual activity ; or, on the contrary, inactivity, inability of continued at- tention, stiffness, cramps, twitchings, &c. of the limbs ; animation of the countenance and eyes, which are sometimes red or injected, with strong pulsation of the carotid and temporal arteries, full and somewhat frequent pulse, and slightly in- creased temperature about the head, are the usual symptoms. 137. Morbid appearances.—This state of dis- order never of itself occasions death ; but, as it sometimes occurs in the advanced stages of fatal diseases, it lias been observed to consist of increas- ed vascularity in the brain and its membranes, without further organic change ; but it is some- times accompanied with a slight serous effusion into the ventricles and between the membranes, particularly towards the base of the brain. This effiision seldom amounts to more than may be present in the healthy state of the organ, the excess being probably rather a consequence of death, than its antecedent. 138. Treatment.—Cerebral plethora may gen- erally be removed by avoiding the causes indue- in"' it; by promoting the abdominal secretions and excretions by the usual means ; by the affusion of cold water on the head, and the daily use of the shower-bath, or by sponging the head with cold lotions ; by clothing the lower extremities warm- ly, and promoting the cutaneous perspiration ; by regular daily exercise ; by due attention to the quantity and quality of the food ; and by changes of air in obstinate cases, and sea voyages. Braiw—Congestion of Blood in the.— Coup de Sang. —■ Cerebral Congestion. Classif. II. Class, I. Order (Author). 131. Congestion is an advanced as well as a modified state of cerebral plethora, and consists in too great an accumulation of blood in the ves- sels of the head, particularly in the venous capil- laries and sinuses, occasioned either by too. great a flux of this fluid to the brain, an exhausted tone of the capillaries and smaller vessels, or impeded return of it by the veins. This state of circula- tion in so important an organ as this is, necessa- rily occasions marked lesion, not only of the func- tions which it performs, but also of other func- tions throughout the system. 140. Symptoms.—Cerebral congestion is char- acterised by numbness, vertigo, noises in the ears, somnolency, brilliancy or watering of the eyes, cephalalgia, redness of the countenance, beating of the carotids and temporal arteries, loss of re- collection, &c. These symptoms continue for some time in different degrees, sometimes disap- pearing, and after awhile returning, accompanied, with cramps, twitchings of tlie limbs, generally of both sides r at last the patient loses sense and voluntary motion, in a more or less sudden man- ner. But usually in the course of a few minutes, or, at furthest, some hours, the more urgent of these symptoms disappear ; leaving, however, numbness of the limbs, which generally disap- pears in a short time, or in the course of one or two days. 141. In the more severe cases, and those which more nearly approach complete apoplexy, the attack is preceded by disorder of the stomach, or accompanied by nausea, or vomitings ; and some- times, during the loss of sense and voluntary motion, the stools and urine are voided involun- tarily ; respiration is more or less embarrassed, but not stertorous ; the pulse is strong, frequent, and full ; the temporal and carotid arteries beat strongly ; and the skin is generally warm and nat- ural. Cerebral congestion is almost always gen- eral throughout the brain, but it is also, although rarely, local, affecting only one hemisphere ; and, owing to the numbness and temporary paralysis thereby occasioned, is confined either to one limb or to one side of the body ; simulating apoplexy, or paralysisfrom haemorrhage in the brain. That these local symptoms are, however, owing to par- tial congestion, and not to haemorrhage, is evinced by the celerity with which they disappear under judicious treatment. When the cerebral conges- tion is very great, it constitutes a form of apoplexy, noticed in the article on that disease, and may oc- casion death without any further lesion than con- gestion merely. 142. Appearances on dissection.—The scalp, and even the bones of the cranium, in some cases, are of a red violet colour, and allow of a consid- erable quantity of blood to escape upon being di- vided. The vessels, and particularly the sinuses, are filled with dark blood. When the arachnoid of the pia mater is separated from the brain, a reddish patch, more or less deep, is formed, the vessels running through it being gorged with blood. The surface of the convolutions are of a more or less dark colour ; and, when the cortical sub- stance of the brain is divided, it is of a deeper hue than natural, the orifices of the cut vessels giving out drops of blood proportionate to their size. Upon dividing the medullary structure, which is usually not so white as in health, myriads of minute specks, becoming small bloody drops, rapidly form on the surface. The large vessels, and particularly the veins of the brain, are gorged with blood. When a person cured of repeated attacks of cerebral congestion, dies of a different disease, morbid appearances are seldom detected in the brain. 143. Terminations and complications.—Cere- bral congestion may occasion meningitis ; or in- flammation and softening of the substance of the brain ; or hemorrhage in some situation within the cranium, giving rise to complete apoplexy, or palsy, or both ; and serous effusion in the ven- tricles, or between the membranes ; many of the cases of apoplexy, attended with extravasation of blood, thus commencing in congestion, the extra- vasation being a consecutive change. It may also supervene on organic changes of the heart and lungs, and in the progress of various fevers, and thus be complicated with these diseases. 144. Causes.—The causes of this state of the cerebral circulation, are those which have been already detailed in the articles Apoplexy and Cerebral Plethora (§134.). 145. Treatment.— Blood-letting, general, lo- cal, or both, to an extent which the constitution, habit, and symptoms of the patient indicate, are requisite. Next to blood-letting, active purging by calomel, followed by a dose of senna, croton oil, or some other active cathartic, and promoted by strong cathartic injections, such as the oleum terebinthina:, oleum ricini, extr. colocynth. comp., &c. are required, and should be repeated, so as to procure copious evacuations, and keep up suffi- cient action in the alimentary canal. The affu- sion of cold water on, or cold sponging the head, 228 BRAIN—Inflammation of its Membranes. is generally beneficial; and when the temperature is increased, and the countenance and conjunctiva flushed, a thick oilskin should be placed under the patient's head, which ought always to be kept el- evated, and covered with cold epithems. Due attention should be constantly paid to the state of the evacuations. Accumulations of bile in the gall bladder or hepatic ducts, and of faocal matter and morbid secretions in the alimentary canal, fre- quently predispose to or induce an attack, which will seldom altogether yield to the means em- ployed, unless these morbid collections are remov- ed by appropriate means : and as long as the evacuations continue unhealthy, we may infer that the chief cause of disorder is not altogether re- moved. (See Treatment of Apoplexy.) Brain—Inflammation of the. Clas- sif. 1. Class, Febrile Diseases ; 2. Order, Inflammations (Cullen). 3. Class, Diseases of Sanguineous Function ; 2. Order, Inflam- mation, (Good). III. Class, I. Order (Author, see Preface). 146. Nosol. Defin.—Pain ofthe head more or less violent, with suffusion or prominence of the eyes ; generally tumid or flushed countenance, delirium, or sopor, or both, or a marked pre- dominance of either ; with symptomatic fever ; and frequently with lesion of the senses and functions of relation. Pathol. Defin.—Inflammation of either the membranes or the substance of the brain, or of both, generally with predominating lesion of either the one or the other. 147. The recent researches of anatomists and pathologists have tended to advance our knowledge of the phenomena of inflammations of this import- ant organ. The investigations of M. Ma g e n d i e , who has shown that its membranes exhale in health a limpid serum for the purposes of protect- ing the parts they surround, of facilitating the movements to which they may be subjected, and of accommodating and imparting a certain degree of superficial pressure, so that they may not suf- fer from the varying positions and states of vas- cular plethora to which they are obnoxious, have indirectly thrown considerable light on the pa- thology of the brain. Much, however, is still re- quired to be known, not only as to the further re- lations which these membranes hold to the cere- bral organs, in the performance of their healthy functions, but more particularly as respects the connection which subsists between their organic lesions and their symptomatic or functional dis- orders. 148. We know that the more internal and the most vascular of these membranes are chiefly ap- propriated to the distribution of the circulating fluid by means of the minute capillaries which it transmits to the external surface of the brain. We may thence infer that the functions, and even the organic conditions of the brain, in these situ- ations especially, will be greatly modified, or even altogether changed, by the varying condition of the circulation in this membrane. When, there- fore, it is the seat of inflammation, disease will be more or less extended to the substance of the brain ; and will more or less influence the func- tions of this organ, particularly in the parts which it supplies with blood. The membranes, how- ever, exterior to the pia mater, may be affected to a considerable extent without this latter par- ticipating much in the disorder : and here onr knowledge is both imperfect and deficient in pre- cision : for we are not enabled to state that in such cases the functions of the brain itself are undisturbed, or, if disturbed, in what manner the lesion of these exterior membranes affects this oman ; and, being imperfectly informed respect- ing all the offices of these membranes, we are less able to trace the relation between healthy function and the phenomena which inflammation of them present. Surrounded thus with difficul- ties, which the advances of science will doubt- less'diminish, are we therefore to leave the sub- ject without investigation, or relinquish the at- tempt to place in order and explain those facts which we have already obtained, and which may be made subservient to a further elucidation of the subject ? 149. In no other organ ofthe body is it so diffi- cult as in the brain, to trace the relation between demonstrable change of structure and morbid manifestations of function. This is partly ow- ing, no doubt, to the circumstance of its being a double or symmetrical organ ; lesions seated only in one half or side of the brain, when unattend- ed by absolute disorganization, not occasioning a corresponding degree of disorder as long as the same part of the other side is unaffected. Deli- rium has been conceived to be a symptom indi- cating the existence of inflammation of the mem- branes of the brain ; yet delirium is a disorder of those functions which we conceive to be perform- ed by the cerebral substance itself ; and every experienced practitioner must have observed, and numerous are the cases on record, in which in- flammation to a great extent, and all its conse- quences—us thickening, adhesions, effusions of lymph, or even of purulent matter—have been observed, and yet there had been no delirium. It is, therefore, to be inferred, that, when menin- gitis is accompanied with delirium, the disease extends more or le^s to the pia mater or parts enclosed by it. This inference, however, might lead to a conclusion which seems not well found- ed, viz. that it is impossible to distinguish menin- gitis as a disease independent of inflammation of the substance of the brain. This, doubtless, is often difficult, because both diseases frequently co-exist in different degrees, or co-ordinately ; yet still an extensive experience will show that they often exist separately : and hence the neces- sity of ascertaining what are the characters which are proper to each. In respect of diagnosis, the subject possesses interest ; and although the treat- ment in both is, in its principal points, the same, yet on some occasions it requires to be mod- ified. Brain — Inflammation of its Mem- branes. Syn. Meningitis, Paraphren- ias et Phrenitis, Auct. Var. Recent. Arach- nitis, Parent and Martinet. Cephalitis Me- ningica, Good. Phrenesie, Pinel. Menin- gite, Fr. Die Hirnhautentziindung, Ger. Brain Fever. 150. Defin. Acute pain in the head, with in- tolerance of light and sou7id ; watchfulness, de- lirium ; flushed countenance, and redness of the conjunctiva, or a heavy suffused state of the eyes ; quick pulse ; frequently spasmodic twitch- ings or convulsions, passing into somnolency, coma, and complete relaxation of the limbs. BRAIN — Inflammation of its Membranes. 229 151. We are rarely enabled to distinguish be- tween inflammation of the arachnoid membrane and that of the pia mater by the symptoms during life, I shall therefore comprise under the head of meningitis, inflammations affecting one or more ofthe membranes ofthe brain. 152. Symptoms.—As the uses ofthe cerebral membranes are not rendered sensible by manifest functions, it may be concluded that diseases of these parts may exist to a considerable extent, without any distinctive symptoms. The justness of this observation is but too frequently confirmed by experience ; for there are few practitioners who have diligently employed their opportunities of post mortem research, and have not observed appearances of inflammation, without much dis- order ofthe intellectual faculties, or ofthe move- ments of the body, having been manifested almost up to the moment of death. Such instances are not rare, particularly in persons advanced in life. More frequently, however, when the membranes are inflamed, the adjoining portions of the brain, the functions of which they are probably intend- ed to facilitate, evince some sort of disorder, par- ticularly of their usual functions. These symp- toms, although indirect, are generally similar to those of the inflammation of the cerebral sub- stance itself, and are the chief guides to lead us to the recognition of meningitis. 153. The symptoms vary according to the seat ofthe inflammation, the stage at which it has ar- rived, the severity ofthe attack, and the celerity of its progress. The disease in its usual form pre- sents three periods : 1st, that of invasion; 2d, that of fully developed inflammation ; and, 3d, that of compression. Some one of these periods, however, does not always exist, particularly when the inflammation is very general or very circum- scribed, or when it is very acute or very chronic in its progress. Meningitis affects more frequent- ly that part of the membranes which covers the convexity ofthe cerebral lobes, in adult subjects; and the portions about the base of the brain, in young children. 154. A. Acute meningitis of the convexity of the cerebral lobes is attended with violent pain, which is exasperated at intervals, and often with stupor or somnolency. It occupies various re- gions of the cranium, the frontal, occipital, synci- pital, &c.,and is augmented by motion, particu- larly by rotation of the head, which in children is often drawn backwards. In this class of patients the pain is expressed, particularly upon being roused, by a peculiar cry, which the experienced observer recognises as a diagnostic sign of the dis- ease, and after uttering which the infant sinks into a somnolent stupor, in which it grinds its teeth frequently. The functional derangements occa- sioned by meningitis are usually of a general character, although the inflammation is more fre- quently of limited extent. This is owing to both sides being attacked at the same time; cases where the meninges are inflamed on one side only being very rare. 155. a. Pain in the head is generally preceded by chills or rigors, which may be viewed as the result and indication of the formation of the dis- ease; but cases not infrequently occur, wherein the foregoing signs in a greater or less degree pre- cede the rigors even for a considerable time. The face at first is often pale; but, as the disease 20 becomes fully developed it is more frequently slightly tumid, flushed, and expressive of pain, and the eye-brows knit or contracted; the eyes are heavy or brilliant, injected and watery, gen- erally nearly shut, incapable of bearing the light, and the pupils contracted. The patient thinks he sees fire, or scintillations of light; and some- times the colours of bodies appear differently shaded. The slightest noise is insupportable, and all the senses are in a state of morbid activity. His answers are brief and quick, and there is an evident activity of mind, but as yet no delirium. His disposition, however, seems changed; and he becomes impatient, irritable, abrupt, and quick in liis manner, and his countenance is expressive of irritation and pain. The temperature of the head is now greatly increased; the pulse is fre- quent and developed; the tongue rather dry, its papillae more or less erect and distinct; thirst is complained of; the urine is scanty and high-col- oured, and the bowels are obstinately constipated; but in some instances, in children, either relaxed or irregular, and the evacuations morbid and of- fensive. From the commencement of the attack there is generally vomiting, particularly in chil- dren, which recurs at intervals, is unattended with tenderness or pain at the epigastrium, and is manifestly sympathetic of disease within the head. In adult subjects, vomiting is sometimes absent. It is not infrequently remarked, that this stage either does not occur or passes unobserved in aged persons. The patient loses suddenly his recollection, as in congestion only of the brain; but to this succeed febrile symptoms, distinguish- ing it from this latter affection. 156. b. After an indeterminate period, com- monly varying from one to three or four days, according to the intensity of the attack, violent delirium comes on, but not constantly. If the pain in the head continues, it is not complained of by the delirious patient; and the senses are no longer intolerant of their natural excitants ; the pupils commence to dilate or to contract, and strabismus supervenes ; the countenance has a convulsed appearance; the lips are drawn some- what to one or both sides; the pulse is more or less developed, sometimes irregular and trem- bling, and is rarely at this period feebler or slower than natural ; the tongue presents the same appearances already noted ; the thirst, and frequently the vomiting, still continue. The tem- perature of the head continues excessive, but oc- casionally fluctuates, whilst that of the rest of the body is often not materially augmented. 157. c. To this state succeeds more or less marked exhaustion, which should not be taken for commencing resolution of the disease. The patient ceases to scream; and the symptoms of violence subside; but to these succeed startings of the tendons, carphologia, convulsive motions, and sometimes cramps, chiefly in the upper ex tremities. The pupils are dilated, contract with difficulty on exposure to light; the eyes are rolled in their orbits, become insensible, as Well as the other senses, to the ordinary excitants ; and a complete calm takes the place of the violent delirium; the patient even not answering ques- tions put to him. He has had no sound sleep excepting a fatiguing stupor ; he is now plunged in a profound coma. The limbs are, up to this time, rigid and contracted, but soon become 230 BRAIN—Inflammation of its Substance. completely relaxed. This state is owing, gener- ally, to the effusion of serum, which has now taken place; but it sometimes may exist without increased effusion; injection and congestion of the vessels of the brain, or compression, from whatever other cause, also producing it. At this period ofthe disease the face is pale, the eyes in- expressive, dim, half open, and drawn upwards; the cheek bones prominent, the temples hollow, the nose pinched, the ears cold; the lips dry, applied closely to the teeth, which are covered with a fuliginous coating at their base; the tongue is dry, hard, and brown; deglutition difficult, the abdomen distended with flatus, and the faeces and urine voided involuntarily. The skin is either cold, or covered by a viscid sweat; the pulse is small, unequal,or irregular; the respiration slow, sometimes stertorous; the expired air is cold and foetid; and the patient dies generally in the course of a very few days, or from two to three weeks, and but rarely later. 158. These are the principal symptoms of acute meningitis of the cerebral hemispheres. They present irregular periods of exacerbation; the heat of skin and character of countenance vary- ing at different times without any evident cause. The stages of the disease are not precisely mark- ed; either of them may be wanting, and some- times they seem as if confounded with each other. When the disease terminates favourably, the symptoms subside gradually; resolution taking place, sometimes with, but as frequently without, critical phenomena. 159. According to the observations of MM. Parent, Martinet, and Rostan, when the membranes of the base of the brain, or of the ven- tricles, are the seat ofthe inflammation, the symp- toms are somewhat different. The patient then experiences less delirium, or even preserves his intelligence almost entire; his faculty of attention, and some of the other intellectual powers, being only diminished. He answers slowly, but ration- ally, to questions put to him ; somnolency is al- most continued, and coma more quickly super- venes. In other respects the symptoms are the same. Cephalalgia is complained of chiefly at the bottom and above the orbits; in general, the symptoms of irritation and excitement are less strongly pronounced than in the preceding form ofthe disease. 160. B. Chronic meningitis differs from the acute chiefly in the less intensity of the symp- toms, and slow progress ofthe disease. In many cases the functions of sense and locomotion are but slightly disturbed, and usually the intelligence is unimpaired; at least, as long as the inflamma- tion does not affect the membranes of the convex- ity ofthe hemispheres. When seated, however, in this place, according to M. Bayle, who has devoted considerable research to this subject, de- lirium frequently is also present, but it is seldom violent; sometimes it is taciturn ; and the pa- tient generally is engaged with lofty or ambitious ideas. 161. Chronic meningitis commonly succeeds to the acute form ofthe disease; but it often pre- sents the chronic characters from the commence- ment. There is generally continued headach, with slight somnolency, sluggishness, incapacity and want of desire for intellectual exertion, mo- roseness, irritability of temper, sometimes con- fusion of ideas, embaiTassment of speech, and delirium, terminating in confirmed mania or ma- niacal idiotcy. The motions of the limbs are slow, difficult, or painful, and their muscles are subject to involuntary motions and twitchings, and sometimes are not under the controul of volition, or are altogether paralytic. Vomiting and convulsions are rarely present, excepting in infants, where they are often the chief or almost only signs. In children, the peculiar knitting of the eye-brows, retraction of the angles of the mouth, whining or peevish cry, stupor, grinding of the teeth, scanty urine, obstinate costiveness, and increased heat of the head, are the chief symptoms; these being similar in kind, but much milder in degree than those accompanying the acute or sub-acute states of the disease. In many cases, both in children and adults, the functions of organic life present but few lesions of a marked description until towards the last period of dis- ease, or shortly before death. It will be perceived that many of the phenomena here stated, belong to disease of the brain,—a circumstance which must necessarily obtain; for as the membranes surround the whole of this organ, and are one of the chief media of distributing the blood-vessels to it, any disease affecting its structure, or modify- ing the quantity or properties of the fluid secre- tion furnished by these membranes, for its protec- tion, &c, must necessarily implicate the state of its functions. 162. C. The duration of meningitis necessarily varies with its intensity. In its acute form it ex- tends from three to four days to twenty-eight, and even thirty ; but more frequently from seven to fourteen days. In many cases it is difficult to assign the period of invasion; pain and somno- lency having been complained of even for days before the occurrence of chills or rigors. The disease also not infrequently supervenes on other affections, and occasionally becomes complicated with them, particularly in the course of hooping- cough, and diseases of the prima via, when its invasion may be overlooked, or with difficulty ascertained. The more chronic slates of men- ingitis have no determinate duration : they may proceed gradually and in a slight form, when, unexpectedly, from some exciting cause, or even without any evidence of such occurrence, they may assume an acute character, and terminate more or less rapidly. 163. D. The organic changes consequent upon inflammation of the cerebral membranes are ob- served chiefly in the pia mater, the arachnoid, and the reflection of the arachnoid covering the dura mater; and not infrequently, also, in the cineritious substance of the brain. These consist principally of injection and impregnation of the pia mater with blood, &c.; loss of the transpa- rency of the arachnoid; effusion of serous or sero- albuminous fluids; and the various lesions partic- ularly described in the preceding sections (§ 22— ~1.). Brain—Inflammation ofitsSubstance. Syn. Phrenesis, Phrenismus, Auct. Var Encephalitis, Enkephalins, Hildenbrand. Cephalitis, Auct. Var. Recent. Encephalite, Bouillaud and other French Pathologists. Cerebrite, Foville. Cephalitis Profunda, Good. Gehii-nentzundung, Ger. 164. Defin. Pain ofthehead; vertigo; altered BRAIN — Inflammation of its Substance. 231 sensibility; spasms, or contractions, of one or more limbs ; excited or deranged functions of sense and intellectual power; rapidly terminating in coma. 165. I have stated that meningitis manifests itself to our senses chiefly by the lesion of the cerebral functions ; and that this is occasioned in two ways, viz. by deranging and impeding the functions of the brain, which these membranes are intended to facilitate; and by imparting the inflammatory action to those parts of the brain contiguous to them. But although the relative connection of parts thus necessarily increases the difficulty of distinguishing the symptoms proper to the membranes, or to the brain itself, still there are certain signs which enable us to infer the degree to which either may be separately affected. We shall see in the sequel, that, in cerebritis, the organs of voluntary motion exhibit frequently morbid phenomena which are generally limited in extent; whilst we have seen, in meningitis, these organs are affected generally, and seldom or ever partially, excepting when complicated with inflammation of some portion of the brain ; and if, in cerebritis, all the voluntary actions are affected, the inflammation has commenced in the membranes, and extended itself to the substance of the brain,—the disease existing as meningitis and cerebritis conjoined, which is, perhaps, its most common state, and in which I shall presently consider it. 166. Symptoms. — A. The more immediate functional derangements. The functions of tho brain consisting of sensation, volition, instinctive desires, intelligence, and moral sentiments, it is evident that the phenomena of the disease should be sought after hi this series of manifestations; and that they will vary, in respect of their par- ticular states, their intensity, and progress, ac- cording to the seat, the nature, and extent of the organic change. 167. a. When cerebritis is general, it often presents the same functional disturbances, and the same progress and stages, as meningitis : it is, indeed, very probable that both diseases co-exist, and that the inflammation commences in the pia mater. However, when the whole cerebral mass is inflamed, coma, with relaxation of all the limbs, takes place much earlier than in meningitis; and the disease developes itself with extreme rapidity; the symptoms of vascular excitement scarcely showing themselves, or, at least, for a very short time ; and being frequently altogether absent. This difference is readily explained, when we con- sider that, in meningitis, the brain being only secondarily and slightly affected, it may still ex- ercise its functions, although in a deranged man- ner; whilst in general cerebritis, the change being extensive, its functions must necessarily be sus- pended. The patient, after a rigor, which ushers .in this as well as the majority of other inflam- mations, sometimes loses recollection; but he has generally experienced other symptoms previously, such as obstinate pain of the head, twitchings, pricking sensations, slight numbness or diminu- tion of the sensibility, with painful muscular action, vertigo, sudden want of recollection, and tinnitus aurium. Sometimes the sensibility is morbidly increased at this stage, as well as the functions of sense; the intellects are active, or excited; and there is watchfulness, with other analogous symptoms, for a longer or shorter period before the patient is seized with rigors and insensibility. 168. b. These precursory symptoms M. Rostan considers as the result of an incipient disorder, which he conceives to be local congestion, and that inflammation has not then taken place; but they are, more obviously, signs of an early period of inflammatory action. These symptoms are frequently accompanied with general signs of plethora or determination of blood to the head: the pulse, particularly of the carotids, is hard, or full and developed ; the countenance is injected; the skin hot, &c. The same precursory signs are likewise observed in softening of the brain; but in this affection the pulse is not augmented in frequency or fulness, the skin is cold and pale, and the countenance pale or shrunk. The symp- toms now described indicate, at least, that morbid action has commenced in the brain; and that it is not so extensive or intense as not to subside under judicious treatment. But when the pa- tient has had rigors, the functional disturbance, especially of locomotion, is particularly marked : then ensue clonic or tonic spasms of the muscles, such as starlings of the tendons, carphologia, convulsions, cramps, rigid contraction of the limbs, &c At a more advanced period, par- ticularly when effusion supervenes, paralysis or relaxation, and loss of sensibility of a limb or limbs, take place. 169. c. When cerebritis is general (which is never the case without the pia mater beir.g \7t- flamed), these symptoms affect all the limbs simultaneously; when local, only some of them, according to the seat of inflammation. Spasms, convulsions, or paralysis, affect also the muscles of the face; there is a falling down of the upper eyelid ; the eyelids are shut and contracted ; the commissures of the lips are drawn to one side, either by their natural tonicity, when the antago- nist muscles are paralysed, or from a morbidly increased action. Sometimes this exists on both sides, producing retraction of the angles of the mouth. Very frequently the muscles and limbs are remarkably painful; so that, when attempts are made to move them, or to straighten those that are contracted, or upon attempting to move himself, the patient screams out. 170. d. In partial cerebritis, the action of the muscles and the sensibility of the surface are idso partially, but not permanently, affected; some parts being less disordered, whilst the affection extends to others; or they all become more severely and permanently diseased ; the spastic contractions, which existed at first owing to inflammatory irri- tation, giving place to paralysis, in consequence of pressure or disorganization. The intellectual faculties are also frequently disturbed. The patient's answers are abrupt, rapid, sometimes incoherent, and at other times made very slowly. When merely one hemisphere is affected, it has been supposed that the functions of the other will proceed so as to prevent the appearance of much disturbance ofthe mental faculties; but this may or may not be the case; and, at least, can only occasionally obtain. The mental disturbance, which is extremely various in its forms and states, according to the part of the brain affected, exists only during the first days of the disease, and w soon displaced by coma. 232 BRAIN — Inflammation of the—Symptoms. 171. e. At the commencement, particularly when cerebritis is general, or affects the periphery or more superficial parts of the brain, as in me- ningitis, or meningitis complicated with superficial cerebritis, the functions of the senses are morbidly increased, the least light or noise, or the slightest touch, being insupportable; but when the disease is seated in the centre of the brain, where the senses transmit their impressions, there is either perversion, or complete loss, of these functions. The pupils are then frequently dilated and insen- sible ; the eyes unaffected by light, the ear by sounds; and the other senses are similarly dis- turbed; the patient is either watchful, or is op- pressed by a somnolency intermediate between sleeping and waking; and numbness, with twitch- ings, or local convulsions, are generally observed. 172. In the course of a period, varying from one to three or four days, or sometimes earlier, and occasionally later, the symptoms are changed, owing to the local affection having advanced to disorganization. At this period, copious effusion of serum often takes place, occasioning symptoms of compression. The spasms and convulsions are replaced by relaxation and immobility; and the senses are paralysed, not only on the side oppo- site to the cerebral lesion, but on both sides si- multaneously, owing to the healthy parts of the brain being compressed by the effused serum, or by the tumefaction of the parts inflamed. Sensibi- jity diminishes rapidly, and is at last abolished; the intellects are obscured, and at last overwhelmed, and the patient becomes profoundly comatose; or, in the less acute or chronic cases, hemiplegic, and sometimes ultimately apoplectic, or epileptic. 173. B. The mediate symptoms. — During the first days of the disease,.the countenance is full and coloured ; the eyes brilliant and animated, their expression unusual; the temporal arteries, as well as the carotids, beat strongly; there is no appetite; the tongue is white, loaded, red at its margins and point, and the papilla; developed; there are nausea and vomiting; the bowels are costive; but occasionally in children there is diar- rhoea from the commencement, and the evacu- ations are morbid and offensive; the skin is warm, the pulse strong and frequent, and the respiration accelerated. At a later period, a very manifest change ensues : the countenance is expressive of pain, irritation, and chagrin; the features begin to sink, and become pale; the eyes dull and half closed; and thirst is no longer complained of; deglutition is difficult, or cannot be accomplished; vomiting is produced with difficulty; the abdomen is distended with flatus; and the fasces are passed involuntarily, as well as the urine, which some- times accumulates in the bladder from paralysis of this orgmi; the skin becomes cold, or covered by clammy sweat; the pulse is unequal, irregular, or variable; the respiration laboured, or stertorous; and the patient sinks. In rare cases, at this stage of the disease, the symptoms diminish, and the functions gradually assume their natural states, either with or without the occurrence of phenom- ena which may be regarded critical. The alter- ations of structure produced by cerebritis are fully described in preceding sections of this article (§ 48, et seq.). Brain—Inflammation of the Mem- branes and Substance of the. Syn. Phrenitis (from ^i,, the mind); Encepha- litis, Cephalitis (from xKfa/.i;, the head) Frank and Hildenbrand. Phrinesie, Enciphalite, Fr. Hirnentziindung, Ger. 174. Defin. Violent pain in the head; pro- minent suffused eyes; flushed countenance; violent delirium, followed by profound sopor. 175. Having described inflammation affecting chiefly either the membranes, or the substance of the brain, I now proceed to consider inflamma- tion attacking these structures simultaneously, or rapidly extending from the one to the other, chiefly from the former to the latter. This is cer- tainly the more common form in which inflam- mation seated within the cranium manifests itself in adults, particularly in hot countries, and in temperate climates during hot seasons. In chil- dren, however, a more or less evident limitation of the inflammatory action to either the mem- branes, or the cerebral substance, especially the former, is frequently perceived; and the same re- mark may be extended to aged persons, in whom the substance of the brain is more liable to be affected, chiefly in a sub-acute or chronic form. That the division which I have made of inflam- mations of the brain, is founded in truth and that their diagnosis may be established in prac- tice by a judicious and experienced physician, I have had numerous opportunities of proving at the Infirmary for Children, where the cases admitted with inflammations seated within the head have been entered as cases of meningitis, cerebritis, or encephalitis, as the membranes, the substance of the brain, or both, respectively, were considered chiefly affected. 176. It may be supposed, that the distinctions argued for, granting their accuracy, tend to little practical advantage. This is, however, a very serious mistake; and I cannot more fully demon- strate it, than by the following fact: —About ten years since, I was requested to see a child, at- tended by an able and scientific practitioner, who considered the case as meningitis, which had terminated in effusion; or, in other words, of acute hydrocephalus in its advanced stage, and perfectly beyond the reach of art. After an atten- tive consideration of its history and existing state, I expressed the opinion, that the disease was in- flammation, chiefly affecting the substance of the brain, and that a decided treatment founded on these views might still be successful. Leeches applied behind the ears, and around the occiput, u ith the means which will be hereafter detailed, succeeded in restoring the child to health in a few days. tSince this instance, I have witnessed similar mistakes. The diagnosis, prognosis, and the treatment adopted in these cases proceeded on the important fact already stated (§ 167.), that cerebritis will, owing to the turgescence of the inflamed organ, give rise at a very early stage of the disease to the most profound coma, relaxation of the limbs, and many of the symptoms occasioned by effusion of serum ; wliilst the greater temperature of the head, and strength of the pulsation of the carotids in the former, will often, independently of other signs connected with the history of the case, evince its real nature. 177. Seat. — In the greater number of cases, inflammation commences in the pia mater, and extends itself to the arachnoid on one side, and to the cortical substance of the brain on the other- BRAIN — Inflammation of the — Causes. 233 and not infrequently also to the arachnoid cover- ing the dura mater, and the deep-seated structures of the brain. It is also very probable, that more than one of these different structures may be nearly simultaneously affected. It may, how- ever, originate differently when it arises from ex- ternal injury; as in the dura mater, the substance of the brain itself, or the arachnoid. 178. I. Symptoms.—A. Premonitory. Ence- phalitis generally commences with a sense of heat and fulness in the head; frightful dreams, and unquiet sleep; forgetfulness; confusion of ideas; dimness of sight; vertigo; turgidity of the face and eyes; and moroseness of temper. These symptoms generally precede the occurrence of chills or rigors, and are entirely absent when the disease proceeds from external injuries. In chil- dren, unusual somnolency, or wakefulness; start- ings in sleep, or fretfulness; aversion from sudden or quick motion; dryness ofthe mouth and nostrils; and not infrequently a voracious appetite; are the chief precursory symptoms. 179. B. The invasion, or first stage of ence- phalitis, is indicated by severe chills or rigors; to which succeed a burning heat ofthe head; urgent thirst; sometimes, even thus early, an unnatural absence of thirst, and violent delirium; jactitation ofthe body; intolerance of light; fixed, pulsating, heavy, compressing, and most severe pain of the head, alternating frequently with stupor. Febrile heat rapidly increases; and the head becomes more turgid, and hotter; the eyes more promi- nent, suffused, watery, and intolerant of light; the pupils are contracted ; the eyelids are gen- erally shut, or imperfectly open; the eyebrows are knit; and the countenance is threatening and fierce. Hearing is quicker, is attended with ring- ing in the ears, and intolerance of sound. Epis- taxis sometimes occurs, generally to a small ex- tent, and with only transitory benefit. Insomnia, and delirium of various forms — morose, taciturn, furious, &c. — supervene; and, in proportion as the cerebral organs are excited, those viscera which are supplied with the ganglial nerves are rendered torpid, the patient being insensible to the wants of the digestive organs. 180. C. The second, or advanced stage, is ge- nerally characterised by a marked diminution of the sensibility, which was in the preceding period j morbidly increased. The pulse, which was at j first frequent, hard, and full, becomes slower, fuller, and softer; and, in some cases, quicker, smaller, or harder. The skin is dry; the urine scanty, and high coloured ; the tongue is dry, and loaded at the root; the bowels constipated. In some cases, particularly those in which the cerebral substance is early and generally in- flamed and turgid, instead of phrenetic delirium, an apoplectic sopor, often preceded by convul- sions, quickly supervenes ; with a slow pulse; stertorous, slow, or laborious breathing; turgid or bloated countenance; stortings of the tendons; in- voluntary evacuations; torpor of the senses; and flaccidity of the limbs. In those cases in which delirium is present, and the pulse quick and hard, a similar state of coma to that now men- tioned takes place sooner or later, if not averted by medical aid. In the one, the first stage is short and indistinctly marked; in the other, it is long, and often continuing the greatest part of the whole duration of the disease; the second 20* stage sometimes appearing suddenly, and ter- minating rapidly. In both these states of the disease, the difficulty of swallowing is great, so that fluids are sometimes regurgitated by the nose; and when the substance of the brain is chiefly affected, deglutition is often nearly, or altogether abolished in the most intense cases. In this stage, the pupil becomes at first dilated, and occasionally again contracted; the patient, in some cases, squints, or has double vision; his speech is often much affected; and his mouth is drawn to one side. Deafness also comes on, or increases; and the sopor, or coma, is more pro- found— most probably owing either to incipient effhsion of fluid, or to greater turgidity of the capillaries and veins, or to both these combined, in a part or the whole of the encephalon. The comatose symptoms appear early or late, accord- ing to the intensity of the disease, the extent to which the cerebral structure is affected, and the tone and energy of system. They sometimes partially subside, again recur, or alternate with convulsions. As the disease advances to an unfavourable termination, the pulse becomes re- markably quick, irregular, or intermittent. 181. D. Duration.—Encephalitis usually reaches its acme about the third or fourth day. It then continues in full strength for several days, exhibit- ing slight remissions and exacerbations, and sim- ulating continued fevers. In favourable cases, a change is sometimes observed on the fifth, seventh, or some other critical day, unless a fatal termina- tion occur; and is generally attended with either copious perspiration, or haemorrhage from the nose, free evacuations from the bowels, or a discharge of urine depositing a copious sediment. The disease may assume a sub-acute or a chronic form, presenting a diversity of symptoms, espe- cially in its chronic state, according to the partic- ular part of the brain affected; or it may proceed in a very slow, slight, and insidious manner, and escape detection until a dangerous or fatal change has taken place. The more chronic states may follow an imperfectly cured acute attack; and the latter may suddenly supervene on the former. 182. II. Causes.—d. Predisposing. The san- guineous and nervous temperaments; the epochs of infancy, childhood, and youth—particularly to meningitis ; the period of dentition; advanced age — especially to cerebritis in a sub-acute or chronic form; the male sex; a large head and short neck; children of scrofulous parents, and those who evince precocious talent or acquire- ments; persons subject to perspirations or erup- tions on the head; early or habitual exertions of the mental powers; the indulgence of the more active passions and affections; encouragement of vindictive feelings; anger; continued watchings; venereal excesses; the use of spirits, and narcotics, as opium, tobacco, &c; a too warm state of the head; suppression of epistaxis, haemorrhoids, or of any other accustomed secretion or evacuation; the neglect of sanguineous depletion after tlie habit has been established ; the healing up of chronic ulcers and eruptions; and other disorders of the brain,—are most frequently the predispos- ing circumstances and causes of the disease. 183. B. The exciting causes.—a. Those which act more directly on the encephalon, are blows, fractures, falls, counter-strokes or concussions of the head, all which may not be followed, for 234 BRAIN — Inflammation of the — Diagnosis. many days, by any evident symptoms; whirling children in the air, or tossing them in order to quiet them, or rocking them rudely in cradles; the improper use of narcotics and stimulants in order to quiet them; the action of the sun's rays; protracted study; excessive joy; violent fits of anger, excessive desire, jealousy, and all the ex- citing passions; unusual exertion or irritation of the senses of sight and hearing; exostoses on the inner table of the skull; and the absorption of purulent or morbid matters into the circulation. 6. The causes which act more remotely or indi- rectly, are the diseases with which I have stated encephalitis to be sometimes complicated (§ 186.); nervous or bilious headachs; all painful affections; mania; inflammations of the ear; disorders of the stomach, diaphragm, liver, and bowels; affections of the sexual organs; ingurgitation and intoxica- tion; the exanthemata, particularly when imper- fectly developed on the external surface, or upon the disappearance of the eruption; the metastasis of gout, rheumatism, and erysipelas; suppressed haemorrhages and evacuations, particularly the menses and the urinary secretion; the accumula- tion of sordes and morbid secretions in the prima via and gall bladder; the ingestion of irritating and narcotic poisons ; indulging in cold punch (Frank); violent fits of coughing; long exposure to great cold; and, according to Goelis, the two free use of belladonna, and other narcotics, in the cure of hooping-cough. 184. III. Diagnosis. — A. Characteristic symptoms, a. Pain is an early sign, but the patient often ceases to complain of it very soon, particularly if the cerebral substance be chiefly inflamed; when it is also gravative, and attended with stupor'from the commencement. It is most acute when the membranes are affected, and is always aggravated by shaking tlie head, and the erect position. When the disease supervenes in the progress of fevers and bronchial affections, pain may not be complained of, owing to the impure state of the blood having blunted the sen- sibility, b. Watchfulness and sleep.—Insomnia is generally present during the first days, when the membranes are affected; and, in children, starting from sleep, and screaming. Heaviness, somno- lency, sopor, or even coma, often preceded by convulsions, are early present when the substance of the organ is the chief seat, or the membranes extensively affected; and supervene early, but without convulsions, when the disease occurs in the course of fevers and bronchial affections; but a refreshing sleep is never enjoyed, unless after a favourable change, c. The senses, particularly sight, hearing and touch, are all morbidly active in the first stage, especially when the meninges are inflamed; but they are nearly abolished at this period, when the cerebral substance is chiefly affected. The eye often indicates mental oppres- sion, even when bright and staring. The sensi- bility of the surface is unnaturally increased in meningitis or superficial cerebritis, but is dimin- ished when the substance of the brain is deeply affected, and in the advanced stage, when the membranes generally are inflamed. In partial cerebritis, the sensibility of a limb, or part only, is often lost, and it may be conjoined with spastic rigidity, or paralysis, of the same or of another part. d. The intellectual and moral faculties are more or less disordered; they are unusually ex- cited, or violently deranged, early in the disease; but sopor frequently supervenes without being preceded by this state, when the cerebral structure is inflamed. Reverie or wandering of the mind during night, is the least important form of mental disturbance, indicating a slight affection of the pia mater, extending to the cineritious substance; delirium through the day, and watchfulness in the night, are the most dangerous, and attend a severe affection of the membranes, d. The respiration is often quicker in proportion to the pulse in the first stage, and slower in the second; and in the torpid or somnolent state, when the substance of the organ seems chiefly to be affected, is often attended by deep-drawn sighs, e. The digestive organs are much affected, particularly in children. There are nausea and vomiting, especially at the commencement, and torpor of the bowels. As the disease advances, however, the bowels often become free, or even relaxed. /. The muscles and limbs are more or less pained, contracted, convulsed, particularly in the first stage, and when the cerebral structure is inflamed. The convulsions are often general or severe, on the supervention of the disease, in young subjects. They may be soon followed by coma, which may pass oft", and the convulsions again recur, and terminate life. When the cerebral substance is partially affected, the spasms and contractions may be confined to one or more limbs, whilst the rest are relaxed; or complete paralysis may ensue. In the last stage, muscular power is gen- erally lost, and the limbs are flaccid, g. The pulse is extremely variable. At first it is not re- markably frequent; but it often becomes slower, and again quicker than ever, and at the same time weak, small, irregular, or intermittent. It may be at one time either slow or frequent, and in a few minutes the reverse; but it is never natural in respect of fulness, regularity, or strength. It is generally stronger and fuller in the carotids than elsewhere; and in this situation it ought always to be felt. 185. B. Encephalitis may be mistaken for other diseases; but if attention be paid to the history of the case, and the descriptions now given, this can scarcely happen. It may, however, be con- founded with fevers, apoplexy, delirium tremens, mania, and nervous headachs. a. In fevers, the disturbance of the cerebral functions, when pro- minently marked, generally occurs in their pro- gress, as a complication or consecutive affection. The pulse is always more uniformly frequent and regular than in encephiditis; spasms, convulsions, or paralysis, seldom occur, unless the brain be- comes inflamed; respiration is not laborious, nor deglutition difficult ; nor are the eyes, coun- tenance, and speech affected, as in encephalitis. In idiopathic fever, the muscular power is de- pressed from the commencement, but is neither generally nor partially affected by spasms, con- tractions, or paralysis; and the stomach is less re- markably disordered. There is not observed that falling of the pulse from its former frequency, afterwards followed by great rapidity, trembling, or irregularity, which take place in encephalitis. In fever, the general febrile symptoms are the earliest and most apparent disease; in encephalitis, the functions of the brain, of sense, and of the organs of volition, are prominently and early dis- ordered, and the febrile symptoms much less re- BRAIN — Inflammation of the—Termination. 235 markable in proportion to the severity of the cere- bral disease. When the coma is profound in en- cephalitis, the heat of the whole body, excepting the head, is either not augmented, or depressed. The delirium in fevers also occurs at a remoter period, and is much less violent in its character, than in encephalitis, b. The disturbance of the organic, and particularly the digestive functions, the presence of fever, and the acute character of the disease, distinguish it from maniacal insanity. c. The same symptoms, with the frequent addition of delirium, of disturbance of the senses and gen- eral sensibility, spasms or convulsions, somnolen- cy, sopor, and paralysis, preclude the possibility of confounding it with bilious or nervous headachs. d. Somnolency, sopor, convulsions, and slowness of the pulse, distinguish it from delirium tremens, in which the spectral illusions, the remarkable tremors, timidity; copious, clammy, foetid perspir- ations; and the specific cause of the affection; sufficiently characterise the latter, when occurring in a distinct and uncomplicated form. e. The spasmodic or convulsive symptoms, antecedent delirium, the mode of attack, and progress of dis- ease; the absence of paralysis, or its slower ac- cession when the brain is inflamed, distinguish encephalitis from apoplexy, in which the invasion is sudden, or more rapid, and the paralysis a simultaneous or consecutive symptom. The rela- tion, however, between apoplexy and encephalitis is often intimate, particularly in cases of partial inflammation, or inflammatory softening, of the substance of the organ. 186. IV. States, Forms, and Complica- tions.— Besides the more or less perfect limita- tion of inflammation to either the membranes or the substance ofthe encephalon, other states may present themselves deserving of remark, a. En- cephalitis may result from the metastasis of gout, rheumatism, and erysipelas, or it may arise from the extension of the last-named disease to the brain. In these cases the membranes are chiefly affected; stupor and coma come on early, and are attended with general flaccidity of the limbs, subsultus tendinum, involuntary evacuations, and slowness of pulse; but local cramps, convulsions, or paralysis, are seldom present. 6. The disease may be also consecutive of other diseases, as of in- flammation ofthe ears (§58.), of the bones of the head or pericranium. In these cases it is first ex- tended to the membranes, and afterwards }o the substance of the organ; occasioning contraction, spasms, or paralysis of one or more limbs, or museles of the face, terminating in coma, or al- ternating with stupor and general convulsions. It may also be consecutive of severe ophthalmia, inflammation of the parotids or testes, of the kid- neys, of inflammation of the mucous surface of the bowels, especially in infants, and of the dis- eases of the lungs, c. Encephalitis may likewise supervene on, and be complicated with, the ad- vanced stages of continued and remittent fe- vers, bronchial and pulmonary affections, hooping cough, exanthematous fevers, particularly scarlet fever, and small pox. In all these cases the membranes and superficial parts of the brain are principally affected, generally in a more or less diffused manner, occasioning first delirium, gene- ral convulsions in young children, great pain in the limbs, sensibility and soreness of the surface, followed more or less rapidly by sopor, coma; more rarely by local spasms and paralysis, in- voluntary evacuations, rapid irregular pulse, &c. The complication with typhoid, continued and exanthematous fevers, especially those of certain epidemic constitutions, is extremely frequent and important; and have given occasion for the opin- ions entertained by Willis, Chirac, Werl- hof, Reil, Ploucquet, Clutterbuck, and Marcus, respecting the proximate cause of fe- vers. To this complication also Torti attributes the malignancy occasionally assumed by the re- mittents and intermittents of" the south of Europe. When it thus supervenes on fevers and bronchial diseases, the symptoms are often more insidious, and of a less violent character, although the dis- ease is equally rapid and disorganizing. This is probably owing to the depressed state of the vital manifestations, particularly of the organic nerves and vascular system. Owing also to this circum- stance, encephalitis, when thus complicated, re- quires a modified and less depletory treatment. Inflammation of the brain is also not infrequent after apoplectic seizures, particularly in the part of the organ surrounding extravasated blood. In these cases the disease generally occurs from five or six to ten or twelve days after the attack, and is attended with many of the symptoms of partial encephalitis, particularly spasms, paralysis, deli- rium, &c. 187. V. Terminations and Prognosis.— a. This is always a dangerous disease, and there- fore a very cautious prognosis ought to be given. The termination of encephalitis in health occurs most frequently in persons of a sound constitution, and who have no hereditary disposition to the diseases affecting the encephalon. This change often occurs on critical days, when it is generally attended by some favourable occurrence, as a co- pious discharge from the bowels; a genial and universal perspiration; a copious discharge of urine, depositing a sediment; haemorrhage from the nose, or the presence of the menses; a more natural state of the pulse and respiration; a quiet undis- turbed sleep, distinct from the oppressive somno- lency or sopor which is one of the chief signs of the severity of the disease; a more moist, natural, and clean state ofthe tongue and gums; a decline of the temperature of the head, and of all the other symptoms. 188. b. A fatal termination may take place, 1st, In the inflammatory stage, owing to the very general extension of the disease to the membranes and substance of the organ; the pressure and in- terrupted circulation arising from the turgescence of the inflamed organ annihilating its functions (§ 48.167.): 2d, In a further advanced stage, from an effusion of serum, sero-albuminous fluid, or the deposition of false membranes (§ 21—28.): 3d, In the less acute cases, and at a still more advanced period, from suppuration or inflammatory soften- ing of a portion ofthe brain (§50—76.): and, 4th, This issue may proceed from any two, or the whole, of these changes being conjoined in the same case. The indications of an unfavourable termination are, the persistance of the urgent symp- toms after treatment; violent delirium, watchful- ness, and restlessness; profound lethargy or coma, or the alternation of these states; violent general convulsions, followed by coma, or alternating with it; a morose delirium; retraction ofthe head; severe pains of the limbs, followed by cramps, 236 BRAIN — Inflammation of the — Treatment. contractions, or palsy; haemorrhage from the ears; difficulty or impossibility of deglutition; strabismus, or double vision; loss of speech; slowness of pulse, followed by a sudden increase of frequency; a trembling or irregularity of pulse; obstinate vom- iting, particularly of a greenish fluid; singultus, continued or recurrent; the rapid healing of chro- nic ulcers; the appearance of the disease in the course of other maladies, particularly pneumonia, the exanthemata, and after apoplexy, and in the scrofulous habit, or in persons having an heredi- tary disposition to cerebral affections, or who have been recently affected by other maladies. 189. c. The disease may pass into an obscurely chronic form, which, together with the effects produced by its antecedent state, may give rise to paralysis, epilepsy, various states of mania or mental disturbance, idiotcy, &c. In these cases, many of the chronic changes which have been described as occasionally found in either the membranes or the substance ofthe brain, particu- larly those which affect parts only of these struc- tures, have taken place, as softening, abscess, in- duration, tumours, ossific formations, &c. (§ 50. 71. 102, &c). 190. d. When encephalitis arises from rheu- matism (Encephalitis Rheumatica, J. Frank), the membranes, particularly the dura and arach- noid, are chiefly affected; and the danger has been considered, upon the whole, less than in other states or relations of the disease. The dis- position, however, to effusion, and to many ofthe chronic organic changes described as frequently found in the membranes, is great. It often as- sumes a sub-acute or chronic form, and is usually attended with great distress, but is without deliri- um. The gouty form of encephalitis generally is observed in older persons than the rheumatic; is accompanied with much disorder ofthe stomach, liver, and bowels, and with deficient vital power; and is hence a more dangerous state of the dis- ease. The same remark is applicable to its oc- currence from the extension or suppression of erysipelas. In these, the re-appearance of rheu- matism or gout in a joint or extremity; the erup- tion of the erysipelatous inflammation in any part of the surface, even in the face (J. P. Frank); the supervention of diarrhoea, the haemorrhoidal flux, or any other discharge; are favourable cir- cumstances. Encephalitis, occurring after the disappearance of the eruption in the exanthemata, or during the course of typhoid or epidemic fe- vers, or pulmonary diseases, or after attacks of apoplexy, paralysis, epilepsy, or mania, is much more dangerous than when appearing in a primary form, owing, 1st, to the depression of the vital and nervous powers; 2d, to the vitiated state of the circulating fluids; and, 3d, to the silent and in- sidious manner in which the disease of the brain often advances to disorganization in these compli- cations. According to Hufeland, encephalitis, supervening on the disappearance of the variolous eruption, is generally fatal. The alterations of structure occasioned by encephalitis are fully de- scribed in preceding sections of this article (§11, et seq.). 191. VI. Treatment.—A. Of the idiopathic and simple encephalitis. It must be evident that the treatment should be the same, whether the membranes or the substance of the brain he chief- ly, or entirely, the seat of disease. The causes, the age, the habit of body, and apparent state of vital power, are circumstances which ought to be duly considered when adopting the means of cure, or determining upon the extent to which they ought to be carried, a. The antiphlogistic treatment, in all its departments, must be rigor- ously enforced. Some discretion is, however, required as to the extent to which it should be carried, and the direction, choice, and adaptation of the individual means of which it consists. In ordinary cases, bleeding from the jugular vein; cupping between the shoulders, nape of the neck, behind the ears, or occiput; leeches applied in those latter situations, and bleeding from the arm, are upon the whole the preferable modes. Ar- teriotomy I consider to be attended with no ad- vantages; and in this I am supported by the opin- ion of Hildenbrand and others; but bleeding from the feet, from the haemorrhoidal vessels, and from the groins and insides of the thighs, are undoubtedly preferable when the disease arises from metastasis or the interruption of discharges, especially when conjoined with the treatment I shall presently describe as appropriate to those states. Hildenbrand, and several other Ger- man physicians, recommend the application of leeches to the insides of the nostrils, when the pa- tient has been subject to epistaxis, or if a dispo- sition to critical epistaxis be evinced. As to the extent to which depletion should be carried, no precise opinion can be given. It should be regu- lated according to the circumstances of the case, and its effects upon the circulation, and be con- ducted in the manner I have recommended in the article on the Pathology of the Blood (§ 64.). It ought never to be relied on alone : other means should be simultaneously, or subsequently, em- ployed, with the view of diminishing local and general action, and thereby preventing the re- moval of more blood than may be indispensable. 192. b. The hair should be removed from the head as soon as possible, and a stream of cold water poured upon it from time to time, or every second or third hour, until the temperature be re- duced to the natural standard; and, as morbid heat soon returns, cold epithems, or evaporating lotions, or even pounded ice enclosed in a blad- der, should be constantly applied in the intervals between the cold affusions, and the head be kept elevated, and placed upon a thick oil-skin, or, what is still better, upon a piece of common painted floor-cloth, as long as increased action continues. Cold applications or affusions may, however, be injurious if too long persisted in. They ought never to be continued after the tem- perature is depressed to the natural standard, or a little below it, particularly if sopor or coma be present; and as soon as the heat returns, they should be again resumed. Simultaneously with the affusion, the feet and legs should be immersed in warm water, or in warm water made irritating by means of salt and mustard, and the saphena vein be opened. In some cases, particularly when suppression of the menstrual or hsemor- rhoidal discharge has preceded the attack, the semicupium, or hip-bath, may be substituted for pediluvia. 193. c. The immediate exhibition of cathartics should not be neglected. From ten to twenty grains of calomel may be given at once, and, three or four hours afterwards, an active purgative BRALN—Inflammation of the—Treatment. 237 draught, which shouid be followed by cathartic enemata, particularly the En. Calliart. and the En. Terebinth. (F. 141, and 150.). By these, or similar means, a copious action of the bowels should be procured and continued. With this latter intention, pills calculated to promote the abdominal secretions may be given each night, a purgative draught the following morning, and an enema subsequently, if it be necessary. Calomel combined with digitalis, or with antimony, should be prescribed in full and frequent doses, in addi- tion to the above, so as to change the state of morbid action, particularly when the membranes are chiefly affected. The following, or similar medicines, may be used, and their effects carefully watched:— No. 55. R Calomel, gr. iij.—x.; Pulv. Jacobi Veri gr. iij.; Pulv. DigitaiU (vel Pulv. Colchici) gr. j.—ij.; Syrup. Simp. q. s. M. Fiant Pilulae ij. vel iij. tertia, quinta, vel lexla quaque honi porrigenda?. No. 5o. H Hydrarg. Subniur. gr. iij.—vj.; Pulv. Jacobi Vol i gr. iij.—vj. ; Extr. Colocynth. Couip. gr. vj.; Syrup. Simp. q. s. Fiant Pilula? iij. hora somni suuiantur. No. 57. R Infus. Sennae Comp. * jss. -, Magnes. Sul- phatis ?, ij. (vel Potassw Tart. ^ jss.) ; Vini Antimon. Tart. --; ss.; Tinct. Jalap. ^ j.; Tinct. Cardam. Co. 5 j. M. Fiat Ilauslus, primo mane sumendus. 194. d. In addition to these means, the fre- quent exhibition of refrigerants and saline medi- cines, especially those consisting of the liquor ammon. acet., potasse nil., antimonials, &c, will be of much service. The preparations of anti- mony, judiciously exhibited, have a remarkable influence in diminishing determination of blood to, and inflammatory action in, the brain; and I believe that the effect will be more decidedly beneficial, if their operation as an emetic be carefully avoided. Form. 24. 359. 406. 436. 456. and 854. are of the above description, and, as well as others of a refrigerant and diaphoretic nature, may be employed, in small or moderate, and frequently repeated doses. I may state, as the result of considerable experience, that I have found the saline refrigerants and antimonials most beneficial during the early stage of the disease, and where the membranes were chiefly inflamed. In the stage of coma, or when the substance of the brain itself is affected, and the pulse quick, weak, small, trembling, or irregular, antimonials are not admissible; the preparations of camphor, with liquor ammon. acet. and spirit. ether, nit., being preferable. (See F. 405. 436. 441.) 195. e. Sedative and diuretic medicines, parti- cularly colchicum and digitalis, combined with the liquor ammonie acet. and moderate doses of camphor (F. 395. 400. 514.), are extremely useful in the early stage of the disease, after de- pletion and the free evacuation of the bowels. In the advanced stage, however, much less ad- vantage will be derived from them. After blood- letting has been carried as far as may be thought judicious, and if much restlessness and jactitation be present, great advantage will be derived from the exhibition of a moderate dose of camphor, hyoscyamus, and James's powder, in thi3 or any other appropriate form :— No. 58. R Pulv. Jacobi Veri gr. iij.—v. 5 Camphorae rasa-, gr. ij.—iv.; Extr. Hyo9cyami gr. iv.—vij.; Syr. Pa- pav. q. s. ut fiant Pilulae iij. statim sumenda; et. h. 9. re- pctend. No. 59. R Mist. Camphorae 5 j. ; Liq. Ammon. Acet. ~ ij.; Spirit, ilither. Nit. 3 ss.; Tinct. Colchici Semin. TT1 xij.—xx.; Syrup. Papaveris 3 j. Fiat Haustus, tertiis vel quartis horis capiendus. | 196. /. Derivatives and counter-irritants are useful in many cases, when judiciously prescribed. In the early stage of the disease, and whilst great irritability or delirium is present, they are often prejudicial, excepting simple pediluvia, the semi- cupium and hip-bath, employed simultaneously with cold applications to the head. Great mis- chief has arisen from ordering blisters and mus- tard poultices too early in inflammations, but more particularly in encephalitis, when, instead of deriving the circulation from the inflamed part, they excite the nervous and vascular systems ge- ' nerally, and thus react upon the disease. It is j chiefly in the latter stage, when sopor or coma is present, that benefit is derived from them. Some difference of opinion has existed as to the part to which they —■ particularly blisters — ought to be applied. ' If the coma be profound, some writers have advocated the application of blisters directly to the scalp. Without denying the possibility of circumstances arising to justify this practice, I believe that they will seldom occur. The most profound sopor, weak action of the carotids, a not remarkably frequent pulse, and a temperature of the head much and permanently below the natural standard, would only induce me to apply blisters to the scalp. When derivation can be attempted with safety,—when sopor is present, and morbid sensibility and irritability has nearly disappeared, and depletion has been carried as far as seems judicious, — a large blister to the nape ofthe neck, or between the shoulders, or over the epigastrium, mustard poultices to the insides of the legs or thighs, or irritating liniments (see the Liniments in the Appendix) in the latter situa- tions, will often be used with advantage. The semicupium, warm bath, or pediluvia, are seldom of service when there is much general febrile excitement, particularly in children, unless when used simultaneously with cold affusion on the head. But when the lower parts of the body have their temperature reduced below the natural standard, and when the disease has appeared after suppressed discharges, &c, they are often of service, and may be made more revulsive by salt or mustard. 197. g. Various remedies have been recom- mended in the treatment of this disease, in a more particular manner than others. Amongst these, the most generally employed and most beneficial is calomel, when given in large and repeated doses, and judiciously combined, and until an impression is made upon the disease, or state of the circula- tion. In the meningitis of children, this practice is particularly requisite, as, without it, but little impression will often be made on the disease; and, with due attention, but little risk will be run of experiencing unpleasant results from it. Where we dread impending exhaustion, the calomel may be combined with small doses of camphor and ammonia, and a less restricted regimen allowed. Marcus recommends strongly very large doses of nitre, which may be combined with antimony, or with diuretics; Hedgewisch, the prepara- tions of mercury carried to the extent of saliva- tion; Chaussier, the boracic acid, very nearly as prescribed in F. 343.; several physicians in Italy and in Switzerland, especially Brera, Tommasini, Peschier, Laennec, &c, large and frequently repeated doses of the tartar- ised antimony, so as to act upon the bowels; 238 BRAIN —Inflammatio Loefler (Hufeland's Journ. der Pract. Arz- neik, b. iii. p. 694.), free incisions of the scalp ; and Aret^us (Curat. Acut. 1. i. ch. 1.), Cel- sus (1. iii. ch. IS.), Cjelius Aurelianus (p. 30.), and Zacutus Lusitanus (Med. Pr. Hist. 1. i. p. 85.), scarifications and cupping in the same situation. All these are undoubtedly advantage- ous, when judiciously prescribed. Besides these, there are remedies which are very generally em- ployed, and which are beneficial in certain states of the disease only : these are, camphor, digitalis, hyoscyamus, opium, &c. In the early stage, camphor, unless in very minute doses, is prejudi- cial; but when sopor or coma is present, when depletion has been duly practised, the heat of the head has subsided, the energies of life are depres- sed or exhausted, and the symptoms are apparent- ly the consequence of the lost tone of the capilla- ries of the brain, moderate and frequently repeat- ed doses of this medicine are almost indispensable; particularly in the complications of the disease with typhus, or epidemic fevers, with gout or rheumatism. Digitalis as well as colchicum are principally required in the early stage, when either of them may be combined with calomel: if ex- hibited subsequently, they should be given with camphor, and their effects carefully watched. Both these medicines may be advantageously combined with aperients or with diuretics. Brera recommends digitalis as follows in the earlier stages of the disease :— No. 60. H Pulv. Fol. Digitalis gr. xvj. ; Hydrarg. Sub- mur. gr. x. -, Pulv. Rad. Glvcyrrh. 1 j.; Olei Jump. q. s. IM. Fiant Pilula; viij. Capiat binas tertiis vel quartis horis. The combination of camphor with colchicum is often of service in the gouty and rheumatic forms of the disease. I found it recently of much ad- vantage in a severe case of the latter. 198. Narcotics ought generally to be avoided; yet there are states ofthe disease, chiefly in adult and aged subjects, which are benefited by them. When lethargy or coma, or an obvious disposition to either, is present, narcotics are injurious, par- ticularly in cerebritis; but when the membranes are obviously most affected, and the disease pre- sents much of the phrenitic character; when great irritability, mental excitement, or exhausting watchfulness is present, particularly after deple- tions and other evacuations have been carried as far as seems judicious, and the pulse has been reduced, or become less febrile; a full dose of hyoscyamus, or even the preparations of opium, particularly the acetate or muriate of morphine (F. 315. 674.), the compound tincture of opium (F. 728, 729.), or Battley's sedative liquor, may be exhibited. In cases where the propriety of having recourse to these medicines admits of doubt, they should be combined with moderate or full doses of camphor (F. 554. 787.), or the Spi- ritus JEther. Sulph. Comp.,(Y. 375.) No. 61. R Camphorae rasa? gr. j.—iv.; Gum. Acacia-, Sacchar. Albi, aa ^ ss.; Magnes. Carb. V) j. ; Decocti Al- tha?ae ^ jss. ; Spirit. ./Ether. Sulph. Comp. Tinct. Hyoscy- ami, aa 5 j. (vel. Tinct. Opii Comp. (F. 729.) 3 ss. M. Fiat Haustus. 199. B. Treatment of the complicated states.__ There are certain consecutive and complicated forms of the disease which require a somewhat modified treatment, a. The rheumatic encepha- litis, according to J. Frank, does not admit of cold applications to the head; in other respects, i of the — Treatment. the means of cure do not differ from those already stated. I believe that, in its advanced stage, the application of a blister to the scalp is more likely to be of service in this than in any other form of the disease; and the same remark may be extend- ed to the use of colchicum and camphor — the latter of which may sometimes be advantageously combined with the tartrate of antimony or James's powder. 200. b. In the arthritic complication, after ge- neral and local depletions, -—the latter chiefly on the right hypochondrium, haemorrhoidal vessels, and insides ofthe legs,—followed by active purg- ing stimulating and irritating pediluvia, sinapisms and blisters applied to the lower extremities, and colchicum combined with the sub-carbonates of the fixed alkalies, and diuretics, are chiefly indi- cated. 201. c. When encephalitis occurs in the course of fevers, or when it is seated chiefly in the sub- stance of the brain, and assumes a typhoid cha- racter, from the depressed state ofthe vital powers, either at the commencement or in consequence of treatment, the infusions or decoctions of arnica, senega, or serpentaria, have been recommended by the German writers, after depletions have been carried as far as seems prudent. When the dis- ease is thus complicated, depletions should be em- ployed with caution; and those which are local and derivative ought to be preferred, revulsants being simultaneously prescribed: cold applications to the head require equal oaution. In the early stage of this complication, J. Frank recommends a combination of camphor, cinnabar, and nitre, every two hours. The first of these is amongst the best medicines we possess in every stage of such cases; but it should, in the advanced periods, be exhibited in larger doses than early in the dis- ease; and it may often be advantageously com- bined with calomel. A similar treatment is ap- plicable when the disease appears in the course of bronchitis and other pulmonary diseases. 202. d. The erysipelatous complication of en- cephalitis often requires a more antiphlogistic and depletory treatment than the typhoid form of the disease; but such is not uniformly the case. I conceive that deep and large incisions into the scalp, particularly over the occiput, as recom- mended by Loefler, would be more applicable to this state of the malady than to any other, especially if there be much tumefaction of the scalp or countenance. When encephalitis fol- lows, or is complicated with apoplexy, the treat- ment differs in no respect from that wliich has been recommended for the primary form of the disease. Incisions or scarifications of the scalp may be also practised in this complication. 203. e. The supervention of encephalitis on in- flammations of the digestive mucous surface is not infrequent in children; and in diseases of the liver in persons of middle age, or advanced in life. In these cases the treatment is not mate- rially different from that already advised. Local depletions over the region of the liver; full doses of calomel, so as to affect the mouth; cold af- fusions on the head, particularly in the former state of complication; external and internal revul- sants, and diuretics; are generally indicated. 204. /. The appearance of the disease after irritating and narcotic poisons, particularly after opium, aconitum, belladonna, &c, is not infre- BRAIN — Inflammation of the—Treatment. 239 quent. These occasion, first, congestion, and afterwards inflammatory action. In encephalitis from these substances, vascular depletions, cold affusion on the head; emetics, or the introduction of the stomach-pump; camphor or arnica, com- bined with antimonials or aperients ; external derivatives, and active purging; are amongst the chief means of cure. 205. C. Of the treatment of the more unfa- vourable and anomalous states of the disease. — The practitioner, although he will very fre- quently, or even generally, find the treatment described above successful, may sometimes meet with cases in which the symptoms persist, not- withstanding repeated depletions and the other remedies prescribed : the energies of life being more or less depressed; the pulse becoming very rapid, irregular, trembling; the coma or stupor more profound; and the temperature, even ofthe head, much diminished. He may or may not have had recourse to derivatives; but, in either case, they may be continued or varied ; and catnphor,'musk, valerian, ammonia, Hoffmann's anodyne, and other restorative medicines, vari- ously combined, may be exhibited. If the pulsa- tion of the carotids, and temperature of the head, be not in such cases increased; or if they be diminished, and the energies of life be obviously depressed or exhausted, both in the affected organ and throughout the system; the above diffusible stimulants will often be inefficacious. In this case, the infusion ofthe flowers of arnica, or the infusion of se.pentaria, either simply or com- bined with cinchona; camphor in larger doses, and given occasionally with calomel and small doses of opimn ; active frictions of the surface and lower extremities with rubefacient liniments; and in some instances, particularly if effusions between the membranes be suspected, with mer- curial liniments, or inunction of the scalp; are the principal means that can be adopted. But if, notwithstanding those, the above symptoms con- tinue or increase,— the evacuations being invo- luntary, and the patient unconscious of them ; a vomiting, or rather a pumping up, of whatever is taken into the stomach, with singultus, and an intermitting, trembling pulse, that cannot be dis- tinctly counted, being also present, — are we to continue to give the medicines which we have found inefficacious, thus leaving the patient to his fate ? or are we to resort to still more active means? There can surely be no hesitation as to the part which ought to be taken. In a case of this descrip- tion, consecutive of bronchitis, in a robust man of middle age, who was attended by Mr. Faxon, Dr. Br£», and myself, after depletions and cold appli- cations had been carried as far as it was judged prudent, and blisters were applied on the epigas- trium and nape of the neck, without benefit, full doses of calomel and camphor were given, the following medicines prescribed, and their action promoted by the enema terebinth. (F. 151.) : — No. 62. R Mist. Camphorae rasae gr. iij.; Ammonia; Carbon, gr. iv.; Mucilag. Acacias q. s. Fiant Pilulae ij., omni secunda hora, cum Haustu sequente, sumendae. No. 63. R Mist. Camphorae § j.; Liq. Ammon. Acet. % ijss.; Spirit. jEther. Sulph. Comp. 3 ss.; Tinct. Capsici TT) xij.; Syrup. Croci 5 ss- M. The following draught was also given, four hours after the exhibition of a large dose of calomel and camphor, with the view of deriving the circulation from the head, and of acting decidedly on the abdominal secretions ; and was repeated every hour until three were taken. No. 64. R Olei Terebinth., Olei. Ricini, aa 3 ij.; Tinct. Capsici TT] xij.; Olei Cajeput. TT) vj.; Aquae Menth. Virid. 5 jss. M. The pulse soon afterwards became more distinct and regular, the bloated cast of countenance subsided, and all the symptoms improved. The patient afterwards quickly recovered, and is now in perfect health. At the time the above treat- ment was suggested by me, his recovery was considered almost impossible. Several years ago, I was consulted by Mr. Harry Cox respecting a very similar case, which was consecutive of ery- sipelas. In this a similar treatment to that now noticed was adopted, and the patient recovered from an extreme state of danger. This case is published in the twenty-third volume ofthe London Medical Repository. In those states of the dis- ease which are characterised by profound sopor, depression of vital power, and the symptoms above referred to (§ 180. 205.), other means having proved insufficient, a judicious exhibition of the oleum terebinthinae has very frequently a decidedly beneficial effect, particularly in the typhoid, erysipelatous, and other complications of the disease ; and, when suitably prescribed, will generally allay the irritable state of the sto- mach, with which the worst forms ofthe malady are often attended even during their advanced stages. 206. The inexperienced practitioner should be aware that the existence of profound sopor or coma does not contra-indicate sanguineous deple- tions or cold applications to the head, if, conjoined with this state, the temperature of the head be at all increased, or the pulsations of the carotids strong or full. If these evidences of increased ac- tion be present, those important parts ofthe treat- ment ought not to be omitted; but the depletions should often be moderate or local merely; and, in my opinion, preferably from the scalp of the occi- put or nape of the neck, by cupping, or by deep incisions of the former. When the disease is con- sequent upon suppressed discharges, a derivative intention may be had in view, and the lower ex- tremities, the groins, the vicinity ofthe anus, &c, may be selected as the situations for depletion. In traumatic encephalitis, the fact that the dis- ease either does not appear whilst the wound in the scalp remains open, or is averted by a long- continued discharge from it; and that the worst states of cerebritis often arise after injuries of the head, when the external wound has readily and prematurely healed, furnish a striking indication of the propriety of having recourse to incisions of the scalp in the other forms of the disease, and to issues and setons in the same situation subse- quently, when their sequela; indicate the propriety of having recourse to permanent irritation, with puriform discharge, for their removal. 207. D. Treatment of the sub-acute and chronic states of encephalitis, particularly in children. — a. One of the most frequent forms of sub-acute inflammation of the brain is observed in infants, principally affecting the substance of the organ, and often terminating in dropsy of the ventricles. It is chiefly characterised by want of animation, by slight sopor, indifference to all objects, absence of sound sleep, and a state that is different from waiting. The child is dull, but fretful and irri- 240 BRAIN —Inflammation of the>—Treatment. table upon being roused or handled. The head generally droops, or reclines on one side; the countenance is usually pallid, but occasionally irregularly flushed; the eyes are dull, rolled about, or turned up ; the pupils sometimes di- lated, at other times contracted; and the infant often utters a plaintive moaning, and occasionally starts soon after having fallen asleep, as if pained or frightened. The hands are tossed about or raised to the head; the lower extremities alter- nately extended and drawn up to the abdomen; the head thrown backwards; and occasionally its temperature is slightly increased, whilst the heat ofthe rest ofthe body is either natural, or some- what diminished. This grade of disease may con- tinue for a long time; sometimes fluctuating, at other times passing into either a more acute or more chronic form, or at last terminating in dropsy; the bowels being either relaxed or irregular, but in either case with a morbid and offensive state of the motions. The shades of difference observed in this form of disease are numerous: the pulse is very variable, as well as the appearance ofthe tongue; which is, however, most frequently red at its point and edges, and white or loaded at its middle and base: in some of the more chronic cases, particularly when the disease is compli- cated with chronic disorder of the digestive mucous surface, it has what may be called a strawberry appearance, from the number of bright red dots scattered over it. This variety of the disease is often associated with torpor or imperfect func- tion of the liver, with disease of the mucous sur- face of the stomach or bowels, or with both ; and occasionally with bronchitis, especially dur- ing the period of dentition, when it often super- venes. 208. b. Another variety of this affection is also frequent in infants and children, and seems to be chiefly seated in the arachnoid. Dr. W. Nicholls has termed it sensitive erythism of the brain. It is characterised by a morbidly increased sensi- bility, which distinguishes it from the foregoing variety. The child often cries without any ob- vious reason ; is generally wakeful, lively, but irritable; all the senses, even that of touch, are morbidly acute, particularly the senses of sight and hearing: it frowns, winks its eyes, or closes them upon exposure to light; it sometimes shrieks, clenches its hands with the thumb bent across the palms, tosses backwards its head, and pre- sents many of the symptoms of the preceding form of disease; and not infrequently terminates in effusion; but, more frequently than the fore- going, between the membranes exterior to the hemispheres. 209. c. The Treatment chiefly consists of leech- ing behind the ears or on the occiput; frequent scarifications of the gums ; the affusion of cold water on the head, or cold sponging ; calomel purges, followed by castor oil or other cathartics, and occasionally promoted by terebinthinate en- emata ; frequent warm semicupia; the use of saline aperients combined with diuretics, and strict attention to diet and regimen, with change of air. After the several active calomel purges have been exhibited, and the evacuations have improved, and the more obvious symptoms are abated, small doses of hydrarg. cum creta may be given at night, either alone or combined with a little of the sub-carb. of soda or potash, and a weak saline mixture through the day, similar to the following, or to F. 440. and 441.:— No. 65. R Magnesia; Snlphatis (vel Sodae Sulph.) 3 ij.; Potassae Sulphatis 3 j-} Aquae Fceniculi 5 ivsa. ; Spirit. Either. Nit., Vini Antimonii Tart., Spirit. Juniper. Co., 5a 5 j.; Syrup. Scillae 3 ij. M. Capiat Infans 3 j.— 3 iij. ter quaterve quotidie*. 210. When the morbid sensibility or irritability continue notwithstanding the above treatment, and if the child be not very young, small doses of James's powder, and, if that fail of procuring quiet, ofthe pulv. ipecacuan. comp. may be con- joined with the hydr. cum creta, and given every night; or a little tinct. of hyoscyam., or of the extr. conii, may be added to the above mixture. In the soporose form of the affection, narcotics must be avoided, but the rest of the treatment strictly adhered to. Small doses of camphor and nitrate of potash may also be exhibited, — if in solution, with the spirit. a?ther. nit., and blisters applied either to the nape of the neck or behind the ears. 211. E. Treatment ofthe sequele of encepha- litis.—After an attack of this disease, the patient may complain of vertigo, more or less torpor or weakness ofthe mental powers, cephalalgia, &c.; or of increased sensibility, and marked erythism of the brain and whole nervous system, watch- fulness, incapacity for mental exertion, tinnitus aurium, languor, and pain in the limbs, &c. In all such or similar cases, the diet should be carefully restricted to food of easy digestion, in moderate quantity, and consisting chiefly of the farinacese. Change of air, easy travelling, avoidance of all mental exertion and anxiety, and attention to the secreting and excreting functions of the abdominal viscera and ofthe skin, will generally bring about perfect recovery. If these fail; or if the patient have irregular flushings, or increased heat of head ; or if the carotids pulsate more strongly than usual; the shower-bath, cold sponging the head night and morning, and wearing the hair closely cut, occasional local depletions, the in- sertion of a seton in the neck; or keeping out an eruption, in the same situation, with the tartarised antimonial ointment; or blisters kept open behind the ears for some time; may be prescribed. 212. When the more severe sequelae of the disease are present, — such as cramps, pains, or spasms of the extremities, hebetude or derange- ment of the mental faculties, obstinate headach, &c,—we should suspect the existence of a chronic state of the disease, and resort to occasional local depletions, cold affusions, or sponging of the head; followed by issues in the scalp of the occiput, or the inunction of the tartar emetic ointment in this situation; and to the mercurial preparation at bed- time, with cooling and deobstruent aperients on the following morning; and to the other means above recommended. When we apprehend, from the marked character of the above symptoms, or from the paralysed state of particular muscles or parts, that organic lesion has been produced, the means now recommended should be strenuously persisted in; and the mercurial medicines may be pushed to slight salivation, under the favourable circumstances of pure air and mental quiet; after which, gentle tonics, and a more invigorating treatment and regimen, may be cautiously tried. 213. F. The regimen during the disease should be strictly antiphlogistic. The patient's drink or beverage may consist of either of the formula, BRAIN — Softening of the — Symptoms. 241 No. 590—595. 915. contained in the Appendix; and attention should be paid to the state of the urinary discharge; particularly to the prevention of accumulations of urine in the bladder, which ought to be removed by the catheter whenever any interruption of its evacuation occurs. The diet, and regimen generally, should be as carefully regulated during convalescence, as in the progress ofthe disease; and attention ought to be directed no less to the mental occupations, and moral emotions, than to the natural functions, and phys- ical employments. Care should be taken not to carry abstinence too far in the meningitis or en- cephalitis of infants or children, particularly after large sanguineous depletions and doses of calomel have been employed. The exhaustion arising from too great abstinence, and from the treat- ment, will often simulate effusion into the ventri- cles; and be mistaken for it, if the history of the case be not carefully attended to in connection with existing symptoms. 214. Brain—Softening of the.—RamoL- lissement. Classif. Class, Order (Author, see Preface.)—I have considered this change, apart from those proceeding from inflammation, although it is frequently a consequence of inflam- matory action, occurring either in an acute, sub- acute, or chronic form, and characterised by defi- cient vital power; chiefly because I agree with MM. Rostan, Recamier, and others, in con- sidering that it occasionally is unconnected with inflammation, particularly in aged persons. 215. Symptoms.—This, disease takes place slowly, and we may distinguish in it two stages, the recognition of which is of much importance in the diagnosis, inasmuch as when the first period does not exist, or when the physician cannot obtain a satisfactory knowledge of it, it is difficult to determine the particular hind of disease pres- ent. 1st, The first period.—A. Direct symptoms, a. of non-inflammatory softening. A continued, and more or less severe, pain in the head is gen- erally complained of. To some, the existence of pain may appear pathognomonic of inflammation; but, as M. Rostan has justly said, this is an in— forence not borne out by close observation ; for pains frequently occur, of a most severe descrip- tion, unconnected with any form of increased vascular action, or capillary injection. Cephalal- gia is, however, not always present. At this pe- riod, vertigo is oftener complained of, and there is generally a more or less marked diminution of the intellectual and moral faculties. The per- ceptions, attention, judgment, memory, 'and im- agination, are more or less enfeebled ; and the patient sinks into a species of senile mental alien- ation. Sometimes the mental disturbance is partial or slight, owing to the seat and limited extent of the softening. There are observed, moreover, slowness in the answers; some degree of embarrassment in the motions of the tongue; dejection and sadness of spirits ; hypochondriasis, or an extreme indifference as to events; great in- clination to sleep, with prickings, twitchings, and numbness in the limbs ; and much difficulty of laying hold of objects, particularly those of small size. The sensibility is generally diminished ; vision is often affected, being less distinct than usual, or p irtially or altogether abolished. It very rarely happens, that unequal dilatation of the pupils, or strabismus, occurs. The sense of 21 hearing is generally impaired. These are the chief symptoms of non-inflammatory softening of the brain. 216. b. If the softening proceeds from inflam- matory action, this period is more acute, of longer duration, and presents also certain important dis- tinctions. The pain in the head is then more acute and sharp ; the answers are abrupt and quick, and there is frequently delirium: the sensi- bility of the limbs is often increased, and the pa- tient complains of pain in them, with stiffness, contractions, and cramps. This affection of the limbs may be mistaken for rheumatism, but is to be distinguished from it by the existence of cere- bral symptoms, and the absence of increased heat, redness, or tumefaction. The senses evince ex- cessive sensibility, and cannot tolerate their natu- ral stimuli. (Rostan.) 217. B. Indirect symptoms.—a. The functions of organic life do not present undeviating svmp- toms, and assist but little the diagnosis; the appe- tite may be diminished, the thirst somewhat in- creased, and digestion more or less disturbed, and the mouth and tongue white and clammy. Some- times there is nausea, or even vomiting, with epi- gastric tenderness; and there may be either con- stipation or slight diarrhoea; micturition is more or less difficult, or involuntary; or all these symptoms may be absent. The following are more constant in this non-inflammatory form ofthe disease : the pulse is slower and feebler than natural, a symp- tom which is not observed in inflammatory soften- ing of the brain; the skin is pale, its temperature is lower than natural, and the respiration slow and gentle. 6. In inflammatory softening, the pulse is strong, full, or frequent; skin hot; and there is much thirst, with many ofthe symptoms describ- ed in the section on Cerebritis (§ 164.), but gen- erally in a sub-acute or chronic and slight form. Thus far, the symptoms do not seem very urgent; and they may be so slight, or so obscure, that the patient is not induced to have recourse to medical aid, or the physician overlooks the nature of his ailments. 218. 2d, Secondperiod.—A. Direct symptoms. a. The patient now loses the use of some limb, or even one half of the body, either gradually or suddenly, but generally the latter. The greater part ofthe time his intelligence is but little disturb- ed, but he answers with extreme slowness, and is often incapable of making himself understood, excepting by the aid of painful gesticulation. In certain cases, either complete coma supervenes on the paralysis, or both come on simultaneously. If the latter, the patient often regains his recollection in a day or two afterwards. This change seems attributable to temporary- congestion of the brain. The symptoms, particularly the coma and para- lysis, are increased, the mental faculties and the powers of sense become entirely abolished, and the patient sinks under the most complete coma. (Rostan.) 219. b. In the inflammatory softening, in the place of paralysis, there exist pains, more or less violent, shootings in the limbs, with contractions, cramps, or convulsions, and severe headach. In either the inflammatory or non-inflammatory form of the disease, when the patient complains of pain in the head, and is asked its situation, he carries the unaffected hand slowly to his head, and indicates generally the side opposite to that 242 BRAIN — Softening of the—Treatment. paralysed. In encephalitis, there is generally de- lirium ; in the non-inflammatory form of soften- ing, the intellectual faculties are enfeebled, or much weakened; the countenance is generally pale, colourless, or sometimes even sunk; where- as in inflammatory softening it is red, or more or less injected, or even tumid. 220. B. Indirect symptoms.—a. In this second stage of the disease, the organic functions are more or less affected: there is no appetite; the teeth and gums are dry, the tongue rough, brown, blackish, chopped or traversed by small fissures: deglutition is difficult: sometimes there is vomit- ing, first ofthe ingesta, and afterwards of bile: all the excretions are involuntary; frequently there is constipation : respiration is laboured, and at last stertorous; the pulse feeble, frequently irregular or unequal, or even intermittent, and the skin is cold. b. In inflammatory softening there is great thirst, redness of the tongue, sensibility of the epigastrium and abdomen, hot skin, a strong and frequent pulse, &c, (See § 170.) 221. The second period may be of longer or shorter duration. The morbid phenomena often . continues stationary for a considerable period, and then n.akerapid progress; at other times the pro- gress is slight, but constant; in some cases it is constant and remarkable. This disease very rare- ly retrogrades or evinces much amelioration; its progress is essentially continued and increasing. The anatomical characters of softening have been already fully described (§ 70, et seq.). It may be stated in general, that when it is the result of inflammatory action, as it most frequently is, 1st, The colour of the softened part is, more or less, deeper than natural, or of a rose tint; 2d, It con- tained a certain quantity of pus, sometimes infil- trated through the softened tissue; and, 3d, Febrile symptoms have existed previously to the death of the patient. 222. Treatment.—It is unnecessary to add any thing to what has been already advanced re- specting the treatment ofthe inflammatory states of softening, which are essentially the consequence of partial cerebritis (see § 191, et seq.). When, however, the disease does not present an inflam- matory character, it becomes necessary not only to enjoin abstinence from all debilitating means, but from the commencement to apply rubefa- cients, to throw irritants into the great intestines (see Enem. F. 141.150.), and to have recourse to tonics, aromatics, &c, of which the sulphates of zinc, iron, or quinine, in small doses, with sul- phuric acid, or the less heating astringent tonics belonging to the vegetable kingdom, are the most eligible; preserving, at the same time, a regular state of the alvine secretions and evacuations, and of the other digestive functions. 223. Regimen.—The gently tonic, chalybeate, and aperient mineral waters are of service in the non-inflammatory form of the disease ; whilst those only which are aperient and deobstruent should be ventured upon in its inflammatory states, when they may be tried and varied ; local evacuations, revulsives, particularly setons, issues, &c, being kept discharging at the same time! In both forms of the disease, gentle travelling, and change of air, and agreeable and quiet amuse- ment, without undue mental excitement of any kind, will be of much service. M. Rostan's in- junctions under this head may be summed up as follows:—Those alimentary and medicinal sub- stances which exert a strong and speedy action on the encephalon, should be strictly shunned. Wine, spirits, coffee, and spices, are of this num- ber. Excess at the table is dangerous. The diet should be mild and moderate, and the food easy of digestion, but not too nutritious. The impres- sion of cold air on the head may be favourable: sudden passage into a heated place must be avoided: the patient should inhabit a cool situa- tion. Whatever, by compressing the limbs or the organs contained in cavities, may favour cerebral congestion, must be rigidly proscribed. Warm, as well as cold bathing should be inter- dicted: tepid bathing alone may be permitted, al- though with much caution. Cold lotions to the head are advantageous in the inflammatory form ofthe disease, provided we do not permit reaction to be established; at the same sime pediluvia con- taining mustard may be prescribed. The ordina- ry excretions should be kept up; but sexual indul- gence, too violent exercise, strong emotions, long study, and watching, should be carefully avoided. The age, strength, constitution, habits, and state ofthe patient, and the character of the symptoms, must modify these precepts. Bibliog. and Refer.—I. Diseases of the Mem- branes of the Brain, kc i. Alterations of the DURA Mateh.—Haller, Opera Minora, vol. iii. p. £63.— Burdock, Beilrage. b. i. p. 87.—Gilbert, in Edin. Med. and Surg. Journ. No. 95. (Dura mater absorbed and wasted.). —Otto, Anat. Pathol. &.c.; and Bonetus, Sepulchret. Ana- torn, vol. i. p. 41. (Dura mater thickened to half an inch.). —Lieufaud, Hist. Anatoin. Med. vol. ii. 1. iii. obs. 3. 16. 76. 165.; et Trecourt, J urn. de M#d. t. vi. p. 189.; and B. Brown, Lond. Med. Repos. edit, by Copland, vol. xvii. p. 108. (Dura mater dry, shrivelled fyc).—Gendrin, Histoire Anat. des Inflam. 8vo. Pan's, 1826. (Melanoid deposit in dura mater.).—Ludwig, Adversaria Med. Pract. vol. ii. p. 459.; et J. P. Frank, lie Curand. Horn. Morb. 1. vi. p. 161.; et Voigtel, Handhuch, &.c. b. ii. p. 9. (Water between the bones and dura mater in hydropic children.).—Biermayer, Museum Anatoin. Palholog. No. 14.; et Kilian, Anat. Untcrsuchung, &c. p. 125.; and T^obstein, Comple rendu sur les Travaux Anatom. t. i. p. 56. (Layers of dura mater separated by blood, coagula, and pus.). — Stanley, Med. Chirurg. Society's Trans, vol. iii. p. 24. (Dura muter burst during coughing seven months after trepanning.)—Boeh- mer, De Ossificatione Durst Matris, kc. iio. Dal*, 17C4.— Velten, Casus aliquot Ossificat. in Membr. Cerebri invent. Eon. 1C25.—Loder, Observat. Anatom. Tumoris Scirrhosi in 13asi Cranii, kc 4lo. Jenae, 1779.—Pfranger, De Kungo Dura; Mali is, kc. Elf. ltOl.—A. B. Hotel, Anat. PathoL de Cerebri et Meningum Tuinoribus. 8vo. Her. 1824.—Of(o, Selt. Beobachtungen, t. ii. p. 86. No. 36.—Louis, Sur lej Tumeurs Fongeuses de la Dure Mere, in Mini, de 1'Acad. de Chirurg. t. v. p. 1. Paris, 1774.—Meckel, Handhuch der Palh. Anat. b. ii. 2. p. 324.—Pal/ctta, Excrcitat. Patholoc. vol. i. p. 93—104. ii. Alterations of the Arachnoid and Pia Mater. Piorry, De PIrrilation Encephaliquedrs Enfans, &c. Paris, 1823. — Senn, Sur la Meningile Ai-ue des Enfans, kc Pans, 1825.—Parent-Duihate/et et Martinet, Sur l'lnriam- mation de 1'Aiachnoide Certbrale et Spinale, kc. Paris, 1821.—Baylc, Sur Meningitis Chronica, in Itev.M^d. Fev. 1825.; Meningitis Acuta, Diid. 1827.—Gendrin, Hist. Anat. des Inflammat. 2 t. Paris, 1E26.—Tachcron, Recherches Anat. Pathol, sur la Med. Prat. t. iii. p. 4-36.—Barkhausen, Beobachtungen ubcr den Sauferwahnsiun, oder das Delirium Tremens. Brem. 1828.- Portal, Cours d'Auat. Medicale, L iv. p. 70.—Speranza, Anno Clinico-Medico. Parma, 1823, 1824.—Ed. Thompson, in Lond. Med. Repository, edit, by Copland. Nov. 1824.—Baillie, Eneravings, &c.'fasc. x.— Winze/, De Penitiori Structura Cerebri, cap. i.—Powet, in Trans, of Coll. of Phys. vol. v. p. 234. (Earthy concretions inpta mater ).-Otto, Selt. Beobachtunjen,kc, et Verzeich- niss, &c. passim.—Esquirol, iu Diet." des Sciences Mtd. t. vm. art. Demence. (Cysts containing lime in pia mater.) —Asprey, in Lond. Med. and Phvs. Journ. (Bony co,t- cretions on each side.). — Nasse, fceitschrift f. Anthopo- logie, 1823. p. 11. 4W.-Burdach, Beitiage, kc b. ii. p. 107. 287. (Hydatids, A-c.).—£„,-/<:, in Med. Chirure. 1 fans. vol. xiii. No. 18.—Hooper, Morbid Anat. of t£a Human Brain, 4to. London. 1828. — Aberaombie, On th« BRAIN — Diseases of the—Bibliog. and Refer. 243 Brain, kc. Edin. 1828.—Monro, Morbid Anatomy of the Brain in Hydrocephalus, kc. Edin. 1828.—Bright, Medical Heports, vol. ii. p. 680, et seq. iii. Alterations of its Sinuses and Veins. Blasius, Observat. Med. rarior. Ephemer. Nat. Cur. dec. i. ami. ix. et x. obs. 25., et dec. iii. ami i. p. 1 j7.—Stoll, Ratio Me- dendi, vol. i. p. 217.—Wichmann, Idian zur Diagnostik. b. iii. p. 111.—Licutuud, Hist Anat. Med. 1. iii. ots. 164___. Portul, Anatoinie Medicale, t. iv. p. 22, et seq.—Aber- crombie, Edin. Med. and Surg. Journ. vol. xiv. p. 577.; and Diseases of the Brain and Spinal Cord, 8vo. p. 44.— M. Ribes, Revue Medicale, t. Iii. 1825 — M. L. Tonnelli, Memoire sur les Maladies des Sinus Veineux de la Dure Mere, in Journal Hebdomadaire de Med. t. v. p. 337.— Hooper, Morbid Anatomy of the Brain, 4to. Lond. 1328.— CViili ilhicr, Anatomie Pathologique, 8ienie livr. Paris, 1830. 11. Diseases of the Substance of the Brain, i. Cerebritis. Inflammation, and its Consequences, ^-c.— J. C. Brendelii, Kesp. Ellenbergeri de Phienitide. Goet. 1756.—Schroedr.r, De Indole et Sedc Pluenitidis et Para- phrenia Goet. 1765.—Stoll, Ratio Medendi, par, iii. sect. 3. —Fischer, Dc Cerebri cjusque Memb. iullaimnat. et Sup- pur. Occulta, Goet. 17«7.—W. Nichulls, Pi act. Remarks on disordered States of the Cerebral Structures of Infants, 12mo. Lond. 1821.—Marcus, Entwurf eiuer Speciellen Thempie, t. ii. p. 554.—D. A. G. Richter, Die Specielle Tbeiapie, b. i. p. 445.—Hildenbrand, Institut. Medica: Pi act. t. iii. p. 55.—J. Frank, Praxeos Medica: Univers. Praccp. vol. i. p. ii. sect. i. p. 211. ii. Abscess or Suppuration of the Brain. Bar- tholin, Hist. Anat. Med. Cent. ii. Hist. 34., et C. vi. Hist. 13.—Camerarius, De Vomica Cerebri. Tub. 1711.—Thoner, in Hatter's Biblioth. Med. Pract. vol. iii. p. 22.—Lieutaud, Anal. Med. 1. iii. obs. 1131.—Bianchi, Stor. Med. d'un Apostema nel Cerebello. Rim. 1751.—Reuss, Report. Com- ment. voL xii. p. 78., et vol. xv. p. 107.—Lallemand, Let- ters ii. iii. and iv. passim.—Horn's Archiv. f. Med. Erfahr. 1813. March and April, p. 238. (Several instances of, in the cerebellum, also with erosion of the bones.) —Laugier, Recueil de Med. et Chir. Milit. t. viii. p. 179. 1820. (Cerebellum.).—Bush, in Lond. Med. and Phys. Journ. Dec. 1823.—Hamilton, in Trans, of Med. and Chir. Soc. of Edin. vol. i.—Dickson, in Lond. Med. Repos., Oct. 1824.— Cruveilhier, in Nouv. Biblioth. Med. Nov. 1826.—Frank, Inter. Clin. vol. i. p. 142.—hard, Traits des Malad. de l'Oreille, kc. p. 70. Paris, 1821.—Duncan, in Edin. Med. and Surg. Journ. vol. xvii. p. 331. (Opened through the sphen. and temp, b-.nes.)—Ott ■, in Selt. Beob. part ii. p. 96. (Six cases.).—Pretty, in Lond. Med. Repos. by Copland, vol. xx. Sept. 1823. (Opened through the frontal bone.). —C. G. Frank, in Ephein. Nat. Cur. dec. ii. an. vi. cbs. 193. (Discharged by the nose through carious sphen. bone.). —Syme, in Ed. Med. and Surg. Journ. July, 1828. (On the forehead.).—Raikem, Repert. Gin. d'Anat. et de Physiol. Path. vol. i. No. 2. p. 295. (Discharged through petrous and sphen. bones una nose.). For various other references to abscess in different parts of the brain, some of them in connection with inflammation of the internal ear, others pass- ing through fistulous openings in the skull, see the article Cerebrum in Ptoucquet's Medicina Digesta, and Otto's Compendium of Pathological Anatomy. iii. Softening. Rostan, Rich, sur un Maladie encore Inconnue, &c. Paris, 1820.; et Trailed de Diagnostic, &.c. vol. ii. Paris, 1827.—Cruveilhier, La Med. Eclairire par l'Anat. Pathol, cah. i. Paris, 1821.—Lallemand, Rexh. Anat. Path- ol, sur l'Encephale, kc. leltre i. et ii. Paris, 1820.—A. G. Herbst, De Encephalomacia. Halse, 1825.—Burdach, Vom Baue des Gehirns, vol. iii. p. 534. (Contains numerous ca- ses, original and quoted.)—Guibert, in R6v. Med. March, 1828.—Foville, art. Enciphale, in Diet, de Med. et Chir. Prat. L vii. iv. Sphacelus. Lyserus, De Sphacclo Cerebri. Lips. 1656.—M. Cristin, Revue Med. t. ii. p. 302. 1825.—Gred- ing, Sammtl. M£dic. Schrift. b. i. p. 306. Gangrene is ob- viously a post mortem change, as death must take place before it could supervene as a consequence of acute inflammation. v. Hypertrophy. Haller, Element Physiol, vol. iv. p. 10.—Hcbenstreit, in Haller's Coll. Dissert. Anat. vol. vi. p. 335.—Penchienati, in Mim. de Turin, vol. iv. p. 118,— Meckel's Handbuch der Pathol. Anat. b. i. p. 298.—Scoit- tetten, in Archives Gen. de Mid. t. vii. p. 31.—Otto, in Selt. Beob. part i. p. 106.—Dance, Journ. des Progres. des Scien. M£d. t. xi. p. 232.—Jadelot, in Journ. de Med. t. vi. p. 3.—Hufeland, Rev. Med. t. i. p. 130. 1825.—Portal, Ohserv.sur la Nature et Traitem. de l'Epilepsie. Paris, 1827. vi. Hypertrophy of Pineal Gland. Manget, Theat. Anat. 1. iv. c. ii. p. 309.—Morgagni, Epist. i. 14., x. 17., xxi. 24.—Lieutaud, Hist. Anat. Med. I. iii. obs. 177—210. 381.—Desportes, Hist, des Malad. de St. Domingue, vol. ii. p. 209.—Angeti, Osservaz. Med. Prat, et Chir. Imol. 1793. vol. i. p. 27.—Greding, Sammtl. Med. Schriflen, kc b. i. p. 318. —Blane, Trans, of Soc. for Improv. kc. Lond. vol. ii. p. 16. I vii. Hypertrophy, kc of Pituitary Gland. De Haen, Rat. Med. vol. vi. p. 271.—Greding, p. 282.—Horn's Archiv. f. Med. Erfahrung, 1815, par. iii. p. 463.—Baillie, Morbid Anat. 4to ed. p. —Terminations. and cough. There is at first little or no dvspncna; but the tongue is loaded, the pulse accelerated and full, the face pallid or tumid, and the child has lost its animation. As the disease advances, the breathing becomes more quick and laborious; and fits of dyspnoea come on, generally followed by severe attacks of cough, which often terminate in vomiting; on which occasion only the bronchial secretion is presented for examination, and is found to consist at first of a viscid, watery mucus, and afterwards of a yellowish white, or a tena- cious matter. These exacerbations are followed by remissions, during which the child dozes, and appears relieved, and the pulse becomes less fre- quent. Thus the disease may continue, with al- ternate remissions and exacerbations, for many days, until either a permanent diminution of the symptoms takes place, or an increased frequency of pulse, stupor, lividity of the lips, nails of the fingers, convulsions, &c. supervene, and indicate impending suffocation, with congestion or watery effusion on the brain. 39. Terminations. — A. Duration. The sthenic variety ofthe disease usually runs its course in about seven or nine days; but it may terminate either way as early as the fifth; or it may be pro- longed to the 21st, or even the 28th day. Its duration will, however, chiefly depend upon the treatment employed, the complication it may pre- sent, the severity of the symptoms, and on the age and constitution of the patient. The asthenic form of bronchitis generally runs its course in a slower manner; it seldom terminates either way in less than fourteen days, and generally continues for several weeks (§ 37.). 40. B. In favourable cases, the sthenic form of the disease begins to decline from the fifth to the ninth day. 'Ihe change is first evinced by the state of the sputum, as above described (§ 35.); by an amelioration of the cough, dyspncea, and febrile symptoms: in rare instances, by copious epistaxis; by a more general and copious perspir- ction than that which frequently terminated the febrile exacerbations; by a more copious discharge of a paler urine, depositing a sediment; and by a diminution of the dyspnoea, of the frequency and severity of the cough, and of the quantity of the expectoration, which becomes pearly, opaque, thick, yellowish, or greenish yellow ; at last, febrile symptoms recur only towards evening, and the disease disappears as in the first variety (§31.). 41. C. This favourable change is not, however, always observed, particularly when the attack is very severe, when treatment has either not been soon employed, or has not been sufficient to re- move the disease, or when the secretion into the bronchi has been very profuse, and expectorated with much difficulty. In such cases, it either lapses into the chronic state about to be described; or, ovying to the extension ofthe inflammation, to the air-cells and substance of the lungs, gives origin to pneumonitis, and even to pneumonitis combined with pleuritis, which is thus superadded to the original disease; or, from the great extent of surface affected, the consequent irritative fever and interruption to the pulmonary functions, and the profuse viscid fluid filling up the bronchi, col- lapse of the powers of life supervenes, and the patient dies, either with cerebral affection, or with the usual symptoms of asphyxy, consequent ! upon diminished discharge ofthe morbid secretion, and its accumulation in the air-tubes. I 42. a. When the disease thus terminates in pneumonia, the sputum becomes more rounded, thick, tenacious, and streaked with blood, which is more or less intimately mixed with it, and some- j times of a dark colour, giving it a rusty appear- ance ; and the cough is more tight, hard, and deep. The oppression also increases; the cheeks are flushed with circumscribed red; the pain of chest is more severe, or is now complained of for the first time ; the skin is partially covered with moisture, sometimes very abundant in parts; the chest, which was hitherto sonorous throughout, is dull, in some part or other, upon percussion; and the auscultatory signs of severe and dangerous pneumonia appear, on which delirium and other unfavourable symptoms often supervene, and ter- minate, with coma, the life of the patient. 43. b. Bronchitis, as it occurs either in the sthenic or asthenic form, may also terminate in chronic pleuritis, and in effusion of serum into the pleural cavity, and in some instances also into the pericardium, particularly in persons advanced in life, and in those who have experienced difficulty in the circulation through the cavities of the heart. In some instances of this description, the expectoration, and many of the other symptoms, are suddenly or quickly diminished; but the dys- pnoea continues, and signs of effusion become more apparent as those of bronchitis disappear. In these, the consecutive effusion occurs in the form of a translation or metastasis of the morbid action from the mucous to the serous surface. In other cases, symptoms of pneumonitis, or pleuritis, in- tervene between the change in the bronchitic symptoms and the occurrence of effusion, with pain, more or less severe, loss of resonance in some part of the chest, and other auscultatory signs, indicating the extension of the inflammatory action first to the small bronchi, and thence to the substance of the lungs and the pleura. Dr. Hastings has detailed some cases of this termi- nation in his work, and I have treated several instances at the Children's Infirmary; but it is chiefly the aged who are liable to this unfavoura- ble occurrence. 44. c. In other unfavourable cases, the disease becomes, in the course of a few days, charac- terised by failure of the energies of life ; oppres- sion and uneasiness increase; the cough is more frequent, laborious, and convulsive; the sputum is either more abundant, frothy, tenacious, and glairy, or gelatinous, and excreted with great dif- ficulty, or much diminished in quantity from want of power to excrete it; the pulse is more rapid, small, weak, and irregular, or intermittent; the pain of head more' distressing; the countenance is pale, and the face and neck covered with a clammy sweat; the respiration very frequent and wheezing, sometimes with an audible rattle; and, at last, delirium, lividity, at first of the lips, afterwards of the countenance, great prostration of strength, and coma, supervene, and the patient sinks with all the signs of imperfectly changed blood. In some cases, cerebral symptoms come on much earlier, with either violent or low mut- tering delirium, which soon terminates in most profound coma. In a few cases, this early acces- sion of delirium, or of violent headach, with other symptoms of consecutive inflammatory action, BRONCHI—Acute Inflammation of the — Complications. 253 ending in serous effusion on the brain, altogether removes the original bronchial inflammation, or in others moderates it greatly and masks it. I have observed this in children, and once or twice in robust adult persons; but in both classes of subjects it is a dangerous occurrence. More com- monly, however, the cerebral symptoms continue increasing, with those referrible to the bronchi, till life is extinguished. 45. In other cases of very acute bronchitis, with very high fever and severe local symptoms, particularly with quick, laborious, short respira- tion, dyspnoea, anxiety, great sense of heat under the sternum, and bloated countenance, collapse takes place rapidly, particularly if an appropriate treatment have not been early employed ; and either delirium, coma, and other cerebral symp- toms, or those more directly depending on the circulation of venous blood, appear, and the patient is speedily cut off. In weak and nervous patients, and during unfavourable states of the air, the inflammatory action sometimes seems to in- vade nearly all the respiratory mucous surface, and is soon productive of a copious mucous secre- tion, which, either from its difficult excretion or rapid secretion, in some cases, speedily suffocates the patient. 46. In children, and rarely in adults, cases occur, in which the inflammatory action extends upwards, to the trachea and larynx, occasioning all the symptoms of laryngitis in addition to those of bronchitis, and frequently terminating fatally with convulsions and the signs of congestion in the head. In many of the unfavourable cases of bronchitis in children, the extent of the disease, and the copious secretion, occasion suffocation more or less rapidly, with somnolency, bloated, or livid countenance, convulsions, coma, and, at last, complete asphyxy: and, on dissection, con- gestion of blood, with watery effusion, is found within the cranium; the bronchi are filled with a mucopurulent matter, and the vessels of the lungs are loaded with blood. 47. Complications.'—The most common states of complication, in which bronchitis pre- sents itself in practice, are, 1st, With catarrhal sore throat, coryza, &c. of which it is generally consecutive, and with catarrhal inflammation of the pharynx and oesophagus. 2d, With inflam- mation of the trachea, or larynx, or both, of which it is most frequently consecutive; but also sometimes antecedent, as I have occasionally observed in children. Indeed, we have seldom croup in London uncomplicated with bronchitis in some one of its forms or states. 3d, With measles, scarlatina, or small pox, on which it very frequently supervenes; particularly in measles, sometimes very early in the disease, and before the eruption breaks out; but oftener in consequence of its premature disappearance, or retrocession. 4th, Very commonly with hooping-cough, espe- cially during certain seasons and epidemics. 5th, Not infrequently with continued fevers, particularly in its asthenic form. 6th, Often with disorder, or even sub-acute inflammation, ofthe digestive mu- cous surface, and diarrhoea, in children, when it also assumes this form; the stools being offensive, and the tongue red at its point, &c* 7th, With * During some seasons I have occasionally admitted in one dav, at the Infirmary for Children, several cases, in which it was difficult to determine whether the digestive or the re- 22 disease of the liver, and accumulations of bile in the gall-bladder, chiefly in adults; the tongue then being very deeply loaded with a yellowish brown crust, or fur; and the stools dark coloured, and most offensive. 8th, In some cases with erysi- pelas, particularly its epidemic and infectious form. 9th, With pneumonia, or pleuritis; these being either consecutive ofthe bronchitis, or sim- ultaneous with it. 10th, With dropsical effusion into the pleura or pericardium, especially in aged persons: and, 11th, With inflammatory irritation in the substance ofthe brain, or in its membranes, with disposition to effusion,—a complication most commonly met with in children. 48. All these diseases are greatly aggravated, and their danger increased, from being associated with bronchitis ; and they frequently terminate fatally by one or other of the unfavourable states which the bronchial affection assumes. Bronchitis thus complicated also presents, in consequence, either a more acute character, or the asthenic form ; and, being attended by a more marked disposition to invade the smaller ramifications and air-cells, or by a more profuse secretion of mucus, and a rapid depression of the powers of life, the unfavourable terminations above described quickly supervene. In several of these complications, par- ticularly with pertussis, measles, scarlatina, con- tinued fever, cerebral affections, and diseases of the lungs or pleura, bronchitis often escapes de-. tection, until it becomes either one of the most important, or the most dangerous, or an actually fatal lesion. When thus complicated with measles or other exanthematous diseases, the eruption, if it still continue on the surface, often assumes, as the powers of life sink, a dark or purplish hue; and a slight dirty blueness ofthe skin, particularly of the face, hands, &c. is generally observed in other cases, indicating the impeded functions of respiration, and the consequent changes in the blood. The frequency and importance of the complication of bronchitis with measles, especially before the appearance of the eruption, during its progress, and after its decline; and the occurrence of the former complaint, both during and after convalescence from the latter; are deserving of the careful attention of the practitioner. 49. ii. Sub-acute Bronchitis is character- ised by the symptoms of the sthenic form of the disease in a milder and more chronic form. The cough continues longer dry, and the expectora- tion scanty, or thick, viscid, gelatinous, or albu- minous, with tightness of chest,' and oppressed breathing. In this form of the disease, a plastic albuminous exudation sometimes forms in the large bronchi, and lower part of the trachea, or in the large bronchi of only one lung, and is moulded in the form of the air-tubes; and is either expectorated in fragments, or in large tub- ular branches and ramifications. Cases of thin description are detailed under the appellation of bronchial polypi by the older writers, and figures given of them by Tulpius and others. Mr. Iliff has published (Lond. Med. Repos. vol. xviii. p. 207.) a case of this description, wherein this production retained its ramified and tubular form. I have met with two cases where the albuminous exudation had been formed in the spiratory mucous surface was most affected. This compli- cation is not infrequent during convalescence fiom the exan- themata, particularly measles and soarlet fever. 254 BRONCHI — Chronic Inflammation of the. bronchi, and expectorated in fragments. It gen- erally occurs in an uncomplicated state. 50. iii. Chronic Bronchitis often follows severe attacks of catarrh; and is also frequently consecutive of acute bronchitis; but it sometimes occurs primarily in the chronic state, particularly in aged persons. It differs in nothing from the acute or sub-acute forms, excepting in as far as the symptoms are altogether milder, and their continuance longer; there being no distinct line of demarcation between its grades of activity and chronicity. The chief means, by which we are enabled to infer, that the disease has assumed a chronic form, when it is consequent on the acute, is the continuance ofthe sputum for several days, in undiminished quantity, and the persistence of the opaque, whitish yellow, or yellowish green appearance, which it assumed upon passing from the transparent, fluid, and viscid condition charac- terising the acute form. 51. Chronic bronchitis assumes various grades of severity, and presents different phenomena, according to the changes which have taken place in the bronchi. In its slighter states, and primary form, as it is often met with in persons advanced in life, and as it prevails during winter and spring, or variable seasons, it consists chiefly of a fre- quent and almost habitual cough, with scarcely any pain in the chest, continuing for weeks, or even months, or recurring every autumn, winter, and spring; being most severe in the mornings, and much easier through the day, with slight dyspnma on exertion, and copious viscid mucous expectoration ; but without any marked febrile symptoms, excepting slight acceleration of pulse. Its severer forms are met with in young or middle aged persons, after catarrh or acute bronchitis; and are attended with fits of coughing, and copi- ous expectoration; with oppression at the chest and praecordia; with febrile symptoms, particu- larly towards night; with copious perspirations in the morning, which often seem to increase the cough instead of relieving it; with loss of strength, emaciation, and s'ight disorder of the digestive organs. The cough is increased after getting into bed, and very early in the morning. ri he breath- ing is quick and laborious, particularly on any exertion; and the patient complains of slight tightness of the chest. The pulse generally ranges from 90 to 120; being the former whilst quiet hi bed, and the latter towards evening. 52. Attention to the expectoration is very im- portant, in order to enable us to judge both of the accession of this state of the disease, or of its ag- gravation or change into the acute form, which is not infrequent, and of the concurrent or con- secutive alterations which often take place. The sputum occasionally continues long in the state now described. It is generally then inodorous, and without taste. But it oftener becomes green- ish, or yellowish white, or muco-purulent; is mixed with a colourless watery phlegm, and is more or less abundant. In cases of a worse char- acter, particularly when hectic symptoms are pre- sent, it assumes a more purulent appearance; is sometimes streaked with blood, or mixed with dark specks of blood, or consists chiefly of pus. These changes, however, seldom occur without much antecedent fever, and attendant emaciation, night sweats, occasional diarrhoea, and the symp- toms of confirmed hectic. In rarer cases the sputum becomes remarkably fetid ; but this change cannot be imputed to any particular lesion of the bronchi or lungs, excepting some- times to considerable dilatation of the former. The whole of the symptoms in this class of cases so very nearly resemble tubercular consumption, as to be distinguished from it with much difficulty, and only by attending to the appearances of the sputum, and by examining the chest with the stethoscope. 53. The sputum generally partially swims on the surface of water. When it is thin, transparent, viscid, and frothy, it usually altogether swims; but when it is thick, in tenacious, opaque lumps, or in fragments resembling portions of albuminous exudation, it generally sinks. In all these states it cannot be diffused in the water. When it consists of yellowish white, or greenish yellow matter, it partly sinks, and by agitation is broken into ragged portions, and is partially diffused; and the more it approaches a purulent state, the more completely and readily is it diffused, imparting to the water, by agitation, a yellowish white appearance. 54. Chronic bronchitis is also sometimes conse- cutive of the eruptive diseases; but these diseases have generally altogether or very nearly subsided before the bronchial affection supervened. It occurs primarily from the irritation of minute par- ticles of mineral or vegetable substances floating in the air, as is shown in the article on Arts. It is sometimes also complicated with other chronic diseases of the lungs and pleura, more especially with tubercles; with diseases of the liver; with chronic inflammation, or other disorders of the mucous surface of the digestive tube, particularly of the oesophagus, stomach, and large bowels. In all these consecutive and con plicated states, it presents no certain or unvarying forms; its chief character, its duration, progress, and ter- mination, being modified by its severity, hy the constitutional powers of the patient, by his dia- thesis, and by the quantity of expectoration. In some cases, the secretion from the bronchial sur- face is so profuse as to be the chief cause of the exhaustion and death of the patient. 55. iv. Anatomical Characters of Bronchitis.—A. When the body of a patient is opened, that has sunk under any disease whilst affected at the same time with a mild and recent bronchitis, some redness is foui;d, generally in a circumscribed portion of the mucous membrane, and usually towards the end of the trachea, and in the first divisions of the bronchi. If the in- flammation have been more intense, the redness extends to a greater number of these tubes, and exists, moreover, in the smaller ramifications. It sometimes happens that this redness is exactly limited to the bronchi of one lobe only; and it is the bronchi of the superior lobe which seems to be more particularly disposed to inflammation. The red colour of the bronchi presents itself occasionally under the form of a fine injection, which seems to exist both in the sub-mucous cel- lular tissue, and in the mucous membrane itself, and is usually attended by slight tumefaction. Sometimes the vessels cannot be distinguished, but only a number of small, crowded, red points, which are agglomerated the one around the other. Finally, an uniform red colour is occasionally ob- served. In some cases, the redness diminishes progressively from the large bronchi to the BRONCHI — Inflammation of the—Diagnosis. 255 small ones ; in others, an opposite disposition is remarked. Occasionally the redness only exists in intervals, in the form of bands or of isolated spots, forming, as it were, as many circumscribed phlegmasia?, between which the mucous coat is white and healthy. 56. B. When the inflammation is chronic, the mucous membrane generally loses its lively red- ness: it presents a livid, violet-coloured, or brown- ish tint. Finally, and what is very remarkable, in individuals offering all the symptoms of invete- rate chronic bronchitis, with puriform expectora- tion, the mucous membrane of the lungs has been found scarcely rose-coloured, and even perfectly pale through its whole extent. Bayle and An- dral have particularly noticed this fact. I would not wish to conclude that there is not, and least of all, that there has not been, inflammation in these cases; but I think a very copious secre- tion will often take place from mucous surfaces, and assume even a purulent appearance during its retention in the.bronchi, from lost tone of the extreme capillary vessels, with, perhaps, an in- creased flux or determination of the circulating fluid in order to supply the discharge, all vascu- larity disappearing with the cessation of circula- tion. The other changes observed on post mor- tem inspection, particularly in the more chronic states of bronchitis, consist chiefly of thickening, softening, ulceration, &c. of the mucous mem- brane, dilatation of the bronchi, &c. (See § 7, et seq.). 57. v. Diagnosis.—The characters of the cough, and of the sputa, and the physical signs, are our chief guides in the diagnosis of bronchitis. The history 1 have given of the disease will be generally sufficient to enable even the inexperi- enced to recognise it: but it will often be necessa- ry to arrive at more precise and certain informa- tion as to the extent of lesion, and its existence either in a simple or in a complicated form. 58. A. Of the acute.—a. By auscultation. In the first stage of the disease, the inflammation causes tumefaction of the mucous bronchial sur- face, and consequent diminution of the calibre of the tubea. This state occtisions a modification of the respiratory sound in them: and, hence, either with the unaided ear, or with the stethoscope, we hear at first the " dry bronchial rhonchus;'' consisting chiefly of a sibilous or whistling sound; occasionally with a deeper tone, resembling the note of a violoncello, or the cooing of a pigeon, particularly when the large bronchi are atiected. These sounds (see Auscultation, § 14.), de- nominated the sibilous and sonorous rhonchi, are present chiefly in the early stage, and before ex- pectoration takes place ; and prove the accuracy ofthe rational inference of Dr. Badham, that the difficult breathing of this period is owing to the state ofthe mucous membrane; and I would add, of its sub-mucous cellular tissue also. To these sounds is added the mucous rhonchus; and in proportion as the bronchial secretion, to which it is owing, augments, this sound becomes predomi- nant. When the inflammation is seated in the large tubes, the bubbles of mucous rhonchus are large and uneven ; and the respiration may be still heard over the chest. But when the mucous rhonchus is fine, and is heard constantly, it may be inferred that the small bronchi are invaded. When this is the case in a severe degree, there is also slightly diminished resonance of the chiefly affected part upon percussion. As the disease proceeds, and the secretion passes into an opaque and thickened state, the mucous rhonchus be- comes interrupted, sometimes with obstruction of the respiratory sound in a portion of the lungs, and passes into a sibilant or clicking sound. These changes arise from the entire or partial obstruc- tion of one or more tubes by the thickened mu- cus, and are generally of temporary continuance : occurring now in one part of the chest, and dis- appearing; and now in another. This state of the bronchi fully explains the dyspnoea of this stage. 59. b. Rational diagnosis.—u. The cough in bronchitis is loose, diffused, and deep; in pa- roxysms, and attended with fever, often with wheezing. In pertussis, it is in severe paroxysms, unattended by fever or wheezing; is accompanied with a distinct whoop; and terminates in vomiting. In croup it is sonorous, clanging, and harsh. In laryngitis, it is suffocating, shrill, or grunting; and, on inspiration, attended with a drawing down of the pomuin Adami to the sternum, and retrac- tion of the epigastrium and hypochondria. In pneumonia, it is deep in the chest; frequent and short, often hard; and gives a metallic sort of noise. And, in pleuritis, it is short, dry, hard; sometimes slight, but always suppressed and pain- ful, j?. The expectoration in bronchitis is abundant after the second or third day, or even from the first: in pertussis, it only follows the vomiting: in pneumonia, it is more rounded, distinct, thick- ened, purulent, rusty, and intimately streaked with blood: in pleuritis, croup, and laryngitis, it is scanty, thin, frothy in the latter; sometimes with shreds or pieces of lymph, and entirely different in appearance from that of bronchitis. )'. Pain in bronchitis is scarcely complained of; and consists merely of a sense of soreness, heat, and tightness in the chest, particularly beneath the sternum, and is not increased on full inspira- tion: in pneumonia, it is more marked, especially in certain parts of the chest, generally nearer the lateral regions, and is increased on inspiration or prolonged expiration : in pleuritis, it is very acute, and a full inspiration is impossible: in croup and laryngitis, the pain is increased upon pressing the trachea and larynx. (V. The counte- nance in bronchitis is more frequently pallid or bloated; in pneumonia, it is generally flushed; and dyspnoea is greater in the former than in the latter. The breathing is wheezing and hurried in acute bronchitis; in pneumonia it is less so, and generally without the bronchial wheeze. The pulse, in the former, is frequent, full, free, de- veloped, and soft; in the latter, full, hard, bound- ing or vibrating, and sometimes oppressed and un- developed. The general febrile symptoms are more continued in pneumonia than in bronchitis; morning remissions, with free perspiration, being more frequent in the latter than in the former. The physical signs in pneumonia, pleuritis, &c, are the surest means of their diagnosis. (See art. Lungs — Inflammation of.) 60. Some cases of asthenic bronchitis may be mistaken for humoral asthma ; and occasionally no very distinct line of demarcation can be drawn, both affections either insensibly passing into each other, or being complicated with one another. But, generally, the slow accession of the former, 256 BRONCHI — Inflammation of the—Prognosis. the more continued and less urgent dyspnoea and tightness of the chest, and the presence of febrile symptoms, particularly great quickness of pulse, will distinguish it from humoral asthma; which is commonly characterised by the sudden accession of the paroxysms, their severity during the night, and the attendant orthopnoea, the more or less complete and prolonged intermissions, and espe- cially by the absence of fever, and by the much more marked integrity of the vital and animal powers, than in asthenic bronchitis. In this latter disease, the patient is incapable of leaving his bed or his apartment: in asthma, he may attend to his avocations; or may, at least, change his room in the intervals between the fits. rlhe diagnosis between the sthenic bronchitis and asth- ma is attended with no difficulty. (See Asthma, § 50.) 61. B. Of the chronic.—a. By auscultation. The physical signs of this form of bronchitis are not materially different from the acute. The re- spiration is extremely varied : being sometimes louder, at other times more obscure than natural, and generally accompanied with the mucous rhon- chus ; which, however, is not heard over the chest, but now chiefly in one part and then in another, and seldom during the whole of the respiratory act. The occasional occurrence of the sibilous and sonorous rhonchi indicates that the tubes are sometimes partially obstructed; but this is much less frequent than at the commence- ment of acute bronchitis; and it rarely happens that the respiration is entirely interrupted in a part ofthe lung. Very often, also, when the dyspncea is considerable, or even urgent, the air is heard to enter the lungs as well as usual, the respiratory sound being either distinct or puerile. 'Ihe re- sonance of the chest on percussion is scarcely di- minished. When the bronchitis is very chronic, the tubes sometimes become dilated, from being weakened by the inflammation and strained by the paroxysms of coughing. When this state of the bronchi exists, the sputum is often fetid, and several of the auscultatory signs of tuberculous excavations ofthe substance of the lungs are pres- ent. If the dilatations be large and rounded, it may furnish pectriloquy and the cavernous rhon- chus ; but if, as is more generally the case, it extend to several tubes, or if they be dilated along a considerable portion of their axis, a loud bronchophony is only heard. If this dilatation be extensive, bronchophony, bronchial respiration, sometimes with a "veiled blowing," and even slight pectriloquy, will be heard in corresponding parts of the thorax. On percussion, the sound is often somewhat less than natural, owing to the compression ofthe surrounding pulmonary tissue; and owing, also, to this cause, the dyspncea is often great. Dilated bronchi remain long station- ary; tuberculous excavations generally increase rapidly. The former are most frequently situated in the scapular, mammary, and lateral regions ; the latter in the sub-clavian and sub-acromian regions of the chest. (See the diagnosis in Tu- bercles in the Lungs.) 62. b. Rational diagnosis.—Tt is chiefly with tubercles in the lungs that chronic bronchitis is liable to be confounded; and, indeed, without the aid of auscultation, the diagnosis between them is very difficult. When they both co-exist, and es- pecially when the latter is attended with dilata- tion, we have seen that even auscultation does not easily enable us to ascertain the exact state of disease;: however, by a careful comparison ofthe physical and rational symptoms of both, we may generally form a tolerably correct opinion. Early in chronic bronchitis, the absence of pain during inspiration, the capability of resting on either side, the pallidity of the lips and countenance, the ap- pearance of the sputum (§ 34, 35.), and the wheezing noise on respiration, may readily distin- guish it from tubercular phthisis. As the disease advances, the symptoms more nearly resemble tubercular consumption ; but the pallor of coun- tenance and absence of pain generally continue; or, if the latter be present, it is diffused over the chest, and the patient can draw a larger volume of air into the chest, and retain it longer, than in phthisis. The dvspncea, is less on exertion, consists more of a stuffing sensation, and is more relieved by expectoration; the sputum generally consists of a more considerable portion of mucus, and is more regularly abundant ; and the perspirations are much more partial, the emaciation less, and the paroxysms of hectic much less regular, than in tubercular disease. The cough is very differ- rent. In chronic bronchitis, it is generally deep and sonorous, and in paroxysms; in phthisis, it is short and tickling. When we find copious puru- lent expectoration, but without broken-down por- tions of softened tubercles or of the pulmonary tissues; night sweats; hectic fever, with full deep cough, and absence ofthe physical signs of phthi- sis ;—if, after repeated examinations, there can be detected neither a constant absence of the re- spiratory murmur, nor gurgling cavernous rhon- chus, nor pectriloquy, nor marked defect of reso- nance on percussion,—we may safely conclude the disease to be chronic bronchitis. When this disease depends upon the inhalation of irritating substances, as Dr. Hastings very justly remarks, the cough and copious muco-purulent expectora- tion often continues for months, or even years, without much suffering, with pale countenance, slight lividity of the lips, &c. In these cases there can be no difficulty in the diagnosis. 63. vi. Prognosis.—A. In the acute. When the disease is slight, or limited to a few bronchi only, the disease generally terminates favourably. The change is indicated by a more perfect apy- rex-ia in the mornings, less severe and less fre- quent cough, easier expectoration, and a thicker and more opaque sputum; which, however, gen- erally assumes a more fluid and glairy appearance for a few evenings during the febrile exacerbation. A relapse of the disease is indicated by increase of the fever and cough, and a more transparent, fluid, and glairy expectoration. When the in- flammation is very severe and general, as indi- cated by high fever, dyspnoea, &c, the prognosis should be unfavourable, or given with caution. If symptoms of collapse have appeared, and the mucous rhonchus be heard universally, and with little or no respiratory murmur upon auscultation ; if the pulse become very frequent, small or weak, irregular or intermittent ; and if the countenance be at the same time pallid and anxious, slightly livid, or the nails of the fingers and lips tending to purple ; the danger from asphyxia is extreme. V\ hen the disease occurs in the course of contin- ued or exanthematous fevers, in some epidemic states of hooping-cough, and in the other severe BRONCHI — Acute Inflammation of—Treatment. 257 forms of complication (§47,48.); and when the signs indicating the unfavourable terminations already enumerated appear, the danger is also great, although it may not be extreme. The supervention of pneumonia or pleuritis, or of tracheitis or laryngitis ; a sudden diminution of the expectoration ; the occurrence of cerebral symptoms, of orthopnoea, or even continued dyspnoea, with expansion of the nostrils ; a dark red colour of the tongue ; are all unfavourable circumstances, and indicate imminent danger. On the other hand, when spontaneous evacua- tions occur, with a favourable change in the cough and expectoration, particularly on one of the critical days, although the attack has been extremely severe, a favourable result may be looked for ; more particularly if the disease pro- ceeded from cold, and was uncomplicated. 64. The asthenic form of the disease is very dangerous, when occurring at the extremes of age; but less so when it is unattended by marked depression of the powers of life, and by signs of the circulation of venous blood,—circumstances which, in connection with the frequency, weak- ness, and irregularity of the pulse, the quantity and appearance of the sputa, and with the diffi- culty of expectoration, constitute the danger. 65. B. In the sub-acute and chronic.—If it have arisen from catarrhal affection, and be un- attended by much emaciation or hectic, this form of the disease will generally terminate favourably, althougti the expectoration present a puriform appearance. The more purulent, however, this excretion, and the more marked the symptoms of hectic, the greater the danger. But when the sputum seems to consist chiefly of mucus, al- though the quantity expectorated be great, a fa- vourable issue may take place ; and this will be more frequently the case when the chronic bron- chitis has been consecutive of the acute. When there are constant dyspnoea, very frequent pulse, profuse sweats, and copious purulent expectora- tion, with emaciation, hectic fever, colliquative diarrhoea, associated symptoms of disease of the liver, or of the mucous surface of the bowels, with a smooth, glossy, or chopped, a dark red, or raw appearance of the tongue, a most un- favourable prognosis should be given ; and if to these succeed aphthous eruptions about the mouth and tongue or fauces, little hope of recovery can be entertained. The causes and complications of the disease should also materially influence our prognosis. When it has arisen from mechanical irritation of the bronchi, patients often recover from a very unfavourable state, when the irri- tating cause has altogether been removed. The occurrence of bronchitis in the scrofulous diathe- sis, and its association with tubercles in the lungs, are dangerous circumstances. This complica- tion is to be ascertained chiefly by means of the physical signs. If these indicate the existence of tubercles, or do not establish with certainty their absence, a very cautious opinion should be given. The mucous rhonchus, and dulness on percussion, with the rational symptoms of tu- bercles, are indications of a very dangerous mala- dy. The rapid developement of symptoms of 'the acute, in the course of chronic bronchitis, must be viewed as an unfavourable circumstance. The extremes of age also increase the risk in this as well as in the acute state of the disease. I 22* 66. Causes.—A. The predisposing causes are, whatever lowers the energies of the frame, more particularly too warm or crowded apartments ; sleeping with too many clothes ; late rising, late hours, and too great sexual indulgence; very early, and far advanced age ; the lymphatic and san- guineous temperaments ; relaxed habits of body; febrile and exanthematous diseases, and the sup- pression of accustomed eruptions and discharges. 67. B. The exciting causes are, exposure to a cold and moist atmosphere, or to currents of air, particularly when perspiring : rapid vicissitudes of weather and season ; wearing damp clothes or shoes, or sleeping in damp beds or linen ; con- tinued exposure to dry cold; quick refrigeration of the body after being over-heated and fatigued, or upon coming from crowded apartments and assemblies ; wearing too low or very thin dress, with exposure of the neck and chest; rapid at- mospherical changes, particularly during autumn, winter, and spring, and especially from cold to heat ; epidemic constitutions of the atmosphere ; easterly and north-east winds ; exposure to the night air after rain ; the inhalation of irritating gases, vapours, or mineral or vegetable particles (see Arts and Employments, as Causes of Disease, § 40.); sudden passage from the cold air into over-heated apartments ; catarrhal infection; miasmal exhalations in cold and moist states of the air; the imperfect irruption or retrocession of the exanthematous diseases ; and the translation or metastasis of gout, rheumatism, erysipelas, &c. 68. vii.Treatment.—1st, Of Acute Bron- chitis.—A. In its simple states. M. Broussais gives a very concise view of the indications of cure in this form ofthe disease, which has been adopted, verbatim, by Dr. Hastings ; without, however, referring to the original writer. M. Broussais very justly recommends that the excitement of the sanguiferous system should be moderated, by general blood-letting, acidulated and mucilaginous fluids, and abstinence from stimulating food ; that perspiration be favoured, by saline and antimonial medicines, and by emollients, both internally and externally employed ; and that the irritation and congestion of the diseased vessels be relieved by local depletions and emollient revulsants when erythism of the capillaries predominates, and by rubefacients and vesicatories when the nervous powers are depressed. 69. a. In the first variety ofthe disease, blood- letting is seldom requisite ; saline and antimonial medicines, with demulcents, emollients, &c. being generally sufficient. When, however, fever is con- siderable, and the patient complains of soreness or slight pain in the chest, a moderate bleeding— preferably by cupping—will be serviceable ; and full doses of antimony, or as much as the stomach will bear ofthe solution of tartarised antimony, in frequently repeated doses, will soon remove all febrile disturbance. The following mixture has generally answered this purpose in my practice (see also F. 393. 854.):— No. 66. R Mist. Camphorae, Mist. Amvgdal. Dulc, aa % ij.; Liq. Ammonia; Acet. § jss.; Spirit. ./Ether. Nit., Vim Antimon. Tart., ai 3 'j9s-i Syrup Tolutan. 3 jss. M. Capiat. coch. ij. larga secunda quaque flora. 70. In the third variety, or the asthenic form ofthe malady, blood-letting is generally required; but it ought to be resorted to with much caution, and early in the disease, as recommended by Sy- denham and most practical writers of the present 258 BRONCHI —Acute Inflammation of the—Treatment. day. From eight to ten ounces may be taken from a vein, but, I think, preferably from between the shoulders by cupping ; and afterwards, revul- sants, counter-irritants, and expectorants, may be employed. The admissibility of depletion, or of antimonials, or the extent to which they should be carried, and the propriety of having recourse to stimulating expectorants, necessarily depend, in this form of the disease, upon the degree of mor- bid action and of vital power presented by indi- vidual cases, and upon the quantity of the expec- toration and the difficulty to excrete it. Moderate local depletions are more generally required when this state of disease occurs in children, than when it is met with in aged persons ; whilst the latter are more benefited by expectorants, diaphoretics, counter-irritants, an diuretics, than the former class of subjects. 71. In the second variety of bronchitis, particu- larly when the patient is young, plethoric, or ro- bust, blood-letting should be early and energetical- ly employed, and be directed as recommended in the art. on the Blood (§ 64.); and a full impres- sion made upon the circulation, short, however, of syncope. Immediately afterwards, the pre- parations of antimony, combined according to cir- cumstances, should be given in full and frequently repeated doses, so as to prevent the return of ex- cessive local or general action, and to promote a free and universal perspiration. The preparations of antimony that may be selected for this pur- pose .are the ant. tartar., James's powder, or the kermes mineral (F. 637.); and the first doses of them may be advantageously combined with calo- mel. The following may be exhibited ; or F. 24. 513. 530. 638., or other similar formulas contain- ed in the Appendix :— No. 67. R Hvdrarg. Submur. gr. vj.; Pulv. Jacobi Veri gr. v.; Camphorae rasa; gr. j.; Extr. Hvoscyami gr. v.; Con- •erv. Hosar. q. s. ut fiat Bolus statim post veueesectionem •Omendus. No. 68. R Mist. Camphorae ^ j.; Liq. Ammon. Acet. % ij.; Potassae Nitratis gr. vj.—x.; Spirit. .Elher. Nit. ft) xx.; Vini Antimon. Tart, (vel Vini Ipecacuanha-) H] xx.—xxx.; Tinct. Hyn«cyami TT) xv.; Syrup. Tolutan. ^ j. M. Fiat Haustus, tertiis horis rapiendus. When antimonials are given in as large doses as the stomach will bear, and frequently repeated after the first full depletion, a second will not often be necessary ; or local blood-letting will be sufficient. But if the febrile excitement and the state of the pulse and of the blood drawn indicate it, venisection may, in robust subjects, be again repeated to the extent already indicated. When this variety of the disease affects children, blood- letting, either general or local, according to the age, should be prescribed, with saline diaphoretics, followed by the semicupium or pediluvia. In all classes of subjects, blood-letting must be regulated according to the state of the pulse, heat of skin, the character and quantity of the expectoration, the presence of pain, and the prevailing charac- ter of diseases; attention to these circumstances being especially required in children and aged persons. 72. b. The choice of diaphoretics in this dis- ease is deserving of notice. Early in the first and second varieties I have usually preferred tar- tarised antimony, generally in solution, and con- joined with the vin. ipecacuanha?, or with the spirit, aether, nit., small doses of camphor, &c. But in infants or very young children, in the aged, and in the third or asthenic form of the disease, ipecacuanha seems preferable,—in the latter class of subjects particularly, combined with camphor. In the more catarrhal, or less acute, forms of the complaint, ipecacuanha, combined with nitrate of potash and opium ; and, in the more sthenic states of the disease, the same medicines, in larger doses ; will often prove equally serviceable as the preceding. While febrile excitement con- tinues much increased, diaphoretics or diuretics are often exhibited with little advantage, as the restoration of these secretions is rather the conse- quence, than the cause, of diminished or exhaust- ed febrile commotion. The object, therefore, should be, first to lessen the excitement by deple- tion, alvine evacuations, and sedatives ; and then to make choice of those diaphoretics which pro- duce a lowering and refrigerant operation, until the strength of pulse and heat of skin are reduced. Hence the propriety of adopting the medicines already recommended, and combining them with the nitrate of potash, and with each other. 73. c. Emetics are amongst the most beneficial remedies we can resort to in certain states of bronchitis, particularly in the third variety ; and, in the second, after blood-letting: in children they are often remarkably useful. They have the effect of unloading the bronchi of the mucus .ac- cumulated in them, of relaxing the surface, and afterwards of promoting perspiration. For chil- dren, ipecacuanha should be preferred ; and for aged persons, and the third variety ofthe disease, the sulphate of zinc. In the second form, and in all other subjects, the tartarised antimony is the best emetic that can be prescribed, as it operates both by vomiting, by lowering vascular action, and promoting perspiration. Emetics are more particularly required when the expectoration is difficult or suppressed, the cough severe and suf- focating, and when the disorder depends upon the inhalation of irritating particles. They more- over tend to promote the operation of purgatives, which are generally much required in this disease. In cases of extreme depression, with suppressed excretion of the secretion, the stimulating emetics in the Appendix (F. 402, 403.) should be selected. 74. d. Purgatives and cathartics have been considered by several writers as of doubtful ef- ficacy in pulmonic inflammations; and, when expectoration is established, as being even pre- judicial. Such appears also to be partly the opinion of an able reviewer in the Medico- Chirurgical Review for Dec. 1820. But it is not quite in accordance with my experience, which, at the Infirmary for Children alone, must have amounted to some thousand cases of the differ- ent forms of the disease. It should be kept in recollection, that the expectoration in bronchitis is not a salutary discharge from the lungs, the pro- motion of which is a beneficial indication of cure; but that it is the product of a morbid state, of the nature of which it is an index ; that this state is generally inflammatory, and always attended with determination ofthe circulating fluids, there- by keeping up the discharge. It is obvious, that whatever tends to increase the morbid determina- tion to the bronchial surface will increase the dis- ease, and, consequently the expectoration ; and : that whatever derives from this situation will pro- portionately diminish both. That purgatives or cathartics, judiciously combined, have the effect : of deriving from the lungs, by increasuig the se- BRONCHI—Acute Inflammation of the —Treatment. 259 cretions of the liver and digestive mucous surface, must be evident; and I have accordingly found them serviceable when thus prescribed. Severe attacks of bronchitis, moreover, are favoured by congestions and accumulations of bile in the bilia- ry organs, and by sordes retained on the mucous surface of the bowels. In all those cases more especially — wherein the stools are generally very offensive — and at the commencement of all the forms of the disease, these medicines ought to be exhibited, with the view not only of promoting the abdominal secretions, and of removing faecal matters and sordes, but also of deriving the circu- lation from the seat of disease; and the bowels should be kept very freely open throughout the treatment. It is, of course, understood that we are not to prescribe cathartics to the extent of de- pressing the energies of the frame too low, espe- cially when they are already weak. Indeed, purgatives may be as much required, and as ben- eficially employed, in asthenic cases, as in others of a more phlogistic description, particularly if the bowels have been neglected; effects of a very different nature from that of mere evacuation arising from a judicious choice and combination of them. Thus, when prescribed with bitters, tonics, stimulants, or antispasmodics (F. 266. 471. 572. 880, 881. 887.), in the asthenic or suffocative states of the disease, not only will full alvine evacuations be procured, but also a tonic effect on the digestive organs; and, consecutively, a more moderate secretion in the bronchi, with an easier expectoration, will be produced. I have observed that the combination of purgatives, espe- cially calomel, or those ofthe resinous class, with camphor, antimony, and hyoscyamus, according to the circumstances of the case, is particularly serviceable in bronchial diseases. 75. e. Expectorants have been much, abused in inflammations of the bronchi; chiefly from the circumstance of the expectoration being too gen- erally viewed as a salutary discharge which ought to be promoted, instead of its being a product of the inflammatory state, or of active determination to the surface ofthe air-vessels. I consider them quite inadmissible when there is much fever or heat of skin, or when the sputum is abundant and fluid, the patient having sufficient strength to bring it up; and generally in the second variety of the disease. On the other hand, in the third variety, or when the expectoration is arrested evidently from want of power to throw it off, or to excrete it, or from its great viscidity, expectorants will be of much service. In such cases, ammonia and camphor should be first tried, as being generally least detrimental in doubtful cases, and most quickly beneficial. Where the admissibility of expectorants is evident, especially in the asthenic form of the disease, and in aged persons, squills, ammoniacum, galbanum, or senega, may be di- rected; with the precautions, and in the forms, recommended when treating of them with refer- ence to humoral asthma. (See Asthma, § 89. 103.; and R No. 41—46.) When expectoration is rendered difficult, and the cough suffocative, from the tenacity and consistence of the sputum, as is sometimes the case, attenuants and altera- tives, as the fixed alkalies combined with ipeca- cuanha, &c, or as prescribed in the article on Asthma (§ 103. R No. 50, 51.), and exhibited with camphor or ammonia, will be found of much service. In nearly all states of bronchitis, cam- phor is a most valuable medicine, its virtues have been singularly overlooked by the writers on this disease; but, when combined with colchi- cum, or with antimony, nitrate of potash, ipeca- cuanha, &c, and given in small doses, in the more inflammatory and febrile states of the dis- ease; or when prescribed in progressively larger quantities, with diuretics, the spirit, aether, nit., opium, &c, as the vascular excitement subsides, and febrile heat disappears; and in large doses (from five to ten grains), with ammonia, ammo- niacum, senega, opium, &c, when exhaustion and difficulty of expectoration from deficient power are urgent; it is one ofthe most valuable remedies we possess in this, as well as in several other diseases. 76. f. The inhalation of emollient and medi- cated vapours are occasionally of much benefit in the sthenic form of the disease, but chiefly in its first and second stages. The vapour arising from a decoction of marsh mallows, or from linseed tea, or from simple warm water, is the best suited to this state; and should be employed from time to time, the temperature ofthe apartment being du- ly regulated through the treatment, and constant- ly preserved from about 66° of Fahr. to 75°. Dr. Paris recommends, during the dry easterly winds of spring (when the disease is so preva- lent) , the vapour of warm water to be diffused in the patient's apartment. In the early stage it may be of advantage. In the case of the son of an eminent medical writer, attended by Dr. Gordon, Mr. Annesley, and myself, this was tried in the state of the air alluded to, but with no benefit The case terminated fatally, from extension of the disease to the air-cells and substance of the lungs. When the expectoration becomes whitish, opaque, and thick, the vapour may be rendered somewhat more resolvent by adding a solution of camphor in vinegar, and extract of conium or hyoscyamus to the hot water, or to the emollient infusions now mentioned; and in the asthenic variety, par- ticularly when the difficulty of expectoration, and the fits of dyspncea, are distressing, or when the excretion of the morbid matter is impeded or sup- pressed from want of power, the medicated va- pours and gases recommended in the chronic state of the disease (§ 98.), and in humoral Asthma (§ 88.) may be tried. 77. g. There are various medicines which are occasionally useful, when exhibited in appropriate states and periods of the disease. Amongst these, narcotics and sedatives deserve an especial notice. Opium should not be exhibited alone, as long as febrile action is great; but, in combination with antimony, or ipecacuanha, and nitre, it is often a most valuable medicine. It is best given in small or moderate doses, in conjunction with camphor and expectorants, where vital power is reduced and expectoration difficult (§37.). In general, when the skin becomes cool, the bowels are well evacuated, and the air-tubes remain irritable, opium, or some other narcotic or anodyne, is in- dispensable. Opium, and others of this class of medicines, particularly when judiciously prescrib- ed, are then of service, not only in diminishing the irritability of the system and of the air-pas- sages, and in lessening the cough, the frequency or severity of which often aggravates the inflamma- tory irritation of, and determination to, the bron- chial surface, but also in equalising the circulation, 260 BRONCHI — Acutk Inflammation of the—Treatment. in determining to the skin, and promoting per- spiration. In the more phlogistic states of the disease, and at its commencement, colchicum or digitalis will be often of advantage, in diminish- ing vascular action, local determination, and mor- bid irritability. They ought, however, seldom to be used at the same time. In the more sthenic cases, digitalis is very beneficially associated with the preparations of antimony. When the sputum is thick and opaque, colchicum is generally less beneficial than at an earlier period, excepting in conjunction with diuretii s and camphor. \\ hen the skin has become cool, it is no longer of use. In the third variety, it is se'dom indicated, unless at the commencement of the disease, or when combined with ammonia and camphor. Upon the whole, both colchicum and digitaiis are less to be depended upon in acute bronchitis, than a ju- dicious combination of antimonials with anodynes, &c. Hyoscyamus, conium, and the extracts of poppy and of lettuce, are also very generally ser- viceable in the ditferent forms of bronchitis. Put with them, likewise, the amount of advantage will entirely depend upon the manner in which they are prescribed. In the sthenic and febrile states of the disease, and at its commencement, they should be associated with antimonials, ipecacuan- ha, refrigerants, demulcents, and emollients (F. 24. 208. 427. 554.); with diaphoretics (F. 394. 568. 809.); and with diuretics (F. 818. 865. 893.); or in other similar forms, of which there are several in the Appendix. When the disorder assumes an asthenic state, or when expectoration is difficult, the cough distressing, and the skin cool, any of the sedatives particularised may be con- joined with either ammonia, camphor, or the fix- ed alkalies, or with other attenuants (F. 835.), and with expectorants, &c. (F. 356. 555. 558. 811. 895.) according to circumstances. 78. h. When the acute form of the complaint seems to be about lapsing into the chronic, the combination of gentle tonics with emollients and diaphoretics is often of service, as was first point- ed out by M. Proussais, who allowed also red wines much diluted with water in this state. The infusion or decoction of cinchona, or the infusion of uva uisi, may be thus prescribed: — No. 69. \\ Decocli vel Infusi Cinchona; giijss.; Liq. Amnion. Acet. " jss.; Mucilag. Acaciae %*s.; Spirit. ^ther. Nit. ~, ijss.; Tinct. Camphorae Comp. ^ss.; Extr. Conii gr. xx.; Syrup. Tolutan. >,«. M. Capiat Cochleare iinum amplum secunda vel tertia quaque hora, vel Coch. ij. quintis vel sextis horis. 79. i. External measures ought not to be over- looked during the course of the disease. In re- spect of local or general depletions nothing need be added to what has been already stated. The former of these should always be preferred when doubts are entertained as to the propriety of tak- ing any considerable quantity of blood; and, in the sthenic form of the disease, may be resorted to at an advanced stage, particularly when the change in the expectoration, and other symptoms (§ 35.), indicate a return or exacerbation of the inflammatory action. Blisters are not admissible in the early stages of sthenic bronchitis. But, in the asthenic disease, or when inflammatory ac- tion and febrile heat have been subdued by deple- tions, &c, blisters are of much service, and may be applied either between the shoulders or on the breast; and, in some severe cases, re-applied or kept discharging for some time. In youn<» child- ren, and in adult or aged persons, when the secre- tion ofthe bronchial surface is profuse, and the powers of life much exhausted, I have derived more permanent advantage from the use of the rubefacient liniments in the Appendix (F. 295, 296. 311.), rubbed assiduously twice a day over the chest or back, than from blisters. When blis- ters are employed, much benefit will sometimes arise fi om removing them as soon as slight redness ofthe skin is produced, and covering the part with a large warm bread and water poultice, which ought to be frequently renewed; or by applying a succession of warm fomentations. In some ex- treme cases of this description, I have seen much advantage derived from applying over the epigas- trium and lower part of the chest, a flannel wrung ' out of hot water, and immediately afterwards soaked with the spir. terebinth., and allowing it to remain until severe burning heat ofthe skin is pro- duced by it. If suffocation be threatened either by the profuseness of the secretion, by its difficult ex- pectoration, or by exhaustion ofthe vital energy; and if we be, as we then unfortunately are, at a loss for any probable means of success; this will sometimes have a remarkable effect, and save the life of the patient, particularly when assisted by the internal use of camphor, ammonia, &c. At the time of my writing this, a case occurred, at- tended by Mr. Faxon and myself, where imme- diate relief and a speedy recovery followed this almost dernier resort. And I have often wit- nessed a similar result, in other most dangerous cases of this description, from the internal as well as the external use of this most valuable remedy, particularly at the Infirmary for Children, where I have for many years had recourse to it in cases of danger. SO. The tepid bath, or semicupium, will often be of service early in the disease; and in its course sponging the surface ofthe chest, or ofthe whole trunk, with warm water and vinegar, and after- wards with the warm nitro-muriatic acid lotion (F. 834.), particularly towards the decline ofthe dis- ease, when we dread its lapsing into the chronic, and in the asthenic variety, will often prove of es- sential service. The common beverage of the patient during the treatment should be regulated according to the state of febrile action, and its compatibility with the treatment directed. Bailey water, with any of the vegetable acids, tamarii.d water, or any of the formulae or drinks (vide Po- tus), contained in the Appendix, may be directed. 81. B. Of the complicated states. — a. Pron- chitis is not infrequently associated, particularly at its commencement, with sore throat; inflam- mation existing not only in the fauces, but extend- ing to the pharynx, and through the larynx down the trachea and bronchi. This state of disorder sometimes obtains in scarlet fever, forming a com- plication of remarkable danger. I have also ob- served it, in a very severe form, affect six members of one family, and three of another, both living in the vicinity of the metropolis, in a low damp situ- ation, all of whom had long previously had scar- latina. In some of these cases the danger was great, and all were severe and of the asthenic type. Purgatives, first consisting of calomel and James's powder, and subsequently combined with stimulants and tonics, were actively exhibited. Demulcent linctures (see Linctus, in the Appen- dix), or astringent, cooling, and antiseptic gargles; external revulsants, and rubefacients ; the inter- BRONCHI — Complicated Inflammations of the—Treatment. 261 nal exhibition of camphor, combined with anti- monials, hyoscyamus, diuretics, and afterwards with ammonia, mild attenuants, expectorants, and tonics; the liquor ammoniae acetatis, with infus. cinchona?, spirit, aether, nit., or spirit, am- mon. arom., &c, formed also the chief means of cure. All the cases terminated favourably. 82. 6. When the disease is complicated with scarlet fever, the treatment will altogether depend upon, the character of the prevailing; epidemic, and the circumstances of the case. Early in the complication, local depletions are sometimes re- quired ; and afterwards, full doses of camphor or ammonia, or of both,—particularly if the eruption prematurely disappear, or present a dark tint, or if the anginous affection assume an ash-colour, or a dark red, or brownish hue,—are amongst the chief remedies to be depended on. I have met with severe cases in which the bronchial disease either preceded, or followed, the efflorescence and decline of the eruption in scarlet fever; and in the course of this association most violent cerebral symptoms have supervened; thus forming a dou- ble complication. These cases, although ex- tremely dangerous, are not necessarily fatal. Lo- cal depletion, sometimes to a very considerable extent, may be practised, chiefly by leeches ap- plied over the sternum, behind the ears, or below the occiput, or by cupping on the nape of the neck; and calomel, antimony, revulsants, purga- tives, camphor, ammonia, &c, according to the circumstances of the case, should be prescribed. Counter-irritation by rubefacient liniments is par- ticularly required in complications of the disease with scarlatina or measles. Formulae No. 299. and 300. may be used for this purpose, or the following :— No. 70. R Camphorae 5 j.; Pulv. Capsici ?, ss.; Olei Macis TTT xxx.; Olei OJiva: J jss.; Liq. Ammon. 5 vj. Misce. Fiat Linimentum. 83. c. The appearance of the disease with measles, either previous to, in the course of, or subsequently to, the eruption; or even its accession during convalescence, is a very frequent occur- rence. This association was very common in the winter and spring seasons of 1829, 1830, 1831, and 1832; during which epoch, blood-letting was not so generally indicated, nor so well borne, as in former years, the bronchial affection being more frequently of the asthenic type. In general, however, local depletions are required early in the disease, and, in some cases, may be carried to a considerable extent; often much further than in its association with scarlatina. I have some- times found it necessary to deplete locally in both these states of complication, at the very time when I judged it proper to exhibit camphor or ammonia in considerable doses. But in many instances, particularly during the years above specified, patients have recovered as readily when no sanguineous depletion has been employed, as where it has. Bronchitis occurring either in the course of scarlatina, measles, or small pox, re- quires active counter-irritation and revulsion; and the means recommended for this purpose (§ 79.) to be decidedly enforced. The observations I have already made respecting the use of inhala- tion (§ 76.) also apply to such cases. When these exanthemata commence with bronchial symptoms, emetics are then of decided advantage. And, if they be accompanied with sore throat, ' purgatives ought to be given in decided doses, the bowels freely acted upon throughout, and enemata occasionally thrown up, particularly F. 140. 149. 794. 84. d. When bronchitis occurs in the course of continued fevers, the same general principles of treatment are required, as have been specified in respect of scarlatina and measles. In all these states of complication, this disease should be viewed as a marked manifestation, in a particular organ, ofthe morbid state prevailing more or less throughout the frame; and it should be kept in recollection, that this affection always, in some measure, impedes the changes effected by respir- ation on the blood, thereby increasing the morbid condition of this fluid existing more or less in all severe cases of exanthematous fevers, and at least the disposition to it that obtains even in simple continued fever. The extent to which depletion should be carried in this complication, or the propriety of employing it at all must depend upon the character of the fever, of the prevailing epi- demics, and the particular symptoms and circum- stances of the case. I have seen a strong, and regular-living man, with fever thus complicated, very dangerously depressed by a single small de- pletion. Purgatives are, however, better borne, particularly when combined with camphor or ammonia; and occasional large doses of calomel combined with camphor, and followed in a few hours by a cathartic draught, will be found of much service in promoting the functions of the liver, and enabling it to remove those elements from the blood, which so readily accumulate in it to a hurtful extent, when their elimination by the lungs is impeded. Much advantage will also arise from the use of blisters applied for a few hours, and often repeated; from the use of the rubefacient liniments above specified; and from the inhalation of the vapour of warm water, with a solution of camphor in vinegar added to it. 85. d. The association of the sthenic form of bronchitis with tracheitis and laryngitis, either affection preceding the other, requires full deple- tion, general or local, or both; large and repeat- ed doses of calomel, with antimony; the tepid or warm bath, semicupium; internal and external revulsion, by cathartics, purgative enemata, &c.; emetics, particularly when the paroxysms of suf- focation and stridulous respiration are urgent; the inhalation of watery, emollient, and anodyne vapours; and a free use of diluents, emollients, &c, with the sub-carbonate of soda, the sulphu- ret of potash, small doses of the sulphuret of ammonia, or of the sulphuret of copper, in ex- treme cases, until nausea or vomiting is occasion- ed, &c. Blisters are seldom of much service in this state of disease, particularly whilst the symptoms of croup are present. They ought never to be applied over the throat, as occasion- ally directed, and, in some cases, not without mis- chief; although recovery has taken place in others, notwithstanding the risk they occasioned of in- creasing the local irritation. 86. e. One of the most frequent complications presented to us in practice is that of bronchitis with hooping cough. In some cases, this com- plication commences with the usual symptoms of catarrh, on which those of bronchitis supervene; the characteristic signs of hooping cough, par- ticularly the convulsive fits of coughing, with the 262 BRONCHI —Chronic Inflami inspiratory whoop, and vomitings, uot appearing for some days subsequently. In other cases—and those, perhaps the most numerous,—the inflam- matory affection has not appeared until after the invasion of pertussis. When thus associated, bronchitis may be either sthenic or asthenic; the one or the other being more generally prevalent in some seasons than in others. During the years specified above (§ 83.), the asthenic state was most common; and I have seen several cases in which sanguineous depletion had been injudi- ciously practised, particularly as respects quantity. Cerebral symptoms are apt to occur during this complication, and also infiltration or hepatisation of a part of the substance of the lungs. 'I hese unfavourable terminations should be anticipated and prevented by small local depletions,—by leeches applied behind the ears; by the exhibi- tion of camphor combined with ipecacuanha or antimonials, and narcotics, particularly conium or hyoscyamus; by diaphoretics with diuretics; and more especially by the use of the liniments and revulsants already recommended (§ 79.). (See Hooping Cough.) * 87. /. The simultaneous occurrence of inflam- matory action in both the digestive and respiratory mucous surfaces is not infrequent, particularly in children; and means calculated to benefit the one, generally aggravates the other, or risks the ac- cession of cerebral disease. I have found small local depletions, followed by the pulv. ipecacu- anha- comp., combined with small doses of calo- mel, or hydrarg. cum creta and camphor; the warm bath and frictions, with the stimulating liniments already specified (§ 79.); the applica- tion of blisters for a few hours only, and often re- peated; the liq. ammonia; acet., with spirit, aether. nit., can.phor mixture, diuretics, &c., constitute the principal means of cure. 88. g. The association of hepatic disorder with bronchitis is not rare. But the affection of the biliary organs does not always precede the bronchial disease : it often occurs in its progress; an increased, as well as a morbid, secretion of bile supervening, probably in consequence of the vicarious increase of function ofthe liver, and its irritation by, and elimination of, the morbid ele- ments accumulated in the blood owing to the impeded function of the lungs. This complica- tion requires t!?e use of mercurial purges com- bined with camphor and antimony, particularly James's or kermes powder (F. 637.); external irritants and revulsants, cathartic enemata (F. 151.), &c. A similar treatment is indicated when the disease is connected with the translation of erysipelas, gout, or rheumatism. 89. h. If the inflammation extend to the sub- stance of the lungs or pleura, the antiphlogistic treatment should be rigorously enforced: the solution of tartarised antimony ought to be given in frequent doses, and carried as far as circum- stances will permit; internal and external revul- sants resorted to at the same time; and diapho- retics and diuretics suited to individual cases pre- scribed. In some instances, either colchicum or digitalis, or both, may be substituted for the an- timony; but they answer better, particularly the digitalis, after this medicine has previously been used. If we have reason to suppose that effusion of serum has taken place in the thoracic cavities, diuretics, and, amongst others, digitalis, should be kation of the—Treatment. employed; recollecting, however, that the accu- mulative and sinking effects of either digitalis or colchicum sometimes appear very rapidly, and in an alarming degree, when they are given either at the same time or after the exhibition of tartar- ised antimony. Disease ofthe brain or its mem- branes supervening in the course of bronchitis has been considered in the article Brain (§ 186.). 90. rIhe sub-acute form of bronchitis re- quires in all respects the same treatment as the acute uncomplicated disease, but not carried so far; the activity of the means should have due relation to the acuteness of the attack, and the effects they produce. 91. 2d. Of Chronic Bronchitis. — M. Broussais has very justly stated the indications of cure in chronic bronchitis to be, 1st, to diminish the general excitability, and to keep the circulation quiet; 2d, to solicit the excitement and the fluids to other organs, particularly towards the skin; and, to these I would add a 3d, viz., to restore the healthy tone and functions of the bronchial surface, by means which seem to have this effect either directly or indirectly. It is obvious, however, that the ac- complishment ofthe first und second intentions have an indirect influence in bringing about the third. 92. a. General blood-letting is inadmissible in this state ofthe disease; and even local bleedings should in many cases be employed with caution. Cupping, however, to a moderate extent, is very frequently required; and it is evidently more ad- vantageous to repeat the operation to a small ex- tent, than to abstract a large quantity at once. When the disease has existed long, and is at- tended with a copious discharge, much general debility, and absence of pain upon full inspiration, even local depletion cannot he ventured on. Next in importance to depletion is counter-irritation; and for this purpose several means are presented to us. When there is a tendency to acute action, or when the cough is at all painful, and the spu- tum puriform, either the tartarised antimonial ointment, or a large issue or seton in the side, is preferable; but when there is very marked relax- ation of the bronchial mucous surfaces, blisters, and rubefacients, or a succession of them, seem more appropriate. I have, how ever, found, in a number of cases, the liniments, No. 296, 297. 311. in the Appendix, productive of much greater advantage, and more generally applicable, than either blisters or the ointments, 'lhey may be employed once or twice daily. The vapour aris- ing from them, and diffusing itself around, has also a direct and beneficial effect, by being inhaled, upon the diseased mucous membrane. M. Brous- sais is very favourable to the use of setons and issues; and I have seen several instances of mark- i ed benefit from them, particularly in the obstinate state of the disease which simulates tubercular phthisis. He also recommends warm cataplasms I to the chest, made rubefacient by the addition of mustard. I have seen advantage produced by | warm bread and water poultices applied over blis- I tered surfaces, and the seats of issues formed by the | mezereon bark, and by the same kind of poultices, j to each of which one or two table-spoonsful of the | nitro-muriatic lotion (F. 834.) had been added. j But it is chiefly early in the chronic disease, or : when it has recently passed into this state from the acute, that issues and setons prove successful. They exhaust the energies of the system too BRONCHI — Chronic Inflammation of the—Treatment. 263 much to be of service in the latter stages, or when the discharge from the lungs is profuse, and the vital energies much depressed. 93. b. Expectorants have been much employ- ed in this state of disease; and though more ap- propriate in it, than in the acute, they are often hurtful from their too exciting operation on the vessels of the bronchial surface. This is especi- ally the case with squills, ammoniacum, and se- nega, which ought to be used with much caution, and never whilst the sputum is purulent, and pain or soreness complained of in the chest, with fever, heat of skin, &c. The best expectorants are those which are also astringent, or at least not very heating: amongst these, the sulphate or oxide of zinc, with small doses of myrrh or gal- banum, and extract of conium; or small doses of sulphate of quinine, or of the sulphate of iron, with ipecacuanha and opium; or the sulphuret of potash, and the Balsamum Su/phuris (F. 21, 22.), are the most eligible, when the state of the ex- pectoration, of the skin, and pulse, indicates the propriety of having recourse to tonic expectorants. Opium has been too much reprobated in cases of this description, as well as in acute bronchitis, owing to the dogma that it suppresses expecto- ration. I believe, however, that, when judicious- ly combined, particularly with ipecacuanha, with the muriate of lime, or either of the sulphates of potash, of alumina, or of ziuc; or with the nitrate of potash; with camphor, with kermes mineral, or James's powder, according to the circumstan- ces ofthe case, it is a valuable medicine; and that the diminution of the expectoration produced by it, and which has been unaccountably dreaded, is, when it occurs, a consequence of its changing the morbid state of the vesse's forming the ex- creted matter. If it be the object—as necessarily follows from the doctrine of some writers—to preserve a copious and free expectoration in this disease, how can it ever be cured ? Frequently have I seen this end pursued, as if it constituted all that was required, and squills, ammoniacum, senega, &c. given accordingly; and the more abundant and easy the expectoration thereby produced, the more rapidly did the powers of life give way, or complete hectic, with all its attend- ants, manifest itself. The following have proved serviceable when the pulse was soft, and not re- markably frequent; the skin cool and moist; the sputum very abundant, and consisting chiefly of mucus; and the weakness and emaciation con- siderable :— No. 71. Pulv. Ipecacuanha; gr. j.; Camphorae rasas gr. «s.—j.; Extr. Conii gr. iv.—vj.; Mucil. Acacia; q. s. M. Fiant i'il. ij. ter die capiendae. No. 72. R Zinci Sulphatis gr. vj.; Massae Pilul. Galban Co. » j.; Extr. Conii 3 ss.; Syrup, q. s. M. Fiant Pilu- lae xij., quarum capiat unain tertiis horis. No. 73. R Pulv. Ipecacuan. Comp. gr. xxv.; Quinine Sulphatis gr. vj.; Pulv. Acacias 9 j.; Extr. Lactuca; }) j- j Svrup. Papaveris q. s. M. Fiant Pilulae xviij., quarum ca- piat binas ter quotidn*. No. 74. R Quinina; Sulphatis gr. vj.; Pulv. Ipecacuan- ha; gr. iv.; Camphorae rasae gr. iv.; Opii Puri gr. vj.; Pulv. Rad. Glycyrrh. (vel Extr.) J as-> Mucilag. Acaciae q. s. Misce bene, et fiant Pilulae xx., quarum capiat binas ter qua- terve quotidie. No. 75. R Balsam. Sulphuris 3 ss.; Pulv. Ipecac, gr. vi.; Extr. Conii }) ij.; Pulv. et Mucilag. Acaciae q. s. M. t iant, secundum artem, Pil. xx., quarum capiat binas quarta quaque hora. No. 76. R Solut. Muriatis Calcis TTJ xx.—xxxv.; Mist. Camphors 5 x.; Tinct. Opii Comp. (F. 729.) TTj x.—xx ; (vel. Tiucl. Camphorae Comp. 3 jss0 M- * 'at Haustus ter die capiendus. 94. c. In cases of this description, any of the formulae given under the head Balsams, in the Appendix, may be employed. Dr. Armstrong strongly recommended the balsam of copaiva in chronic bronchitis; but it is seldom beneficial, and is certainly inferior to the other balsams and ter- ebinthinates in this affection (F. 486, 487. 538. 571.). In the more advanced stages of chronic bronchitis, particularly when the colliquative sweats or diarrhoea occur, the most essential ben- efit has been derived from the following mixture, in several cases in which I prescribed it; but even where the bowels are regular, I have found it by no means productive of costiveness. At the time that I was giving this medicine to the third patient on whom 1 had tried it, a case, showing the suc- cess of a nearly similar treatment, was published by Dr. Hastings (Midland Med. Repor. vol. ii. p. 376.), — a coincidence fully evincing the propriety of the practice. No. 77. K Mist. Cretae " vjss. ; Vini Ipecac. 5 jss.; Tinct. Opii 3 j-j (vc' Tinct. Camphorae Comp. 3 vj.); Syrup. Tolutan. 5 ''j. M. Capiat Cochlearia duo larga ter quaterve in die. The cretaceous mixture will often be of service when used alone, or with a little of the muriate of lime, or with the addition of mucilage, or of hyoscyamus, or conium, or extr. lactucse, or the extr. papaveris, according to circumstances. In this state ofthe disease, also, I have seen sulphur given with advantage in mucilaginous electuaries. Dr. L. Kerckhoffs states, that he has adminis- tered it with success, in conjunction with the pow- der of the white willow bark. M. Broussais relies chiefly upon mucilages and demulcents, combined with ipecacuanha and opium, and cer- tainly with great justice. (See F. 284, et seq.). 'ihe extr. lactucae, as recommended by Dr. Dun- can, may occasionally be substituted for the opium. The decoctions of Iceland moss, and the infusions of conium, of marrubium, of the uoa ursi, or of the melissa (F. 230. 237, 238. 245. 267.), with mucilages, anodynes, and ipecacuan- ha, are also very serviceable. I have given the preparations of iodine in a few cases, in small do- ses; and, in some instances, especially when there was little or no febrile action, nor much emacia- tion, benefit appeared to be derived from them. 95. d. When the disease is attended with dyspnoea, and profuse or difficult expectoration, emetics are of great, although often of temporary advantage, particularly in aged persons. Ipecac- uanha, or sulphate of zinc, with the addition of diffusive stimulants (F. 402.), are the most ap- propriate in the majority of cases. After their operation, and if the strength be not very much reduced, the digitalis or colchicum may be pre- scribed, in conjunction with diuretics and gentle astringents (F. 203.). These active medicines are chiefly suited to the more febrile states of the disease, or when soreness or slight pain of chest are complained of, with a puriform expectoration; and are best combined with small doses of blue pill, camphor, and opium,—with pectoral infu- sions and mixtures (see App. F. 244. 426. 497.) with demulcents (F. 389.), and with diuretics (F. 194, 195. 236, 237.). Dr. Hastings recom- mends a combination of digitalis and colchicum; but I have seen more harm than benefit occasion- ed by it in some cases of chronic bronchitis,—a result which might, a priori, be expected from the associated operation of two most depressing 264 BRONCHI —Chronic Inflam mation of the—Treatment. medicines, given in a state of disease character- ised by irritative, rather than by acute, vascular action. I have found them most beneficial when exhibited singly with diuretics, or diaphoretics, in the chronic forms of bronchitis consecutive of exanthematous fevers (§54.); sometimes re- sorting also to the warm bath, followed by fric- tions of the surface with the liniments F. 297. or 311. The combination of colchicum and digita- lis, in small or moderate doses, has proved more serviceable, hi my practice, in tubercular disease of the lungs, or when bronchitis has been com- plicated with tubercles. In cases where the pro- priety of giving these medicines is doubtful, a com- bination of them with the alkalies, or their carbon- ates, and with tonic infusions or decoctions, or F. 515—517., or the following, may be prescribed:— No. 78. ft Pulv. Colchici (vel Pulv. Digitalis) gr. j.— ij. ; Massae Pilul Hydrarg.gr. ij.; Massae Pilul. Galban. Comp. gr. v.; Extr. Opii gr. ss.; Syrup, q. s. M. Fiant Pil. ij. bis terve quotidie sumendae. No. 79. ft Infus. Uvae Ursi 3 xij.; Acidi Sulph. Dil. TT] xx.; Tinct. Digitalis TT] x.—xv.; Tinct. Camphorae Comp. 3 j- i Syrup. Papaveris 3 ss- M. Fiat Haustus, bis terve1 in die sumendus. No. 80. 15 Sodae Sub-carbon, (vel Liq. Potassae) 3 j- 5 Infus. Calumba; (vel Decocti Cinchona?) ^ vj.; Tinct. Col- chici Semin. 3 j-—-ijss.'; Tinct. Digitalis TT] xxx. M. Capiat Coch. ij larga ter in die. No. 81. R Mist. Diosma; Crenatae (F. 396.) § vss.; Tinct. Digitalis If] xxxv. (vel Tinct. Semin. Colchici 3j.— 3 'j- i) Extr. Conii gr. xxvj. (vel Extr. Lactuea; 3 ss.).; Syrup To- lutan. § ss. M. Fiat Mist., Cujus sumat Coch. ij.-larga ter quaterve in die. No. 82. R Pulv. Acaciae % ij.; Mist. Amvgdal. Dulc. et Camphorae aa X iijss. ; Acidi Hydrocyanici "IT] vj.—xij.; Spir. ./Ether. Sulph. Comp. 3 ij-—"j.; Oxymellis Scillae § ss. M. Coch. ij. vel. iij. larga ter in die. 96. Prussic acid is often of much service in the chronic forms of bronchitis, especially in their complications with disorder of the digestive or- gans, and may be exhibited with demulcents, gentle tonics, astringents, or expectorants, or as prescribed in the Appendix (F. 344. 858.). When the disease is associated with derangement of the hepatic functions, or even of the stomach and bowels, it will be necessary to give small doses of blue pill, or of the hydrarg. cum creta, with deobstruents and gentle tonics; and, on some occasions, full doses of calomel from time to time, either alone, or in suitable forms of combination, followed by a purgative. No. 83. R Pilul. Hydrarg. gr. vj. (vel. Hydr. cum Cre- ta gr. xviij.); Pulv. Ipecacuanha? gr. viij.; Extr. Sarsae et Ext. Taraxaci aa 3 j-; Gum. Assaioetida; et Saponis Castil. aa '£) j. M. Fiant Pilulae xlviij., quarum capiat binas ter quaterve in die. No. 84. -R Hydrarg. Submur. gr. vj.; Kermes Mineral. .xij.; Camphora; rasas gr. xij. : Extr. Taraxaci 3 ijss.; xtr. Humuli 3 jss. M. Divide in Pilulas lxiv., quarum capiat ij. vel iij. ter quaterve in die. 97. The treatment which has been already re- commended for Humoral Asthma (see par- ticularly § 100, et omn. seq.), and the tonics and astringents, especially the sulphates of zinc, iron, or quinine, already noticed (§ 93.), are applicable^ with but little variation, to the more chronic and humoral states of the disease, especially in per- sons advanced in life, and in children, when it has assumed a chronic form after hooping-cough and the exanthemata. I have also occasionally seen benefit derived, in these states of chronic bronchitis, from the chlorate of potash, o-iven to adults, in from two to six grains, threVor four times a day. This medicine was often prescribed by myself and one of my colleagues, at the In- firmary for Children, during the years 1826__ 1828, and subsequently, in the more chronic forms of bronchitis, and in various disorders of debility; in which latter it was generally beneficial: but little advantage was frequently derived from it in this disease, unless in those fornjs*©f it now mentioned, where it was often of great use, par- ticularly when the morbid action seemed connect- ed with deficient tone of the bronchial vessels, and of the system generally. Mr. Murray, in a recent publication, states, that he has employed it successfully in consumption, — a name which has usually comprised most of the cases of this form of bronchitis. 98. e. Inhalations of medicated or tar vapours have been recommended by Crichton, Pagen- stecher, Hufeland, Forbes, Hastings, Elliotson, Gannal, and others noticed in the article on Asthma, and been disapproved of by some. I believe that they have frequently been used in too concentrated a state; or too much of the vapour has been diffused in the respired air, occasioning irritation of the bronchial membrane, instead of a gently tonic and healing effect. Whenever any of the vapours advised in this dis- ease produce an increase ofthe cough, either its use should be left off, or its strength greatly reduced. The manner of having recourse to such vapours, as well as the choice of substances emitting them, have not, in my opinion, always been judicious. The tar vapour is occasionally of service, chiefly from the quantity of turpentine it contains; while the acrid enipyreumatic fumes which it also emits, counteract whatever good effect theibrmer con- stituent might produce. Would it not, therefore, be preferable to try the effects of the substance from which the advantage is obviously derived ? I have done so in a few cases of this disease, and seen marked benefit result from it; and therefore recom- mend it to the notice of other practitioners. In former times, medication by fumigations and va- pours was much resorted to; and it is probable, that the early use of incense and various balsamic and aromatic fumes in religious rites had some relation to their prophylactic effect against disease, or even to their curative influence; the more especially, as the priests of antiquity also exercised the healing art. In several of the productions attributed to Hippocrates, the inhalation of vapours and fumes of various resinous and balsamic substances is recommended; and a number of writers in the 16th, 17th, and 18th centuries, have advised a nearly similar method, and employed camphor, benzoin, amber, frankincense, myrrh, storax, as- safoetida, sulphur, cloves, the balsams, &c. for this purpose. This practice was employed by Benedict (see his Theatrum Tabidorum) in consumptive diseases: and Boerhaave gives several formula, in his Materia Medica, for fumi- gations with the above substances. Mead, in his Monita et Precepta, offers several judicious re- marks on this subject. He observes—" that fumi- gations with balsamics, &c. is of vast service in some cases: which is to be done by throwing the ingredients on red coals, and receiving the fumes through a proper tube directed to the windpipe." After noticing the' undeserved neglect of this practice, and the propriety of thus applying me- dicinal substances directly to the seat of disease, he states, that the smoke of the balsam of Tolu conveyed into the lungs, or the smoking this substance like tobacco, is of signal service in BRONCHI—Chronic Inflammation of the—Treatment. 265 diseases of this organ, (p. 58.) It appears from the writings of Fracastori that the fumes of cinnabar were much employed by inhalation in the treatment ofthe constitutional forms of syphilis, at an owly period of the history of that disease, when it assumed a pestilential form. 99. Notwithstanding the unsuccessful attempts of Beddoes to revive the practice, by employ- ing the elementary and permanently elastic gases, but according to views too exclusively chemical, the practice of inhalation has long been neg- lected, or undeservedly fallen into the hands of empirics. Very recently, however, it has been brought again into notice by M. Gannal, Mr. Murray, and Sir C. Scudamore; and chlorine gas, the fumes of iodine, and watery vapour holding in solution various narcotics, have been recommended to be inhaled. I have tried those substances in a few cases of chronic bronchitis; but in not more than two or three cases of tuber- cular phthisis. The chlorine was used in so di- luted a state as not to excite irritation or cough. The sulphuret of iodine, and the liquor hydriodatis potassa concentratus (F. 328.) were also employ- ed; one or two drachms of the latter being added to about a pint of water at the temperature of 1303, and the fumes inhaled for ten or twelve minutes, twice or thrice daily. The tinctures or extracts of hyoscyamus and conium, with camphor, added to water at about the above temperature, were likewise made trial of; and, although the cases have been few in which these substances have been thus used by me, yet sufficient evidence of advantage has been furnished to warrant the recommendation of them in this state of the disease. 100. Inhalations also of the fumes of the bal- sams, of the terebinthinates, of the odoriferous resins, &c. are evidently, from what I have seen of their effects, of much service in the chronic forms of bronchitis : and I believe that fliey have fallen into disuse, from having been inhaled as they arise in a column or current from the sub- stances yielding them, and before they have been sufficiently diffused in the air. When thus em- ployed, they not only occasion too great excite- ment of the bronchial surface, but also intercept an equal portion of respirable air, and thereby interfere with the already sufficiently impeded function of respiration. M. Nystf.n has shown (Diet, des Scien. Med. t. xvii. p. 143.) that am- moniacal and other stimulating fumes, when inhaled into the lungs in too concentrated a state, produce most acute inflammation of the air-tubes, generally terminating in death; and re- fers to a case in which he observed this result from an incautious trial of this practice. I con- ceive, therefore, that the vapours emitted by the more fluid balsams, terebinthinates, the resins, camphor, vinegar, &c, and from chlorine and the preparations of iodine, should be more diluted by admixture with the atmosphere, previously to being inhaled, than they usually are. According to this view, I have directed them to be diffused in the air of the patient's apartment, regulating the quantity of the fumes, the continuance of the process, and the frequency of its repetition, by the effects produced on the cough, on the quan- tity and state ofthe sputa, and on the respiration. The objects had in view have been gradually to diminish the quantity of the sputum, by cliauging 23 the action of the vessels secreting it; without exciting cough, or increasing the tightness of the chest, or otherwise disordering respiration. From this it will appear, that the prolonged respir- ation of air containing a weak dose of medicated fumes or vapours, is to be preferred to a short inhalation of them in their more concentrated states. The want of success which Dr. Hast- ings and others have experienced, evidently has been partly owing to the mode of adminis- tering them, and partly to having prescribed them inappropriately. When the patient com- plains of acute pain in any part of the chest, as in some of Dr. Hastings's cases, they are as likely to be mischievous as beneficial. Where benefit has been obtained, it will be found that it was when the fumes of the more stimulating of those substances were diffused, in moderate quan- tity, in the air of the patient's apartments ; or when he passed, at several periods daily, some time in a room moderately charged with the vapour or fumes of the substance or substances selected for use. (See the remarks on Inhalation in Humoral Asthma, § 88. for an account of various medicines that may be employed in this manner.) 101. f. Sponging the surface ofthe chest, and trunk ofthe body, first with tepid, and afterwards with cold lotions, has often been practised by me with advantage in several states of this disease. When the expectoration has been profuse, the. debility great, and little or no febrile heat pre- sent, I have preferred for this purpose the nitro- muriatic acid lotion (F. 834.), in a warm or tepid state, night or morning, or both. When the dis- ease is more active, the habit of body being, nevertheless, relaxed and debilitated, a solution of common salt in water, or the lotion, R 54., seems preferable; and the directions given re- specting this treatment in the article Asthma (§ 116, 117.) should be strictly followed. I have observed much benefit derived from the appli- cation, for a considerable time, of one of the plasters, F. 111. 115. 118, 119., between the shoulders; whilst cold sponging the anterior of the trunk with the lotions referred to has also been directed. 102. g. The complications of chronic bronchitis require generally no particular modification of treatment from that now detailed : indeed, some of them have been already noticed. I may, how- ever, add, that, in the chronic asthenic states of the disease frequently met with in aged persons, and often occurring in children after exanthema- j tous diseases, hooping-cough, and bowel com- plaints, the flowers of sulphur, the preparations of zinc, the oxide of bismuth, and the chlorates of potash and of lime, have severally been of great service, especially when combined with narcotics — with opium in the aged, and conium in the young, — their constipating effects upon the bowels being duly obviated by the occasional exhibition of purgatives. The chronic bronchitis complicated with, or consecutive of, hooping- cough, the characteristic cough of the latter either still continuing, or having altogether dis- ! appeared, is frequently attended with dilatation I of the bronchi. In these cases, balsams, inhal- ation, the use of tonics, particularly the sulphate j of iron, quinine, the liniments already noticed, j frequent doses of sulphur, or moderate doses of 266 BRONCHI—Dilatation of the—Treatment. the chlorate of potash, are required. If the child be not very young, either of these latter may be combined with belladonna, or with conium, and given in honey or syrup of squills; or with simple syrup, sugar, powdered liquorice root, or with the compound tragacanth powder. When the disease is associated with chronic irritation of the mucous surface ofthe bowels, the chlorate of lime will be of much service, and will soon restrain the latter affection; the use of the liniments already recom- mended (F. 296. 311.), in addition, generally con- tributing to cure the bronchial disease. Either of these liniments has often been sufficient of itself to remove all disorder, both in the consecutive states, and in the different complications noticed at this place; and, when bronchitis seems to have a tendency to terminate, or has actually termi- nated, in effusion, they have powerfully assisted the treatment. When, however, dropsies super- vene, in addition to them, colchicum or digitalis, with astringent tonics; squills, with blue pill, ta- raxacum, or extract of sarsaparilla; the prepar- ations of iodine, alone or with narcotics ; super- tartrate of potash, with the sub-borate of soda, particularly this last ; and various other diuretic and deobstruent medicines in different forms of combination — of which numerous examples are given in the Appendix — and the general plan of treatment recommended in the article Dropsy; should be employed. 103. C. The regimenal treatment of bronchitis requires strict attention. — a. In the sthenic acute disease it should be strictly antiphlogistic; and, at the commencement of convalescence, a farina- ceous diet adopted, until out-of-door exercise may be taken, or shortly before. In the asthenic states of acute bronchitis, this regimen is chiefly appli- cable to the commencement of the disease : sub- sequently, nourishment in small quantities, suited, in kind and frequency of partaking of it, to the state ofthe symptoms, the powers ofthe digestive organs, and feelings of the patient, should' be permitted; and even animal food of a digestible nature, in moderate quantity, may in some cases, particularly in the aged, be permitted once a day. The decoction of Iceland moss, jollies, mucilagin- ous and emollient soups; shell-fish ; the different kinds of white fish, dressed either with sweet oil or the oil obtained by boiling their fresh livers; the lighter kinds of animal food; and, in the case of infants, attention to the milk ofthe mother, or a healthy wet-nurse; are all occasionally of ser- vice during early convalescence from the acute forms of bronchitis, and in the progress ofthe more febrile states of the chronic disease. In the more asthenic cases of this latter, or when the expec- toration is profuse, the skin cool and moist, and the babit of body lymphatic, relaxed, or wasted, ani- mal food, especially fresh beef or mutton, under- done, and in moderate quantity ; new-laid raw eggs ; or a due proportion of digestible and sti- mulating food ; will be found most serviceable. In nearly all the chronic states of the disease, particularly in their advanced stages, a light nu- tritious diet is necessary. 104. b. The patient's beverage should receive particular attention. Lemonade, imperial, barley- water, and the cooling and aperient drinks pre- scribed in the Appendix (F. 588—595. 916.), should be employed in the sthenic form of the acute disease. In the asthenic and chronic states, the red Bordeaux wines, or the wines of Bur- gundy — the former generally reduced by one third or one half water ; or beer or ale, also reduced, to which a little of the liquor potassa>, or of Brandish's alkaline solution, has been added, may also be tried at meals; and either of these, or of the more cooling beverages, adopted, that may be found to agree best with the patient. If the disease evince a disposition to terminate in dropsy, the imperial drink, with the addition of a little borax, or F. 590, 591., will be most service- able. In the advanced period of chronic, or during convalescence from acute, bronchitis, the sulphu- reous mineral waters will often be beneficial. Those of Harrowgate, Leamington, or Moffat, may be tried; or of Enghein, Bonnes, Bareges, or Cauterets (Roche) ; or the artificial waters of Ems or Carlsbad. 105. c. Few diseases are more benefited than chronic bronchitis by change of air. A resid- ence on the southern coast, particularly at Tor- quay, and in various other parts of Devonshire, during the winter and spring months, guarding against vicissitudes of climate, •— which, how- ever, is milder and less variable in this part of the island than any where else; wearing flannel next the skin, especially during winter and spring; gentle exercise on horseback, or the use of the swing; and constant attention to the state of the bowels; are severally of great importance. During the progress of convalescence, as well as in the earlier stages of disease, particularly if the secre- tion from the bronchi continue, it will be neces- sary to resort occasionally to an emetic; and in a day or two subsequently, notwithstanding the bowels may be freely open, to an active cathartic. In these cases, the addition of a vegetable bitter or tonic to a purgative medicine, — as the sul- phate of quinine to aloes, or the infusion or ex- tract of gentian to senna,—will have a decidedly cathartic operation, without lowering the energies of the frame. There are few diseases more Dene- fited, either in their progress or decline, than those now discussed, by active purging; but it will often be requisite to combine the purgatives with stimulants or tonics, in order that an active or continued operation on the bowels may not ex- haust the patient. During convalescence, the free use of purgatives requires a liberal and in- vigorating diet. 106. V. Dilatation of the Bronchi.— The anatomical characters and physical signs of this change of the bronchi have been already described (§ 19.). It is almost entirely a con- sequence of, or an attendant upon, the more chronic cases of bronchitis, or of hooping-cough complicated with bronchitis. The expectoration, besides being copious and puriform, is often foetid, — a diagnostic symptom of this alteration, with- out which, M. Louis, and other pathologists, who have devoted much attention to pulmonary dis- eases, has sometimes failed of distinguishing it from phthisis. 107. The Treatment of this alteration is near- ly the same as that which has been recommended in the more chronic states of bronchitis. The means which are especially indicated consist of the in- halation of balsamic and terebinthinate fumes; of those of chlorine, iodine, &c. (§ 99,100.); the in- ternal use of balsams, tonics, and bitters, particu- larly the sulphates of quinine, or of zinc, or iron; BRONCHIAL FLUX —Diagnosis. 267 and other preparations of cinchona or steel; with the use ofthe liniments already noticed (§ 102.); or the nitro-muriatic lotion on the chest. The chlo- rate of potash, or of lime, seems indicated in this form ofthe disease. An open state ofthe bowels, an occasional cathartic, nutritious diet, and change of air, are also evidently required. In other re- spects, the treatment already detailed (§ 101, et seq.) may be followed ; or modified according to the peculiarities of the case. 108. VI. Ulceration of the Bronchi (see § 7, 8.) is another alteration which is pro- duced by, or is attendant on the advanced stages of, chronic bronchitis; most frequently, however, when complicated with tubercular phthisis. It is not infrequently met with, particularly after bron- chitis occasioned by the mechanical irritation of mineral, vegetable, or animal molecules. The existence of ulceration, when seated in the bron- chi, is not indicated by any sign in addition to those which accompany the most chronic states of bronchitis, or tubercular disease, when it arises from, or is complicated with, this change. When affecting the Larynx or Trachea (see these articles), it may frequently be suspected, or oc- casionally prognosticated. In a case which occur- red in the trachea, a prognosis to this effect was given by me long before death. 109. The Treatment of this lesion, even could its existence be ascertained during life, cannot be different from that required in some other states of chronic bronchitis. That ulcera- tion may take place in the bronchi, and heal, as evinced by the appearance of cicatrices, has been ascertained by M. Laennec, and other patholo- gists. In addition to the means of cure already described, the establishment of local drains ofthe most active kind is obviously required. Blisters and issues applied to a tlistant part have not been found of use by M. Laennec He prefers the repeated application of small moxas as near the seat of disease as possible, and the preservation of absolute rest and silence. The inhalation of emollient, anodyne and balsamic vapours and fumes may likewise be tried; and, if the disease be devoid of marked febrile excitement, the ex- pectoration abundant, and the powers of life con- sequently reduced, the treatment advised for dila- tation of the bronchi (§ 19.) may be employed in all its parts. (For the treatment of other organic changes of the air-passages, see arts. Croup, Larynx, Lungs—Hamorrhage from, and Trachea). VII. Bronchial Flux. — Bronchorrhcea (from /'tf.) Syn. Bron- chorrhie (Roche). Catarrhe Pituiteux (Laennec). Mucous Flux. Classif. I. Class. III. Order (Author). 110. Defin. A flux of watery mucus, or phlegm, from the chest, with more or less cough, but without fever; frequently occasioning exhaus- tion. 111. This affection varies considerably. It is often a variety of chronic bronchitis; being con- secutive of it in persons advanced in life, or those of a relaxed and phlegmatic or pituitous habit of body. In other Ciises it appears from the com- mencement, or consecutively of slight catarrh, as intermediate between chronic bronchitis and hu- moral asthma. This appellation may, upon the whole, therefore, be viewed as applicable to those ] cases which are attended with a more abundant, fluid, and transparent expectoration, than is ob- served in chronic bronchitis, and are devoid of fever and all other signs of inflammatory action; whilst they are equally without the severe dys- pnoea, the paroxysms of suffocation and cough, and the intermissions, characterising humid asthma. 112. Bronchorrhoea proceeds generally from similar causes to those which produce common catarrh, or bronchitis, even although it be not consecutive of some one ofthe forms of bronchial inflammation. It is very frequently, either at its commencement, or recurrence, connected with cold and moist states of the atmosphere, or occa- sioned by exposure to cold in some one or other of its forms. When it occurs as a sequela of bronchitis, it may be viewed as arising from lost tone of the vessels and of the bronchial surface, the flux or determination to this part still continu- ing, from peculiarity of habit or some other cause, after all inflammatory and febrile symptoms have been removed. Thus it is very frequent in aged persons of relaxed fibres, who have experienced repeated attacks of pulmonary catarrh. 113. Diagnostic symptoms. — Bronchorrhoea may be distinguished from chronic bronchitis, tubercular phthisis, and humoral asthma, by the following characters :—The quantity of fluid ex- pectorated is veiy great ; being, in some cases, as much as four or five pounds in the twenty- four hours. The sputum is colourless, ropy, transparent, slightly frothy on the surface, and resembling the white of egg mixed with water. It is without the thickened sputa generally ac- companying chronic bronchitis. There is con- siderable dyspnoea, but the chest sounds well throughout upon percussion; and the cough is slight comparatively to the quantity ofthe expec- toration, being evidently no more than is occa- sioned by the discharge of the secreted fluid. The pulse and temperature of the skin are natu- ral, and there are no night sweats. The appetite is generally unimpaired; and emaciation is not remarkable, or not at all observed, unless the quantity of the sputum be extremely great. M. Nauche states, that the expectoration in this state of disease is always more or less acid, and reddens turnsole paper, whilst that proceeding from inflammatory action restores the blue tint to this paper after being reddened by acids. On auscultation, the respiratory murmur is common- ly weak, but is very rarely suspended. The sib- ilous rhonchus is heard more or less distinctly, and often mixed with the sonorous, and occasion- ally with the mucous rhonchus, the bubbles of which seem to burst upon the surface of a fluid of less consistence than in bronchitis. 114. Bronchorrhoea usually commences with catarrhal symptoms, and frequently without fever. In other cases, after bronchitis has continued chronic for a longer or shorter period, the expec- toration becomes less consistent and less opaque, more abundant, and similar to that described; arid the affection becomes established,—aggravated at times by disorder of the stomach or bowels, or by changes of the air, especially by cold and moisture, or by arrest of the cutaneous transpira- tion from any cause,—and ameliorated at other times by a warm dry air, an open state of the bowels, and light nourishing diet, taken in mod- erate quantity. Vacillating in this manner, the 268 BRONCHIAL FLUX —Treatment. disease may continue for years if it be not severe, without materially affecting the strength. But more frequently the discharge increases, after irregularly prolonged, and more or less slight in- tervals; the patient loses his flesh, and becomes paler; his strength is impaired; dyspnma increases; and, in some cases, the affection either runs into humoral asthma, or the quantity of expectoration is augmented so as to exhaust his energies, and to occasion suffocating paroxysms of cough. In rarer cases, the quantity of the bronchial dis- charge has been so great as to occasion the ex- haustion and death of the patient. M. Andral has detailed two cases of this description, wherein, upon dissection, no evidence of inflammation or congestion could be found in the air-tubes. M. Roche has described, what he has designated an acute form of this affection, which other French pathologists have named catarrhe suffocant; but it differs in no respects from the more humoral states of asthma, described in its more appropriate place, and presenting all the symptoms of spasm of the air-passages, with a copious viscid expec- toration ; the spasm and other symptoms subsiding after the bronchi and trachea are unloaded of the secretion accumulated in them. Bronchorrhoea has, in rare instances, been the means of remov- ing other diseases. M. Andral states that he has seen hydrothorax disappear after the establish- ment of a copious bronchial flux. ' 115. Treatment.—After the full exposition that has been given of the means of cure in the different states of chronic bronchitis, to some of which bronchorrhcea is closely allied, it will be sufficient to enumerate succinctly the various means wliich are applicable to this affection. As the disease essentially consists of an increased secretion and exhalation from the respiratory mucous membrane, with a determination of the circulation to that quarter, and deficient tone of the vessels distributed to it, the obvious indica- tions are, to increase the secretions from other surfaces and organs, thereby to derive from the lungs, and to restore the lost tone of this mem- brane and its vessels. In some cases, accord- ingly, it will be advantageous to commence with an ipecacuanha or sulphate of zinc emetic, and afterwards to act freely upon the secretions and alvine excretions by purgatives. I have never seen a case of the disease which has not been much relieved by purgatives ; taking care, how- ever, that they should not lower the energies of the constitution, by combining them with tonics, bitters, or stimulants, and allowing sufficient light nourishment to admit of this mode of deriva- tion being satisfactorily employed. In the inter- vals between the exhibition of purgatives, diuret- ics and diaphoretics may be exhibited, and the cutaneous functions promoted by wearing flannel next the skin during the winter and spring months. 116. Expectorants are very much employed in this affection; but some of this class of medicines are seldom of benefit in it, unless combined with opium. The balsams and terebinthinates (F. 484 —487. 489.); the sulphate of zinc, with myrrh, or the compound galbanum pill; and either of these, with camphor and opium; are often of service. In addition to these, inhalations, as recommended in another part (§99, 100.), may be employed. Although astringents and inhala- tions are often required, yet we should be cau- tious in using them when the disease lias been of very long continuance, particularly in persons advanced in age, or when there is any irregulari- ty of the action of the heart, or physical sign of organic change about this organ, complicated with it; inasmuch as the arrest of an habitual discharge will, in such circumstances, risk the supervention of efiusion in the cavities of the thorax. It will be more judicious, in these cases, to confide in purgatives combined with bitter tonics; in diuretics, and in diaphoretics, so as to moderate the discharge, and prevent its increase, or its exhausting effects upon the system. At the same time the vital energies should be pro- moted by a light nutritious diet, moderate exer- cise, and change of air, with the sulphureous or gently tonic mineral waters. In other cases, where the age of the patient, the regular or heal- thy state ofthe heart "s action, the absence of leu- cophlegmasia, and the circumstances of the case altogether, are such as to preclude die d of the consequences of suppressing this discharge, cold sponging the surface of the body by the nitro- muriatic lotion, &c. (§ 101.), and the liniments already noticed (F. 296. 311.), with the inter- nal use of the more astringent tonics, particularly the sulphates of iron or of quinine, in addition to the measures already recommended, may also be practised. Bibliog. and. Refer.—Morhof, Princeps Medicus, 4to. Rost. 1665.—Radcrer, Disser. de Catarrho Phthisin Mentientc, 4to. Goet. 1758.—Richter, On Mucous Con- sumption, in Med. and Surgical Observations. Edinburgh, 1794.—Beddoes, On the Medicinal Use of Factitious Airs, &c. Brist. n95.—Englehart, De Catanho Inflaininalorio, 4to. Lund. 1799.—La Roche, Essai sur le Catarrhe Pul- monale Aigu, Svo. Paris, 1802. — Beitrand, Sur la Dis- tinction du Catarrhe, de la Pleurisie, et Peripneum. kc 4lo. Paris, 1804.—Cabanis, Observ. sur les Affect. Catarrh. Svo. Paris, 1807.—Budhum, On the Inflammatory Affec- tions of the Mucous Memb. of the Bronchia1, 8vo. Lond. 1B10.—J. P. Frank, Interp. Clinic, p. 110. Tub. 1812.— J. Frank, Praxis Medica, kc part ii. vol. vi. p. 359.—Fer- riur, On the Effects of Pneumatic Medicine, Medical His- tories, kc. vol. ii. p. 261. Lond. 1810. — Broussais, Histoire des Phlecmasics on Inflammations Chionique*, kc t. i. p. 69. 3d edit. Paris, 1822.—Cheyne, On the Pathol, of the Larvnx and Bionchia. Edinb. 1809.—Alard, Du Siege et de la Nature des Maladies, 2 t. Paris, 1821.—Villermi, Diet, des Scien. Mfd. t. xxxii. p. 208. — Hastings, On In- flam. of the Mucous Membrane of the Lungs, &:c. 8vo. Lond. 1820.; and Midland Medical Reporter, vol. ii. p. 397.—Roche et Sanson, Nouvcaux Eltmens de Pathol. Medico-Chiiurgicale, t. i. p. 560.; et Diet, de Med. et Chir. Prat. t. iv. p. 258.—Armstrong, On Scarlet Fever, Measles, and Consumption, 2d edit. Lond. 1818. — Bouillaud, in Journ. Complement, de Diet, de Sciences Med. t. xix. p. 5. — Dunctm, Observations on Pulmonarv Consump- tion. 2d edit. p. 162.—Laeninc, Traite de l'Auscullation Mediate, et des Maladies des Poumons, kc 2d edit. Paris, 1826.; et Rev. Mtd. t. i. p. 384. 1824.—Andral, Clinique Medicale, &c. t. ii. p. 1.; ct Anatomie Patho- logique, t. ii. p. 465.; et Archives G. ner. dc Medicine, t.'iv. p. S14.—Ro,,e>-Collard, Nouv. Biblioth. Med. t. i. p. 196. 1826.—Sa-.in, Rev. Medicale, t. ii. p. 520. 1826.— Mills, Account of Morbid Appearances from Disorders of the Lungs and Heart, Svo. Lond. 1830. — Alcoik, On In- flammation of the Mucous Memb. of the Organs of Re- spiration, Medical Intelligencer, Nos. vii. and viii. p. 151. —R. Harrison, in Medical and Physical Journ. Julv, 1820. — Johnson's Medico-Chiiurg. Review, Dec. 1820. p. 341.—Chomel, Diet, de Med. t. iv. p. 417. art. Catarrhe Pulmonaire.) — Hildenbrand, Institut. Prs>ctico-Medica>, t. iii. p. 470.—Pagenstecher, in Hufelnmi's Journ. der Pract Heilk. Nov. 1827.—Crichtm, On the Treatment of several Varieties of Pulmonary Consumption, and on the Vapour of Tar in that Disease,'8vo. Lond. 1823. — Elliot- son, Lond. Medical Gazette, t. viii. p. 289.; and Lancet, vol. xvii. p. 467.—Bayle, Recherches sur la Phthisie (in some cases of chronic bronchitis found the bronchial sur- face pale, and zvithout change , obs. xlix. p. 392. Paris, 1810.—Abercrombie, in Edin. Medical and Surgical Jour- nal, vol. xvii. p. 39. (Ulceration of the bronchi.)—J. BRONCHOCELE — Causes and Morbid Relations. 269 Forbes, On Tar Vapour in Diseases of the Lungs, Sec, in Medical and Physical Journ. vol. xlviii. p. 281.— Wil- liams, On the Physical Signs of Diseases of the Lungs, kc. p. 60. 8vo. Lond. 1829. — Forbes, Original Cases, illus- trating the Use of the Stethoscope and Percussion, Svo. Lond. 1824. — Gendrin, Histoire Anatom. des Inflamma- tions, &c. t. i. p. 545. Paris, 1826. — Bright, Reports of Medical Cases, kc p. 127. 4to. Lond. 1827. BRONCHOCELE (from Bq6Y/oc, throat, and x/JAi/, a swelling). Syn. Hernia Gutturalis, Gossum, Luftrohrenbruch, Kropf, Ger. Goi- tre, Fr. Broncocele, Gozzo, Ital. Thyro- phraxia, Alibert. Cynanche Thyroidea, Con- radi. Goitre, " Derbyshire Neck." Classif. 4. Class, Local Diseases; 6. Or- der, Tumours (Cullen). 6. Class, Ex- cernent Function; 1. Order, Affecting the Parenchyma (Good). IV. Class, IV. ' Order (Author, see Preface). 1. Defin. Chronic enlargement of the thy- roid gland, sometimes with change in the sur- rounding parts, generally increasing slowly, of- ten continuing for years, and depending upon constitutional causes. 2. I. Causes, and Morbid Relations.— This disease is endemical in Derbyshire, and some other parts of this country; but most remarkably so in Switzerland, various adjoining districts, and in some places in South America. It usually oc- curs during the early epochs of life, most frequent- ly about the period of puberty, in persons of a weak and lax fibre, and generally in females; it very seldom being observed in Great Britain in males: but the comparative frequency of it in the latter sex is greater in Switzerland, and other parts where it is very prevalent, and is connected with cretinism. In a considerable number of cases which have come before me in females, I have never met with any before the period of commencing puberty,—not even at the Infirma- ry for Children; although the menses have often been delayed for a year or two, or even longer, when the tumour has appeared at this epoch; and I have seldom observed an instance in this sex unconnected with some kind of irregularity of the menstrual discharge, or disorder ofthe uterine functions. In two cases, occurring in married females, who were under my care, unhealthy or irregular menstruation had existed during the continuance of the goitre; in one case for eight years, in the other for five: upon its disappear- ance, pregnancy took place in both. Suppres- sion of the menses has sometimes caused its sud- den appearance and rapid developement; and it more rarely has originated during pregnancy and the puerperal states. Authors have adduced con- clusive proofs of its occurrence hereditarily, inde- pendently of endemic influence. 3. Dr. Good has attributed the disease, in a great measure, to poverty, and the nature of the food: the rich being exempt from it. This is, however, very far from being the case. I have seen several cases of bronchocele in the richest in this metropolis. He is also wrong in attributing it to the use, in Derbyshire, of oaten cakes. In Scotland, where this article of diet is in general use, bronchocele is rare. 4. That it chiefly depends upon certain phy- sical causes is shown by its prevalence in certain districts in preference to others, and by the cir- cumstance of its disappearance when persons af- fected by it endemically have changed their resi- 23* dence. M. Alibert mentions his having seen it disappear after a residence in Paris. It has been very generally imputed to the water used- by those affected. Since the time of Pliny, it has been attributed to the use of snow water. But it prevails in several places where this cause does not exist, as in Sumatra, and several parts of South America. The Swiss who drink snow water are free from the disease, while those who use hard spring water are most commonly affect- ed. Captain Franklin states, that at a part in his journey to the Polar Sea, where bronchocele prevails, it is confined to those who drink river water, and that those who use melted snow es- cape. Mr. Bally ascribes its frequency, in a district in Switzerland, to the use of spring water impregnated with calcareous or mineral substan- ces; and he states, that those who use not this wa- ter are free from both goitre and cretinism. Dr. Coindet observed that the inhabitants of Gene- va, who drink the hard pump waters, are those most liable to bronchocele. Its prevalence in Not- tingham is ascribed by Dr. Manson to the same cause; which also seems to occasion it in Sussex and Hampshire, in the valleys of which counties it is frequently met with. 5. That this is, however, not the only cause, may be inferred from other physical circumstanc- es connected with its endemical prevalence. Its great frequency in low, moist, marshy, and warm valleys, and the exemption of the inhabitants of dry and elevated situations, have been shown by Larrey, Fodere, Saussure, Reeves, Clark, Valentin, Postiglione,, and J. Johnson, as respects various districts in Switzer- land, the Tyrol, Carinthia, the Vallais, and the north of Italy. Similar facts have been adduced by Dr. Gibson, and Humboldt, in regard to the United States, and South America. It is most probable, however, that the exhalations from the soil of those localities are not the only, but a concurrent cause, cooperating with others possessing equal influence in the production of the disease, and particularly with the nature of the water. But it as certainly sometimes- appears where neither of those causes can be traced, as in London; disorder of some kind in the uterine functions being the most frequent morbid relation it lias presented, as far as my experience hast gone. Its connection with cretinism in the dis- tricts on the Continent above alluded to, and the occasional appearance ofthe disease at very early periods of life ■— it being even sometimes congenv- ital, in these countries, as well as being more common there in the male sex than in this country — are matters of some interest, and not readily admitting of explanation; since poverty, close, confined, and ill-ventilated apartments, are not the chief causes of those phenomena, as shown by their absence in the poorest classes in this metropolis. Dr. Parry has seen goitre follow diseases of the heart, and epilepsy. Fla- jani has noticed the common occurrence of pal- pitations and affections of the lungs from the dis- order it has occasioned of the respiratory func- tion. When the tumour is very large, or hard, or when it has increased suddenly, it not infre- quently occasions most urgent symptoms, by its pressure on the trachea, oesophagus, and jugular veins. 6. As respects the External and internal ap- 270 BRONCHOCELE —Diagnosis—Treatment. pearances of this tumour, I may briefly observe that it affects generally the whole gland; but is also sometimes confined to the lateral or to the middle lobes: it is more rarely larger on one side than another. At first it is commonly compact, rounded, and equal; but, as it increases, it is either soft and flabby to the touch, or unequal, irregular, hard, and obscurely lobulated. It is usually free from pain, and is not discoloured. When it is greatly increased in size, and is soft, it appears pendulous, chiefly owing to its lower parts being most enlarged. When the tumour is divided, the cells of the gland are found, accord- ing to Hunter, Baillie, and B. Bell, filled with a more or less viscid fluid; and are of vari- ous sizes, generally from that of a pea down- wards, not only in different cases, but even in the same gland. In the older, harder, and more ir- regular forms ofthe tumour, melicerous, steatom- atous, cartilaginous, and ossific deposits have been met with in parts of it, by Celsus, Dr. Haen, Freytag, Giraud, Hedenus, and others. The usual state in which this disease presents it- self, obviously, is that of an increased secretion into the cells of the gland, distending them more or less; the other changes sometimes observed, being consequences of obscure irritation induced in parts of it during its continuance or growth. 7. II. Diagnosis. — It is necessary to be aware that other diseases of either a more acute or malignant character may affect the thyroid gland and its vicinity, and be mistaken for bron- chocele. 1st, The gland may be either healthy, or but little enlarged; the tumour consisting chief- ly of thickened surrounding cellular tissue, some- times containing cysts filled either with a serous, albuminous, or purulent matter. Large encysted tumours may also form in the course of the tra- chea. But these may be readily distinguished by their situation, form, and fluctuation. 2d, The gland itself may be the seat of chronic or acute inflammation. In this case the swelling increases more rapidly, but seldom attains a large size; and is generally attended by redness of its surface, and increased temperature. It is also painful, parti- cularly on pressure, and is very hard. I lately saw a case of this description, in a married female of about thirty, who was also seen by Mr. Lloyd, where the inflammation had proceeded to suppu- ration, and had terminated in an external opening. I believe that inflammation of the gland never occurs but in scrofulous habits. 3d, The gland may also be the seat of scirrhus, which may ul- timately go on to carcinomatous ulceration; but this is a rare occurrence. In this case the gland is very hard, seldom large, sometimes scarcely increased in bulk, and is the seat of sharp darting pains. It is only met with in persons advanced in age. Alibert states, that he has observed a case of goitre pass into cancer; but I doubt the fact; cancer having a very wide and indetermin- ate signification with this writer. The disease can scarcely be mistaken for aneurism of any of the thyroidal arteries, if any share of attention be directed to the subject. Bronchocele has been considered in the light of a strumous disease__ as a form of scrofula. Dr. Postiglione, how- ever, contends that no connection exists between these diseases. As respects the state of morbid action in the gland, the concomitant phenomena, and the respective terminations of both diseases, i there is certainly no intimate relation between I them. S. III. Treatment. — Previous to the use 6f iodine in the cure of bronchocele, numerous rem- edial means were recommended by writers. Of these, the most common were frictions with vari- ous liniments; dry rubbing; stimulating and astrin- 1 gent lotions; cold bathing, and cold douches; mercurial applications; plasters with cicuta and I ammoniacum, or with ammoniacum and hydrarg.; repeated blistering; leeches applied to the tu- mour; electricity and galvanism; moxas, issues, and setons; ligature of the arteries supplying the gland; and extirpation of the gland itself. Amongst the internal remedies recommended, I may notice the various preparations of mercury; digitalis combined with camphor (Ossiander); sulphuret of potash; muriate of barytes (Posti- glione); cicuta or belladonna, either aione, or with the muriate of baryta; the muriate of lime; preparations of potash and soda; various mineral springs; the use of sea water, and of distilled water; the ammoniated muriate of iron; burnt sponge, given either alone, or with mercury; and the ashes of the fucus vesiculosus (Russell). 9. Of all these, the most celebrated was burnt sponge; and, after the discovery of iodine, this substance, which, having been found by Dr. Straub, of Berne, to be contained in officinal sponge, was recommended by him in 1829, and adopted by Dr. Coindet, of Geneva: and so successful has this medicine proved in the treat- ment of bronchocele, that, of a hundred and twen- ty cases treated with it by Dr. Man son, of Not- tingham, seventy-nine were cured, eleven great- ly relieved, and two only were not benefited by i it. Of several cases of the disease which have come before me since the introduction of this remedy into practice, there has not been one which has not either been cured or remarkably improved by it. I believe, however, that al- though it has been found the most certainly ben- eficial of any medicine ever employed in bron- chocele, some other practitioners have not deriv- ed an equally uniform advantage from its use. I can account foi this only by considering that it has been given in too large and irritating doses, or in an improper form; and without due atten- tion having been paid to certain morbid and con- stitutional relations ofthe disease during the treat- ment. The cases of two females who were late- ly completely cured by the remedy confirm this inference. They had both had the tumour for several years, one for nine years; and had, on former occasions, gone through long courses of • iodine, prescribed by judicious and eminent prac- ! titioners, but without advantage. When this med- icine was ordered by me, it was, therefore, with great difficulty that they were induced to have re- course to it again. It was ordered in very small doses, often repeated, and strict attention was I paid to the state of the secretions, and to the | uterine functions. In the course of a fortnight an improvement was manifest; and of a few weeks longer, a great decrease of the tumours had [ taken place. One of these females, a married woman, who had been once pregnant nine years before, upon the disappearance of the tumour came with child; soon after which it somewhat suddenly reappeared, but the resumption of the 1 iodine again dispersed it. The preparations given BULLAE. 271 in the Appendix (F. 204. 277, 278. 302. 323, 324.) are those which an extensive experience of its effects in various diseases, as well as in this, has led me to adopt. 10. In respect of the use of iodine in bron- chocele, the weaker preparations should be at first preferred ; and care should be taken never to exhibit them to the extent of irritating the stomach or bowels : when this effect is produced, little or no benefit will be derived from them. The suc- cess which Dr. Manson and M. Lugol have de- rived from this valuable medicine, I know from experience to be chiefly owing to the small and soluble doses in which they exhibited it. In some ofthe more obstinate cases, it will be often requisite to assist the operation of iodine by other means. Sometimes the occasional use of emmenagogue aperients will be of much service; and when the uterine functions evince disorder, as they very frequently do in cases occurring in females, I have usually directed either the sub-borate of soda, or milk of sulphur, to be taken, in the form of electuary, every night (F. 89. 281.). A calomel purge will also be sometimes of service. I have generally preferred the internal to the external use of the medicine in this disease. In some more obstinate cases, they may be both employed; but its external application should be of the mildest kind. In some cases, a moderate blood-letting may be premised; and some writers recommend that leeches should be applied to the tumour itself. Nearly all the cases which I have seen, having occurred in females, in whom it appeared requisite either to promote the menstrual discharge or to subdue uterine irritation, I have usually di- rected the bleeding, when practised, to be per- formed in the feet, or leeches to be applied to the groins. Dr. Coster has adduced a case in which galvanism materially assisted the iodine in remov- ing bronchocele. 11. Dr. Kolley has stated, that iodine should not be exhibited where there is a disposition to congestion in the head and internal viscera; when febrile and inflammatory symptoms are present; when gastric, hepatic, or intestinal disorder exists; and when there is a disposition either to hydro- cephalus or to pulmonary consumption. This is in some respects just; but after depletions, and when the more marked symptoms of these dis- orders are subdued, iodine may, notwithstanding, be exhibited, if its effects be carefully watched, and if the mildest and weakest preparations be selected, and these be combined with anodynes and narcotics. I have observed that a continued course of iodine has sometimes had the effect, particularly during cold weather, of producing pains in the limbs or joints resembling rheum- atism, which have continued to increase if the medicine was not for a time relinquished. This effect has never appeared during a course of less than six weeks. It has generally soon disappeared after an aperient operation from sulphur, and one or two warm baths. A change to warm weather has also removed it. 12. If iodine fail of reducing the tumour, and if its pressure occasion urgent symptoms, recourse must be had to surgical aid. For a full exposi- tion of this part of the treatment, I must refer the reader to Mr. Cooper's Surgical Dictionary, and limit myself to a brief enumeration of this class of measures. The first and most important of these is the insertion of setons in the tumour. This practice was recommended by Dr. Quadri, of Naples; and practised first in this country by Mr. Copland Hutchison, and with success. According, however, to the experience of Mr. James, Mr. Cooper, and Mr. Gunning, this practice is liable to occasion dangerous haemor- rhage, sloughing of the tumour, and irritation and inflammation of the trachea or larynx. Mr. Ly- ford has, however, employed setons successfully; whilst Hedenus states, that he has seen tetanus occasioned by their introduction. It has been recommended to cut off the supply of blood to the gland by tying its arteries; and the advice has been followed by Blizard, Walther, Coates, Brodie, and Earle. The cases thus treated by Blizard, Coates, and Brodie, terminated unfavourably; whilst those by Walther1 and Earle succeeded. Lastly, the tumour has been altogether removed by excision. Dessault first performed this operation successfully; Gooch at- tempted it in two cases, but failed; Dupuytren andKLEiN also failed; whilst Vogel, Theden, and Graeffe, performed it with success; and Hedenus, of Dresden, succeeded in six cases in which he resorted to this operation. Bibliog. and Refer.—Pliny, lib. ii. cap. 37.—Celsus, lib. vii. cap. 13.—De Haen, Ratio Medendi, pars vii. p. 285. — Rush, Medical and Physical Journ. vol. xvi. p. 408. — Fode're, Traite sur le Goitre et le Cretinisme, 8vo. Paris, An 8.—jFVry (miyCollez. d'Osservazioni e Refiess. de Chirurg. t. iii. p. 270. Roma, 1800. — Baillie, Morbid Anatomv, 8vo. p. 87.—Larrey, Memoires de Chirurg. Milit. t. i. p. 123. — Bully, in Diction, des Sciences Med. t. viii. — Wenzel, Ueb. denCretinismus. Wien. 1802.—Wylie, in Hufeland's Journ. 1809, 2d st. Febr. p. 118. —Maas, Diss. Sistens Gland. Thvroideoideam tarn Sanam tamMorbosam. Wire. 1810, 8vo. — Postiglione, Mem. Patholog. Practica sulla Natura di Gozzo. Flor. 1811. — Alibert, Nosologie Naturelle, t. i. p. 464. fol. Paris, 1817. — Straub, in Naturwissenchaftlicher Auz. der AUgemeiner Schweiz. Gesell. kc. von Fr. Meisner, 4to. Bern. 1820. — Coindet, Decouverte d'un Nouveau Re- made contre le Goitre, in Bibl. Univers. Juil. 1820, p. 190.; et Feb. 1821, p. 140.—Carro, in Ibid. Mai, 1821. — Brera, Saggio Clinico sull' Iodio, &c. Pad. 1822. — Quadri, in Medlco-Chirurgical Society's Transact, vol. x. p. 16. — Coates, in Ibid. vol. x. p. 312. — Hutchison, in Ibid. vol. xi. p. 2*15.—Roots, in Ibid. vol. xii. p. 310.—Kennedy, in Lond. Medical Repos. vol. xvii. p. 177. Humboldt, in Magendie, Journ. de Physiol. Exper. t. iv. p. 109. — He- denus, Tractat. de Gland. Thyroid. tec. Lips. 1822.—Coster, Archives Gener. de Medecine, Juillet, 1823. — Gairdner, On the Effects of Iodine, &c. 8vo. Load. 1824. — Kolley, Medico-Chirurgical Review, vol. vi. p. 229.—Tael, Journ. Complement des Sciences Med. t. xxiii. Nov. 1825.— Pes- chier, Biblioth. Univers. Oct. 1824, p. 146.—Manson, Medi- cal Researches on the Effects of Iodine in Bronchocele, &c. 8vo. 1825. — Georgiani, De Praecipuis Thyrophraxiam Cu- randi Methodis, 8vo Pavia, 1825.—Krugelstein, Die Knnst d. Krankh. d. Schilddriise u. d. Kropf zu Heilen, &c. Gotha. 8vo. 1826. — Earle, in Lond. Med. and Phys. Journ. Sept. 1826.—Lawrence, Lectures by, Medical Gazette>vol. *vi. p. 719.—J. Johnson, On Change of Air, kc. BULIMIA. (See Appetite.) BULLAE. — Blains. Syn. \vxraivai, Gr. Phlyctenee, Ampulla, Auct. Lat Bulla, Plenck. Ecphlysis, Good. Dartre Phlyclen- oide, Alibert. Bulles, Ampoules, Fr. Blasen, Wasserblattern, Ger. Blebs, Eng. Classif. 6. Class, 3. Order (Good). 4. Or- der (Willan). IV. Class, IV. Order (Author). 1. Defin. An eruption of large vesicles con- taining a serous or sero-puriform fluid; frequent- ly succeeded by yellowish or yellowish brown scabs, and sometimes by ulcerations. 2. Plenck first separated the individual erup- tions belonging to this order from the vesicular 272 CACHEXY. eruptions, to which they are intimately related, and formed them into a distinct class. Will an afterwards adopted a nearly similar arrangement, comprising under this head ensipelas, but leaving out rupia. M. Biett has, however, with stricter propriety, excluded from it the former disease, and introduced the latter. Adopting, therefore, his classification, this order of erruptions embrace pemphigus, pompholyx, and rupia. These forms of bulla? proceed from internal causes; but various irritants, applied externally, will also give rise to a similar eruption. The influence of cantharides and other rubefacients, of excessive heat or cold, of friction, of poisons, &c, in occasioning vesi- cations, is well known. In a pathological point of view, both the bulla produced by internal causes, and the vesications formed by external causes, depend upon very nearly the same state of the rete mucosum. This tissue is more or less inflamed, or affected in such a way as to secrete a greater quantity of serous fluid than can be exhaled through the cuticle, which is thereby separated from the vascular tissue, and, by the increase of this fluid, elevated into blisters, or bullae, of various dimensions. 3. The eruptions of this class are both acute and chronic. The parts affected are often pre- ceded by more or less redness, and occasionally by a very slight elevation. But, in many in- stances, no such inflammatory appearances are observed before the serous effusion beneath the cuticle takes place. After an indefinite period, varying from a few hours to four and twenty, a small vesicle appears, and gradually enlarges, until it reaches, generally within eight and forty hours, a great size. The bulla? thus formed are at first tense, and the fluid contained in them serous and transparent; but it sometimes becomes, especially at a later stage, sero-purulent, and rarely sero- sanguineous. After an uncertain time the bullae pass from a tense to a flaccid state, the included fluid, at the same time, assuming a very slightly opaque and thickened condition. If they be situ- ated where the epidermis is very thin, or occur in very young infants, they often break before this change in the fluid takes place. But where they are more persistent, the humour becomes thicker, and often forms scabs of a light yellowish colour. The affected parts of the skin are afterwards either provided with a new cuticle, or are affected with more or less .severe ulceration. Bulla: may thus appear in any part of the surface, and even in the scalp, and be more or less numerous, or thickly scattered over the body. I have observed them so extensive, as respects both number and size, as to occasion death, ol>\ iously from the constitutional disturbance and irritation resulting from the loss of the cuticle over more than two thirds of the whole surface ofthe body. 4. These eruptions are also either idiopathic or symptomatic — most frequently the latter. They may also be infectious, or dependent upon the air of an hospital. Thus I have seen them pre- vail (chiefly in the form of pemphigus) at one time, in Queen Charlotte's Lying-in Hospital, to the extent of affecting nearly all the infants born there during several months, notwithstanding fu- migation and whitewashing were resorted to; no other disease having occurred there during 'that period. In a chronic state, they are usually symptomatic of irritation or other disorder of the digestive organs, more especially ofthe alimnnta- ry canal ; of chronic bronchitis, and of general cachexy. They are sometimes observed as an attendant upon small pox, and very rarely in the other exanthemata. , BlBLIOO. AND REFER. — Bateman, Synopsis of Cut. Diseases, fee. 7th ed. p. 193.; and Med. arid Phvs. Journ. vol. xi. p. 230. — Tilesius, in Martens's Parodoxien, kc. Leips. 1802, b. ii. heft. i. p. 18. — Rayer, Traite des Mala- dies de la Peau, kc. t. i. p. 142. Cazenave et Schedel, Abrege Pratique de Maladies de la Peau, &c. Paris, 1828, p. 125. CACHEXY. Syn. Cachexia (from xay.oc, ill or bad, and i-ic, a habit). A bad Habit of Body. Classif. Constitutes the 3d Class in Dr. Cullen's Nosology ; and the 4th Order in the Class, Diseases of the Sanguineous Function, in Dr. Good's Arrangement. I. Class, V. Order (Author, see Preface). 1. Defin. Depravity of the constitution, witli- out fever, affecting more or less the solids, the circulating fluids, and the secretions. 2. 1 he chief characteristics of this state are, want of vigour and vital cohesion of the soft solids, with defective digestion and assimilation, diminished animal warmth, universal languor, and deficient strength or activity. The skin is usually pale, yellowish, or lurid; and the while of the eyes in some cases almost transparent. As this state advances, the countenance becomes pale, white, or bloated; the skin loses its vital tint, and changes either to a dirty white, or to a yellow hue. The muscles are flaccid, and deprived of their healthy elasticity; the mind is inactive; the breathing difficult upon exertion ; the feet and ankles swollen; the pulse slow and soft; the eyelids a'dematous; the urine turbid; the alvine evacua- tions irregular and offensive; the sleep oppressed, and all the vital manifestations are enfeebled and languid. In females, more or less of these symp- toms are associated with suppressed, retained, morbid, or irregular menstruation; pains in the forehead, back, loins, or limbs; palpitations; and longings for noxious or unwholesome articles of food, or for what is not food. (See Appetite — Morbid, and Chlorosis.) 3. This state of disease appears to be chiefly the result of diminished vital energy, produced by various mental and physical causes; in conse- quence of which state the food is not sufficiently elaborated and assimilated, the circulating fluid does not experience the requisite degree of change resulting from nervous influence, and the action ofthe viscera, and the secreting functions are im- perfectly executed, whereby the whole mass of blood is impoverished or depraved, the manifest- ation of the nervous and muscular systems are feebly performed, and, ultimately, the whole of the structures more or less vitiated. (See Blood —Alterations of, in Disease.) Cachectic maladies are very frequently associated with, or preceded by, obstruction, or other disease of some important viscus. If the pulse does not exceed 80 or 84, particularly towards evening, we may conclude that the lungs are sound; and if the pulse be re- gular, and the sleep undisturbed, we may infer that the heart and its capsule are not, at least, seriously affected. The viscera most frequently diseased are the liver, mesenteric and lymphatic glands, the spleen, pancreas, kidneys, uterine or- gans, stomach and bowels; and the affection of these is sometimes a cause of, at other times an CACHEXY—African — Causes. 273 attendant on, or even consecutive of, the cachectic state; the vital endowment ofthe frame being the first to experience the morbid change. It would appear that the earliest manifestation of this change takes place in the ganglial system ; the internal viscera and circulatory organs, whose functions are actuated by this system, becoming next disor- dered, generally in such a manner as to attract the attention ofthe observer to the nature and source of disturbance. 4. The Treatmemt of cachexies chiefly con- sists of light nutritious food, taken in such quan- tity as the digestive organs can easily dispose of; healthy air, or change of air, with gentle and reg- ular exercise, short of fatigue; of tonics combined with deobstruents and gentle aperients, in order permanently to excite the languid powers of life, and to promote the functions of the secreting organs; and of the use of chalybeate and deob- struent mineral waters, with frictions with stimu- lating liniments, and pleasant mental occupation. The sulphate of quinine, or the preparations of chinchona, particularly its compound tincture, with small doses of the oxymuriate of quicksilver; the various vegetable tonics, bitters and aromatics, with the mineral acids, especially the chloric acid ; the preparations of iron ; the chlorates of potash, soda, and lime; sarsaparilla, with guaia- cum, &c; the balsamic and terebinthinate sub- stances; camphor, and the essential oils, and the preparations of iodine; are most serviceable in cachectic diseases, either exhibited singly, or com- bined with laxatives or purgatives so as to pro- mote the secreting and excreting functions. As the various disorders of this description are often connected with obstructed function, or infarction, of some important viscus, it will frequently be requisite to exhibit at the same time, or in con- junction with some of the above remedies, small doses of blue pill, or of the hydrargyrum cum creta; or to combine them with rhubarb, aloes, or other purgatives, and often to add to them ar- omatics or warm gum resins. The object in these cases is to promote a regular action of the viscera, by increasing their vital energy; and this is better attained by adopting measures calculated to benefit the general health, and to increase the action ofthe stomach and bowels, than by the oc- casional use of active and debilitating cathartics; which, however, operate more efficiently and much more beneficially in those cases, when com- bined with bitters and tonics,—a fact long since insisted on by Hoffmann, and others. (See also Mercurial Cachexy, Scrofula, and Syphilitic Cachexy.) Bibliog. and Refer. —Bonetus, Sepulchretum, 1. iii. s. xx. obs. 1—14. — Wedel, De Cachexia. Jen. 1715.— Stahl, Diss, de Cachexia. Halae, 1710. — Hoffmann, De Cachexia, Opera, t. iii. p. 318.—Nicolni, Diss. Sistens Ge- nuinam Cachexia" indolem. Jena;, 1760. — Vogel, Diss. Sistens Cognitionem Morborum. Goet. 1763.—Wedeikind, Ueber die Kachexie im Allgemeinen, 4ic. 8vo. Leips. 1796. Cachexy, African. Syn. CachexiaAfri- cana, Negro Cachexy, Dirt-eating. Mai d'Estomac, Fr. Classif. I. Class, V. Order (Author, see Preface.) 1. Defin. General cachexy, with vitiated functions ofthe stomach and bowels, and a pro- pensity to eat chalk, clay, or other dirty and un- wholesome substances, generally affecting the ab- origines of intertropical countries, Sfc. | 2. This disease is a complication of cachexy with anaemia and pica, or depraved appetite (see Appetite—Depraved), at least in its advanced stages. It is very common amongst the natives of Africa, and the slaves in the West Indian col- onies ; and is attended with loss of appetite, continued pain of stomach, whiteness of tongue, difficulty of breathing upon the slightest exertion, drowsiness, inactivity, and general debility, de- spondency, with fondness of solitude, paleness of | the face, lips, and palms of the hands, coldness, and often cedema of the extremities, glassy state of the tunica adnata, weakness and smallness of pulse, scanty, pale, or milky urine, whitish or clay-coloured stools, with other signs of depressed vital power and deficient assimilation. Owing to the depressed energies of the frame, and partic- ularly of the digestive organs, a vitiated state of the juices of the stomach, with morbid acidity of the prima via, evidently prevails; occasioning sensations which probably excite the patient to have recourse to chalk, clay, or other absorbent matters to relieve them, and which occasion what- ever vitiation of appetite may be additionally ob- served. This morbid condition appears, however, not to be limited to the stomach, but to be ex- tended along the alimentary canal: the mucous surface of the bowels are in a state of morbid ir- ritation, giving rise to offensive evacuations ; the lacteal and mesenteric glands become irritated and obstructed, owing to the passage through them of unhealthy chyle and morbid secretions, and sub- sequently incapable of conveying sufficient nour- ishment into the circulation ; the blood is thus rendered poor, pale, and in all respects such as is described in the article on the Blood (§ 34. et seq.): and the liver, pancreas, spleen, lungs, and heart, become pale, atrophied, and sometimes softened, from being deprived of the requisite nourishment, and supply of the circulating fluid. And at last the patient sinks, from depression of the vital power and anasmia, presenting the fol- lowing appearances on examination :— 3. The stomach is often flabby, softened, appa- rently distended, and pale. Ihe liver is some- times enlarged; occasionally atrophied, hardened, and generally very pale. The bile is usually watery, pale, or straw-coloured: the gall-bladder has contained biliary concretions in a few cases. The mesenteric glands are always enlarged and hardened. The mucous follicles of the intestines are often morbidly developed. The heart is soft and flabby; the blood in its cavities and large veins is watery and thin; and sometimes fibrinous concretions are found in these situations. Serous effusions, to a greater or less extent, are also fre- quently found in the thoracic and abdominal cav- ities. 4. Causes.—This affection is very nearly allied to chlorosis: but whilst the latter affects females, and most commonly about the period of puberty, the former occurs in both sexes, and sometimes at as early an age as six or seven years. It is generally attributable to depressing or debilitating causes — mental or physical. The despondency and grief occasioned by separation from the place of nativity and friends, and by a state of bondage, often dispose to it; and thus it is not infrequently accompanied with nostalgia. The lax and weak habit of body, and the indolent disposition of the negro, seem also to favour the appearance of the 274 CECUM — its Diseases. disease, particularly in those who have been badly nursed and neglected in early life. The chief ex- citing causes are, poor diet, hard labour, harsh treatment, exposure to cold and moisture, insuffi- cient clothing, and venereal excesses early indulg- ed in. The causes of the disease, the symptoms it presents in its progress, and the appearances observed after death, are altogether irrefragable evidence that it proceeds from great depression of the vital energies, especially of the digestive or- gans ; occasioning, in its more advanced states, anaemia, imperfect nutrition, and vitiation of the fluids and soft solids ofthe frame. 5. The Treatment is in no respects different from what has been recommended in general terms in respect of Cachexia and Depraved Appetite (see these artistes). Warm clothing, and a digestible nourishing diet, are indispensable to recovery: and to these should be added, regular but moderate exercise; bathing, followed by fric- tions of the surface; tonic, aromatic, and saline medisines; the use of the carbonates of the alka- lies, combined with tonics and hot spices. Warm stimulating laxatives, such as the compound tinct- ures of rhubarb or aloes, or the bitter aperient tincture (F. 699.); the elixirs prescribed in the Appendix (F. 103—;06.); the preparations of iron, cinchona, and myrrh ; are severally of the greatest benefit, especially in coi junction with ■warmth, a residence in a warm dry situation, and sufficient nourish ment. Care also ought to be taken to preclude any access to the substances for which the morbid propensity is entertained. Bibliog. and Refer. — Davidson, New York Med. Repos. 1799, vol. ii. No. iii. art. 6.—"hisho/me, in Ibid., and Med. and Phys. Journ. 1800, p. 614.—Hinter. On the Ditino caeco," he states, " quidquam dicere praestat, cum in quibusdam animalibus sit summe necessarium, nempe quibus et anplissi- mum, forsanque vicem alterius ventriculi gerit; nam glandulis crassioribus donatur, quorum suc- cus solutione heliotropii rubescit, et solutione sublimati albescit, suisi;uesalibus acidis et volatili- bus praditum est." (De Prima Coctione, p. 270.) Ibis view has been recently confirmed by the able researches of Tiedemann and Gmelin, professors at Heidelberg. The situation of this organ, its capacity, its attachment to the parietes ofthe abdomen, and the circumstance of its con- tents being propelled in opposition to their gravi- ty, are proofs of their longer retention than those of any other part of the digestive tube; and con- firm the view that has been taken as to its being, in some respects, a reservoir, wherein is poured that portion of the materials remaining in the ile- um, in order to undergo the latter stages of diges- tion, and the first of faecation. Besides other proofs of these functions, it may be stated, that it is very abundantly supplied with large follicular glands, which, acco:ding to the experiments of Tie D em ann and Gmelin, secrete an acid, al- buminous, and solvent fluid, which mixes with, ar.d promotes the digestion of, those portions of aliments which have withstood the actions of the stomach and small intestines, or been insufficient- ly changed by them. In order that this office may be the more completely performed, the anatomi- cal relations of the caecum adn it of the remora, for a longer or shorter time, ofthe matters which pass into it; so that a last effort is here made to obtain the remaining nourishment from the inges- ta: and thus it performs, if not the very last act of digestion, at least the last important part of it. Put it also seems to fill an additional office, name- ly, that of secreting, chiefly from its numerous follicles, an unctuous or oily fluid for the protec- tion of the suiface of the large bowels from the irritating effect of the faecal matters passing along them; and it is p.obable that the constituents both of this fluid, and of the other secretions poured out from its suiface, consist of elements that require to be eliminated from the blood; so that, in addition to its other functions, it is also a depurating organ. 3. The usual contents ofthe caseum are of the consistence of a soft bouillie, or gruel, of a brown- ish yellow colour, and here first acquire their facculent odour; which, according to Tiede- mann and Gmelin, proceeds from the volatile oily substance secreted by its follicles. During the changes that are et'ected by the ca&cum on its contents, an acid and h\ dro-sulphuret- ted hydrogen gas is disengaged. rl his gas seems to be generated only in small quantities during the healthy functions of the organ; but when its vital energies are diminished, and when, consequently, a greater remora than usual of its contents takes place, air is disengaged in much greater quantities, and sometimes to the extent of injuring its healthy tone. Whilst the caecum reacts energetically on the distending power, this flatus, along with a portion of its contents, are thereby propelled along the colon : but on many occasions, and under particu- lar circumstances, considerable opposition about I CAECUM — Functional Disorder or. 275 the right flexure of this bowel is offered to their transit; and hence, pain and uneasiness in this part of the colon, as well as in the caecum, are complained of; giving rise to the idea of the ex- istence of either hepatic or nephritic disease. 4. Under other circumstances of protracted dis- order of the digestive organs, as when acidity is generated in the stomach and small intestines, and the food imperfectly digested; or when the ingesta are of a stimulating, irritating, or other- wise unwholesome kind; or when the secretions of the liver, pancreas, and mucous surface of the small intestines, are of a morbid or excoriating nature, — then the accumulation and remora of these matters in the caecum are productive of disorder of its functions, of inflammation, and even of change of its structure. I. Disordered Functions ofthzC^cum. Classif. I. Class, I. Order (Author). 5. When the vital energies are weakened, and the alimentary canal debilitated, the caecum often betrays greater disorder than any other part of the digestive system. Its situation and functions will, from what has already been stated, account for the frequency and importance of its diseases. In some cases, the irritation produced by morbid or accumulated matters in it is slight, and readily productive of sufficient reaction of its muscular coats to propel them along the colon. In other instances, the efforts made to accomplish this end, owing to the obstructions occasioned by the lodgment of flatus about the right flexure of the colon, or by irregular spasmodic contractions of this bowel, are ineffectual, and give rise to colicky pains. If the interruption is removed, disorder soon subsides; but if it continue for any con- siderable time, the more violent forms of colic or ileus supervene. When the internal surface of the caecum is in an irritable state, disorders of this description are readily produced by the accu- mulation, even to a small e.\teut, of the intestinal matters poured into it from the ileum, especially when they are of a more than usually stimulating kind, or if the secretions be morbid. In young, irritable, or nervous persons, and in those who partake of much acid or unripe fruit, or who neglect their bowels, particularly females who wear very elose cinctures around the upper part of the abdomen, diseases affecting the alimentary canal, and, sympathetically, some other parts of the frame, not infrequently thus originate in this viscus. Accumulations, however, of alimentary and faecal matters sometimes take place in it to a great extent, without producing much disorder, until the distension and irritation thereby occa- sioned give rise to disease of its internal surface, of its follicles, or its parietes generally. Persons advanced in life, of a phlegmatic temperament, or lax and torpid habit of body; those who take little exercise, or whose occupations are seden- tary; and especially aged females; are very liable to be thus affected. During this state of infarction, the retained matters are more or less changed, partially decomposed, become acrid, excoriating, and a source of irritation both to the mucous sur- face itself, and to its follicles; which are thereby obstructed, and ultimately inflamed and ulcerated. In this way, most of the morbid states about to be described originate. 6. Several instances have been recorded by the older writers, where the stones of fruits, biliary and intestinal concretions, and hardened faecal matters lodged in the caecum, have occa- sioned severe colic, and even fatal ileus. Some cases of this kind are referred to in Dr. Monro's instructive work on Morbid Anatomy, as having occurred in his and his father's practice. In one of these, a concretion upwards of seven inches in circumference filled up this viscus. Fontanus found an earthy concretion in it, as the only morbid appearance after death from ileus; and Helm, nearly three hundred cherry stones in the same situation, and in the ileum before it opens into the caecum, in a fatal case of this disease. In some instances, accumulations of faecal mat- ters with great distension occur, without much suffering referrible immediately to the caecum being experienced; the organs affected second- arily evincing the most marked disorder. This was shown by the case detailed by M. Odier, of Geneva, of the celebrated M. de Saussure, in whom this viscus was very greatly dilated. When very much distended, it is generally dis- eased in other respects; its coats are more or less thickened, inflamed, and ulcerated, or its follicles enlarged. Monro, Nacquart, and others, have adduced instances in which its engorgement and enlargement were accompanied with chronic inflammation and thickening. Mr. Wilmot re- lates a case in which it was dilated to the extent of containing a gallon, filled with faecal matters, and perforated by a circular ulceration. When the distension by accumulated matter is great, it may, from rising high in the abdomen, and press- ing upon the nerves, vessels, and ducts in its vicinity, occasion numbness, and cedema of the right lower extremity, retraction of the testicle, and derangement of the urinary secretion; and thus be mistaken for disease of the kidney. M. Ducos has detailed an instructive case of this kind ; and two similar instances have been ob- served by me. Tn general, the seat of the tumour arising from collections of morbid matters in the caecum, and the disorders connected with it, readily lead to the recognition of its nature, as in the case recorded by Dr. Barlow. When, however, there is little or no tumour formed, and the symptoms are of a chronic and less violent kind, the cause of disorder may long exist in this situation, and escape detection. In a case of a young lady whom I attended with Mr. Annes- ley, this part was considered as the seat of dis- order, from its fulness and hardness upon an ex- amination made when the patient was semi- recumbent, and the thigh slightly bent, and a treatment in accordance with this view strenuously insisted upon. She had been attended by several eminent physicians during the preceding three or four years, and very different opinions entertained of the nature of her ailments. After persistence in the treatment about to be recommended, an evacuation of hardened balls, containing indiges- tible substances which she had chewed many months previously, were evacuated, the fulness and hardness in the right iliac region disappeared, and the patient perfectly recovered. Two nearly similar cases to this were detailed by me in a work referred to below. 7. Substances incapable of digestion, either taken accidentally or from a depraved appetite, also frequently lodge in the caecum, and remain in it for a very long period, sometimes without 276 CAECUM — Functional Disorder of. producing much disorder, at other times occasion- ing the most violent effects. In other cases, in addition to various morbid matters, large balls of worms, both lumbrici and ascarides, collect in this viscus, and occasion much local irritation, or even inflammation of its inner surface, and con- stitutional disturbance. Mr. Blackadder has detailed some interesting instances of this occur- rence. He found, in a patient who had com- plained of disorder of various organs, and of a gnawing soreness in the right iliac region, ragged ulceration of the inner surface of the caecum, which contained an immense number of worms. The rest of the alimentary canal was sound. 8. When the caecum is much enlarged, or otherwise diseased, it may also be displaced. Cases are recorded by Salzmann and Annes- ley, in which its attachment to the internal iliac muscle had yielded so far that it had passed over to the left side; and others, in which it had de- scended very low into the middle of the pelvis, and pressed upon the urinary bladder. 9. Not only may indigestible substances and morbid concretions sometimes lodge in the caecum, producing much local irritation and general dis- turbance, but they may, when small, sometimes pass into the vermiform appendage, where they occasion, as will be shown in the sequel, the most dangerous effects. It does not, however, appear that the simple presence of any of these substances in this process is always followed by such results. Mr. Blackadder relates a case in which he found a small concretion in this part, and yet the patient had not complained of any symptom referrible to the right iliac region. I have treated, or been consulted respecting, four cases, in which foreign bodies and concretions were found in the appendix after death; and in all, the symptoms were those of the most violent peritonitis complicated with ileus, and termin- ating in sphacelation of this process itself. Two of these I attended with Mr. Fainter, of Craw- ford-street, by whom the inspections were made; and who ascertained that the substance found in tfo appendix, in one case, consisted chiefly of cholesterine. 10. The phenomena usually occasioned by faecal matters collected in the caecum, and by dis- tension, enlargement, or irritation of this viscus, will necessarily vary with the nature of the offending substances, the extent to which they j may have accumulated, and the age, tempera- I ment, and habit of body ofthe patient. The dis- \ orders which result are, 1st, Local; 2d, Symp- tomatic, and 3d, Constitutional, a. The local signs are more or less fulness, hardness, or dis- I tension in the right iliac region: sometimes, on examination carefull with the points of the fingers, the abdominal muscles being relaxed, a doughy hardness is felt. In other cases little or no pain, even upon a minute examination, is complained of; but occasionally, especially if the disorder be about inducing inflammation, both tenderness and pain either exist more or less con- stantly, or come on in paroxysms; and the patient generally reposes on the right side. When the bowels are constipated, and interruption of the passage of matters through the caseum occurs, the paroxysms of pain are very acute, and some- times attended by vomiting, and all the symp- toms of the most severe colic, or even those of ileus. In such cases, upon examination, signs of obstruction either in the cacum or in its vicinity are detected, unless general peritonitis may have come on; and then the origin of disease is very generally referred to the caecal region, or the tenderness and pain are most acute in tliat situation. 11. b. The symptomatic disorders, when this viscus is much distended, either by focal or other matters, or by flatus, or by both, as is most com- monly the case, are, numbness of the right thigh, oedema of the right foot and ankle ; sometimes retraction of the testicle, or frequent calls to empty the bladder, and sometimes haemorrhoids; uneasiness or pain in the right iliac region, often extending to the hypochondrium ; various dys- peptic symptoms, costive or irregular state of the bowels; occasionally diarrhoea, with scanty, of- fensive, and mucous stools; and, if irritation be excited in the mucous surface and follicles of the organ, the efforts made to evacuate the bowels are attended by severe tormina, and even by retching. I have seen several cases of varicose veins of the leg, or indolent ulcers, and a case of disease of the bones of the foot, the occurrence of which was evidently connected with great distension and accumulations in the caecum; the symptoms of this disorder, with more or less tumefaction and hardness in the iliac region, having been found on examination. The just- ness of this view was fully shown by the success ofthe treatment, which was based upon it. 12. c. As long as the states of disorder have not advanced to inflammation or ulceration, the effects are often not very manifest upon the con- stitution. The countenance and skin, however, are pale and lax; the complexion is deficient of clearness, and, with the surface generally, often covered with an oily or dirty moisture; the per- spiration is foetid, and the breath offensive; the soft solids lose their elasticity, and are slightly emaciated; the lips are usually pale, the tongue white or loaded at its centre and base, sometimes red at its point and edges; the pulse is weak, soft, or small, frequently slow, but easily acceler- ated; and, at an advanced stage, the symptoms more clearly manifest that the blood is imper- fectly depurated, or that it is affected by the absorption of a portion of the excrementitious matters retained in the caecum. In addition to these symptoms, general debility, and disincli- nation to any physical or mental exertion, are often complained of. The above states of disor- der continue for a longer or shorter period; when at last the local irritation either produces increased action of the muscular coat of the caecum, and ultimately the dislodgment of the offending mat- ters, or gives rise to acute or chronic states of inflammation, and various consecutive organic changes. In some instances, the accumulation in this viscus, and the spasm of the adjoining parts, amount to complete obstruction of the passage through the alimentary canal, even with- out inflammation or any disorganization of the ca-cum itself having taken place; causing violent colic and ileus, as in the cases already noticed (§10.); the most marked symptoms during life being referrible to the superior portions of the tube, and the lesions after death being most re- markable in those parts, particularly about the CECUM — Inflammation of—Causes. 277 termination of the ileum, and the ileo-csecal valve. 13. Treatment.—The intentions in this state of disorder are very obvious; namely, 1st, to evacuate morbid collections; and, 2d, to prevent their re-accumulation, by preserving a regular tonic action of the viscus, and by strengthening the digestive organs generally, a. The evacua- tion of the accumulated or retained matters is to be attempted by means appropriate to the cir- cumstances of the cases. If there exist irrita- bility of stomach, or even any tendency to it, or to febrile action; or if there be any pain or sore- ness in the iliac region; full doses of calomel should be first exhibited, the enemata about to be suggested administered, and the liniments pre- scribed in the Appendix (F. 296. 311.) assidu- ously rubbed over the ciecal region, with the view of exciting the healthy action of the viscus. If, on the other hand, the stomach and bowels be torpid, and the former can retain purgative or cathartic medicines, they may be given, select- ing those which are the least irritating in their effects. I have seen inattention to this caution, the most stimulating cathartics having been ex- hibited, productive of the worst consequences; a state of disorder simply functional, or colic from distension and obstruction of the caecum, being converted into either inflammation of the bowels or dangerous ileus. When, therefore, an irritable state of the stomach supervenes in our attempts to remove obstructions of this viscus, we should desist from the exhibition of purgatives, or even of aperients by the mouth, excepting full doses of calomel, or calomel combined with hyoscyamus or opium, and moderate doses of nitrate of potash, or sub-carbonate of soda, or of both, which will generally be retained, and will allay the sickness and retchings. But we ought strenuously to per- sist in the administration of enemata—preferring those which are oleaginous, saponaceous, and solvent—and in the use of the liniments. The enemata should be always large, and injected by means ofthe valve-syringe now in use, so that they may reach the seat of obstruction. In ob- stinate cases, this object will be facilitated by placing the patient upon his knees and elbows during their administration, and elevating the pelvis as much as possible above the rest of the trunk. The practitioner should not be discour- aged by the ineffectual administration of several injections, but repeat them according to circum- stances, employing at the same time frictions over the abdomen with the liniments already advised. If flatulent distension of the abdomen be present, they will assist in removing it; but in such cases the terebinthinate enemata ought to be preferred. When we suspect the presence of worms, in ad- dition to other morbid matters, aloes and the al- kaline solutions, assafoetida, camphor, lime-water, &c. may be used in the injections. In the slight- er and more usual cases, the aperients in common use, particularly castor oil, the compound decoc- tion of aloes, the combination ofthe compound in- fusions of senna and of gentian, or the infusion of senna with decoction of cinchona, or the several formulae of this description contained in the Ap- pendix (F. 215. 266. 562. 575.), may be pre- scribed, as they may appear appropriate to the circumstances of the case. 14. b. Having apparently removed whatever 24 obstruction may have existed,—the csecal region being soft and natural, and the actions of the bowels free,—the object is next to prevent the recurrence of disorder, and to strengthen the di- gestive organs, by vegetable tonics and bitters combined with aperients; by sulphate of quinine with aloes; by small doses of blue pill with the alkaline carbonates and other deobstruents, and given occasionally with the view of promoting and correcting the secretion; by the occasional use of the liniments above referred to, or by wear- ing a warm stimulating plaster (see F. 109. 115. 117.) over the right inferior regions of the abdo- men. In every case, attention should be paid to the state of the digestive, assimilating, and secre- ting functions; regular evacuations of the bowels promoted, by the occasional use of enemata; and the diet strictly attended to. II. Inflammation of the C^cum. Clas- sif. III. Class, I. Order (Author). 15. Although inflammations of this viscus have been generally overlooked or confounded with those affecting either the colon, the small intes- tines, or the peritoneum, there are few diseases more defined in their character, or more distinctly limited in the great proportion of the instances of their ocurrence, than they are. In respect of its seat, inflammation may affect chiefly the mu- cous surface, or the follicles, or all the coats of the organ more or less: or it may attack the ver- miform appendix only, or the cellular tissue con- necting the caecum to the internal iliac muscle. As to the character of the inflammatory action, it may be sthenic and acute; or acute, asthenic, and spreading, as in dysentery and fever: it may also be more or less chronic. Cases of all these states of disease are to be found scattered through the works of modern medical authors, and most of them have come before me. The first case which attracted my attention to the importance of attending to the state of this viscus in various abdominal diseases, occurred in 1816, in a hot climate. The patient had the usual symptoms of inflammatory dysentery, with violent pain, and subsequently tumefaction in the caecal region. The disease had been neglected in its early sta- ges; and it was only shortly before the sudden subsidence of this tumour that I observed it. Upon straining at stool, a sensation of something having burst internally was felt; and very soon afterwards above a pint of purulent matter, mixed with a little blood, was discharged. Upon exa- mination six hours after death, the ctccum was found ulcerated, discoloured, and nearly sphace- lated, with an opening through the part attached to the abdominal parietes leading to the nearly empty sac of an abscess which had formed in the cellular tissue connecting this viscus to the side; the mucous membrane of the colon was inflamed in parts, and excoriated. 16. i. The Causes of inflammations ofthe c.t- cum are chiefly the functional disorders already described. A morbid state of the abdominal se- cretions, and particularly an increased secretion of vitiated acrid bile; the irritation of foreign bodies, indigestible substances, and of worms; a strangu- lated hernia, or the pressure of an ill-constructed truss; the suppression of the hajmorrhoidal and menstrual discharges; and the presence of biliary or intestinal concretions, hardened fa-ces, or the stones of fruits, or their escape into the vermiform 278 CECUM — Infla.uma.tion of the Appendix or. appendage. Inflammatory irritation of the mu- cous membrane and follicles of the viscus is not infrequent after child-birth, and as an attendant upon some of the diseases which affect cliiefly the bowels of females at this period. In connec- tion with the accumulation and retention of mor- bid matters, it very often constitutes the earliest pathological state in dysentery and diarrhoea, and consequently then arises from the same causes that produce those diseases. 17. ii. Symptoms.—A. Of inflammation ofthe mucous surface of the cacum. These chiefly con- sist of an irregular, mucous, offensive, and some- t.mes slightly bloody appearance of the stools, with tenderness upon pressure or examination of the caecal region. The evacuations are generally preceded by tormina or griping pain, extending from this part upwards to the right side, and down towards the pelvis. The tongue is slightly loaded or furred; and more or less symptomatic fever is present. This state of disorder is liable to lapse into a chronic form, and to continue for a long period; or it occurs primarily, from the functional disorders already described, and some- times fluctuates as to the degree of severity. In the more slight or chronic states of inflammation of this surface, the patient often complains of little beyond irregularity of the bowels and co- licky pains in the abdomen, with slight emacia- tion, and loss of the healthy complexion; till, at last, an acute attack of the disease supervenes, from the extension of the inflammatory action to the more exterior coats; or the chronic organic change has proceeded so far as to implicate ad- joining parts, and to occasion a train of severe symptoms. In this manner, the more dangerous forms of dysentery not infrequently take place. During the earlier states of inflammation of the internal surface of the caecum, ulceration may have commenced, or the follicles become diseased, and the coats successively perforated, until the peritoneal covering is attacked; when the inflam- mation assumes more serious features, owing both to its extension, and to the nature of the tissues which are now invaded by it. The perforation may, however, take place in that part of the pa- rietes of the viscus where it is attached to the iliac muscle; and thus inflammation be extended to, and abscess form in, the cellular tissue exterior to it, and break either externally, or into the cae- cum, or both; a sinuous communication being thus formed between the cavity of the organ and the surface of the body. In the manner now de- scribed, the more acute states of inflammation of the caecum, and its connecting tissue, may arise; or these states may primarily affect the different structures composing its parietes, or may originate in its vermiform appendage. 18. B. Acute inflammation ofthe coats of the cacum generally commences with violent pain in the right iliac region, frequently attended with a burning sensation, and most exquisite tenderness, particularly when the serous coat of the viscus is affected. It is accompanied with the most severe tormina, extending from the above region upwards to the right hypochondrium, across the abdomen, down into the pelvis, and along the thigh of that side. If the disease be attended by distension of, or faecal collections in, the caecum, the testicle is retracted, and the thigh either very painful or numb. While the pain occurs in paroxysms, and shoots in various direc- tions throughout the abdominal cavity, it is con- stant and fixed in the situation of the caecum. The regions ofthe abdomen, although sometimes distended and tense, bear examination, excepting in the caecal region and its immediate vicinity, where the least pressure cannot be tolerated. The pain is usually increa.sed when the body is erect; and the patient reclines on the right side, with the trunk slightly bent, and the thighs drawn upwards, so as to relax. the parts in the vicinity of the disease. The bowels are generally torpid; but vomiting is not complained of, un- less obstinate constipation exists, or drastic purga- tives have been given early in the disease. 1 he pulse is usually quicker than natural; but it is occasionally not much affected; and the temper- ature ofthe surface is increased. In some cases, the above constitute the chief symptoms; but in others much more disturbance ensues, particu- larly if the disease advances, or is neglected in its early stages, and the peritoneal surface of the caecum is affected. When such is the case, the local symptoms increase in severity; the abdo- men becomes more generally tense and painful, owing to the extension of the inflammation over the peritoneal covering of the viscus and the ad- joining parts; and the symptoms of peritonitis, often attended by obstinate vomiting, supervene, with great frequency of pulse, and general fever. If the appendix participate in the disease, the symptoms are still more acute; general peritonitis is very quickly produced; adhesions are formed between it and the adjoining peritoneal surface; and the appendix soon sphacelates; a fatal result taking place, usually in a very short time. In other cases the disease- assumes a somewhat less violent character, and terminates in suppuration, owing to the cellular tissue connecting the coats of the intestine to one another and to the ab- dominal parietes being chiefly affected. When this occurs, the issue is not so rapid as in the former instances, but is sometimes prolonged for a considerable period; and, in some cases, re- covery is at last brought about. The foregoing history applies more strictly to inflammation ori- ginating in the caecum; but when it commences in the appendix, or in the external connecting cellular tissue, the symptoms are often much modified. 19. C. Inflammation of the appendix cad ap- pears to be attended from its commencement with more acute symptoms than that of the ca-curn itself. In four cases of this description which I have seen, this part was primarily and chiefly in- flamed, owing to hard substances having escaped into it, and had occasioned general peritonitis, and gangrene of the appendix itself. In all of these, obstructions of the bowels, with obstinate retchings, was present at the time when I first saw them; and in the latter stages ofthe disease, vomiting was attended by violent tormina, and the discharge of matters evidently from the small intestines. Thus the symptoms of ileus were superadded to those of peritonitis. Upon dissection, the caseum was found inflamed only in its peritoneal surface, in tliree of the cases; in the fourth, inflammation was observed also in its inner surface. In one, where the appendix con- tained a small biliary concretion, its extremity adhered to the surface of the caecum after passing CECUM — Chronic Inflammation of. 279 around a convolution of the ileum, which it had evidently strangulated; but at the time of the in- spection it was quite gangrenous on each side of the concretion. In another case, appearances of strangulation were manifested in a less satisfactory manner ; the surrounding parts being so agglu- tinated by albuminous exudations, that their re- spective relations were not obvious. It does not appear, however, that inflammation originating in the appendix always arises from substances having escaped into it. M. Louyer Villermay has detailed two cases of a similar state and termina- tion pf disease to the above; one occurring with- out any apparent cause, the other seemingly from the pressure of a bandage in hernia. In one, pub- lished by Mr. Parkinson, ulceration and per- foration of the appendix had taken place from the lodgment of a small portion of indurated faeces in it. A very interesting case, where violent abdominal symptoms were occasioned by a large lutnbricus, which had passed into the caecal ap- pendage of a person otherwise diseased, is record- ed by Mr. Black adder. M. Thiery found this part engorged with faecal matters, and in- flamed, in a fatal case of ileus; the caecum being narrowed, but not otherwise diseased. Heister met with the appendix inflamed and ulcerated after death, with similar symptoms. Amyand detected a small nail in this part after fatal ileus. Moreau andKLOECKHOFF record instances of this disease produced by strangulation of the ileum by the caecal appendage. Mr. Waldron dis- covered a small concretion in it after fatal perito- nitis; and Morgagni, Van Doeveren,Sandi- fort, and several others, have detailed cases of both peritonitis and ileus, in which this part had adhered to adjoining parts; and, in some instances, a loop of intestine had been enclosed by it, and strictured. From the history of these and other cases, which have occurred to several of my medical friends, it may be inferred, that inflam- mation affecting primarily the caecal appendage is most frequently brought on by hard substances having escaped into it; and that the inflammation rapidly extends to the peritoneum; giving rise to the exudation of albuminous lymph, to adhesion of its opposite surfaces, and of the appendix to adjoining parts, and to gangrene of this process. 20. Very acute pain, tumefaction, and tender- ness, are complained of upon the invasion of this form of the disease, first in the right iliac region, and subsequently more or less over the abdomen; with excruciating tormina, obstinate constipation of the bowels, a very frequent, small, or con- tracted pulse, heat of skin, dry tongue, great thirst, sometimes with numbness of the right leg, or pain shooting down the thigh, and retraction of the testicle. Vomiting comes on sooner or later, and is often, at one period or another, attended by the discharge of matters from the small in- testines—at least, in the cases which I have seen. The patient at last becomes restless, his coun- tenance sunk, and a fatal termination takes place, generally from the third to the sixth day, pre- ceded by the symptoms ushering in dissolution from intestinal peritonitis. 21. D. Inflammation of the pericacal tissue is occasionally met with. Several interesting cases of it have been published by French writers, es- pecially by MM. Dupuytren and Meniere. Mr. Cop el and has detailed a case where a urinary calculus was extracted from an abscess which opened externally, and communicated internally with the cavity of the caecum. It is probable that the calculus, in passing along the ureter, had produced inflammation, extending to the cellular tissue exterior to the caecum, and terminating in abscess, which had opened in both directions. In a case contained in Dr. Johnson's Journal, abscess had formed in the cellular tissue, external to the caecum, had also burst into this viscus, and pointed externally: and a similar instance is recorded by M. Duplay. In all these a sinuous communi- cation between fhe cavity of the intestine and external surface was formed. Several of the cases of inflammation of the caecum and connecting tissue, detailed or referred to by M. Meniere, terminated in suppuration, and opened either in- ternally or in the right iliac fossa. In some of those published by M. Dupuytren, the purulent matter had infiltrated itself as high as the kidney, and as low in the pelvis as to collect between the rectum and bladder. 22. The precursory symptoms of this state of disease belong to pathological changes in the functions or coats of the caecum itself, and are often similar to those already described as in- dicating acute or chronic inflammation of its mucous surface and follicles ; the disease in such cases most probably arising from ulcerative per- foration ofthe coats ofthe organ, or the extension of inflammation from its mucous surface. The patient frequently is first affected with either diarrhoea or constipation, or by both alternately, with colicky pains shooting in various directions, but generally radiating from the right iliac region; and he complains of pain or tenderness on pres- sure. To the above symptoms, others sooner or later are added, especially tumefaction, and con- stant pain in this part, and in the right iliac fossa, with anorexia, nausea, fever, and an irregular state of the bowels. As soon as s-ippuration commences, the disease presents the local and constitutional characters usually accompanying the formation of matter, with more or less tu- mour, which is generally situated deep in the iliac fossa. 23. Inflammation in this situation will, if re- cognised early and treated judiciously, terminate by resolution, in perhaps the majority of cases. But suppuration is almost as common a termin- ation as resolution; and when it takes place, the abscess formed most frequently opens internally. In several instances, peritonitis has supervened, either previously or subsequently to suppuration, but more usually the latter. The abscess may also open externally, as in the cases already re- ferred to; but seldom without it having also pre- viously established a communication with the cavity ofthe caecum. 24. iii. Chronic Inflammation of the Caecum generally comes on primarily, slowly, and insidiously, and may be long limited to the internal surface and follicles of the intestine, as noticed above (§17.). It more rarely remains after acute attacks. In the former mode of ap- pearance, it often advances imperceptibly, until serious organic changes have taken place in the coats of the organ; the general health, although more or less affected, not being so far injured as to alarm the patient. In its progress, it sometimes presents occasional accessions of severity, and even 280 CECUM — Inflammation assumes a sub-acute form. In other cases, an acute attack is superinduced, which may terminate in peritonitis, or in suppuration, or even in gan- grene. Chronic inflammation is the most common organic state of disease by which the caecum is affected. 25. A. Causes.—This form of inflammation of the caecum is, I believe, most frequent in females, probably owing to contingencies connected with the uterine functions and child-bearing, and to their modes of dress. It often occurs among them previously to menstruation, or soon after the cli- macteric epoch. The use of unripe or acerb fruits; sedentary occupations, or want of exercise; the depressing passions; previous disorder of the digestive organs, particularly costiveness, and ha- bitually, or occasionally, deferring the earlier in- timations to evacuate the bowels ; suppression of accustomed discharges, especially the hsemorrhoi- dal, the menstrual, and lochial; the pressure of an ill-constructed bandage for hernia; blows or contusions on the caecal region; and occasionally too violent exercise on foot or on horseback; are its most usual exciting causes. 26. B. Symptoms. — At first the general health and strength are not much injured; but the pa- tient loses his healthy appearance, and activity. lie complains of colicky pains occurring occa- sionally, or even periodically, in the right iliac region, shooting through the abdomen, and recur- ring soon after a meal. The appetite is not materially affected, and flatulence is the most constant gastric symptom. The tongue is gene- rally red at its point and edges, and loaded at its root; sickness and vomiting are not present; the pulse is often little affected, or it is quick and (■mail ; the patient lies on the right side, with the body bent and the thighs drawn up, and feels pain or uneasiness in the iliac region on turning to the left side, which is increased by continuing the position. The alvine evacuations are irre- gular and offensive, being at one time frequent, at another retained, generally muco-feculent, fluid, preceded by colic or slight tormina, and affording little relief. The abdomen, on examination, pre- sents little remarkable, until we reach the ca> cal region, where pressure occasions uneasiness, and a deeply seated fulness and hardness are usually detected. If much fulness or distension be present, the urine is generally voided fre- quently, and slight pain or numbness of the right thigh, with cedema ofthe right ankle, is often felt. If the disease go on to ulceration, blood will ap- pear in the stools, which will also be of a more or less dark colour. Such are the usual symptoms, until some one of the acute states of the disease supervenes, when their attendant phenomena will indicate the change. 27. C. The chronic state of the disease may give rise to very great thickening of the parietes of the caecum, either with or without dilatation of its ca- vity, and ulcerations in its internal surface. Fa- bkicius Hildanus describes a case of this kind as one of cancerous ulceration; but it seems rather to have been chronic inflammation, with thickening and ulceration. Dr. Beezelky has detailed an interesting case very nearly of this description, wherein these changes were very remarkable. The patient complained of colic, constipation, flatu- lence, mucous bloody stools, and of a large tumour in the iliac region, which was mistaken for aneu- of the—Complications. rism ofthe iliac artery. On inspection, post mor- tem, the coats of the caecum were found above nn inch in thickness, scirrhous, inflamed, ulcerated, perforated, and its cavity enlarged. When the disease has gone on to thickening, as indicated by the obscure hardness, and tumour, uneasiness, &c. in the iliac region, particularly if it be attended with ulceration, as may be inferred from the pre- sence of small quantities of blood or pus mixed in fluid, or but little consistent, muco-feculent and offensive stools, amendment is procured with great difficulty, under the most favourable circu mstances; but it should not be despaired of, although it may be long in appearing. I have met with severe cases, obviously of this description, where medical treatment was persisted in for many months, and one or two for some years, yet ultimately the health was re-established. In a case recorded by M. Emery, the caecum was remarkably constricted, and the appendix filled with fteces. The patient died of ileus. 28. iv. Complications.—Inflammations of the caecum, particularly of its internal surface, and in their sub-acute and chronic forms, with morbid enlargement and fungous ulceration of its follicles, are very frequently associated with dysentery and fever, in both temperate and warm climates. In- flammation of its external connecting tissue is much less common in these complications. 1 ascertained the fact of the intimate connection of inflammations of the caecum with dysentery, in 1816, my attention having been first directed to it by the case already alluded to (§ 15.). In- deed, they generally constitute the original dis- ease in dysentery; the irritative state of inflam- mation of the mucous surface and follicles of this viscus, together with the acrid secretions and other matters retained in it, producing an ex- coriating state of the discharges, whereby the caecum itself is first affected, and subsequently those parts of the colon and rectum where they are the longest retained; an opposite morbid relation, however, obtains in respect of its complications with fevers, particularly those of a typhoid na- ture; for, while in dysentery it is frequently the primary affection, in fevers it is commonly a consecutive lesion arising from the morbid states of the secretions and matters, either retained in or passing through it, and from the disposition to change possessed by the mucous tissues and fol- licles during these diseases, particularly those of an asthenic character. It should not, however, be overlooked, that lesions of the circum may also arise in the course of dysentery, owing to similar states of the secretions and mucous surface of the intestines as are present in. fevers ; and that the caecal disease will very generally escape detection during life, particularly in fevers, unless the atten- tion of the practitioner is alive to its occurrence. In every case, therefore, should the region of this viscus be attentively examined; and, if symptoms indicating an affection of it be present, the means of cure should be directed accordingly. 29. v. Laceration, or rupture ofthe caecum occurs in rare cases, either in consequence of pre- vious disease and infarction of its cavity, or of external injury. Some mstances of this occur- rence are to be found in early volumes of the Philosophical Transactions, and in the Transac- tions of foreign medical societies. Soemm ering, in his notes to the translation of Dr. Baillie's CECUM —Inflammation of the—Treatment. 231 Morbid Anatomy, mentions a case wherein it was produced by vomiting, which may have arisen from accumulation of morbid matters in the ceecum, with obstruction of its canal, and ul- ceration of its internal surface. Mr. Speer and Mr. Sheward record instances of its rupture from contusion,—an event which is very likely to occur when an injury is sustained over it during distension of its cavity, from whatever cause. The consequence of its laceration generally is rapidly developed, and speedily fatal, peritonitis. Introsusceptions of this part, itself having passed into the colon, or portions of bowel having passed into it, are not infrequent, particularly in young subjects ; but they require no particular notice, farther than as a cause of ileus, inflammation of intestines, &c. 30. vi. The Prognosis in disease ofthe caecum Ls very different in each of its forms.—a. When the ititernal surface is chiefly affected, recovery will take place in most of the cases, unless ulcer- ation has commenced ; and even then a favour- able issue will sometimes follow judicious medical treatment and regimen, b. In the acute states of inflammation affecting the more external coats of the viscus, the prognosis is upon the whole un- favourable, at least it should be stated as such to the friends of the patient; and in every case it should be given with caution, c. If we suspect, from the severity of the symptoms, or from the rapid extension of inflammation from the caecal region over the abdomen, that the appendix is inflamed, it is still more unfavourable ; if, in ad- dition to this circumstance, the retching be fre- quent, and more particularly if the matters eject- ed appear as having come from the small intes- tines, we may infer, not only that the caecum or its appendage is most acutely inflamed, but also that either its canal is obstructed, or some adjoin- ing part of the tube is strangulated ;—in either case the prognosis is most unfavourable. The subsequent Appearance of the symptoms usual- ly indicating gangrene of the intestines leaves no hope, and is soon followed by dissolution. d. When considerable tumour, seated in the iliac fossa, and the signs of inflammation of the peri- cacal tissues, are present (§22.), a favourable opinion of the issue may be entertained, if active treatment have been employed early in the disease, and the patient's constitution be not in fault. But in very many such cases, the general health has been much impaired previously to this disease, and has even predisposed to the attack. In such cases, as well as when evidence of the formation of abscess is observed, a very unfavourable, or at least a very cautious, prognosis ought to be given. e. In the chronic states of the disease any opinion should be offered with much reservation. If the disease have come on slowly, continued long, and the stools present the appearances indicating ul- ceration (§ 26.), an unfavourable state of disease exists ; thickening of the coats of the viscus mere- ly (§ 27.) is more favourable, but is not readily removed. /. The complications of this disease (§ 28.), particularly with typhoid fever, are at- tended by considerable danger. The association of it with dysentery is productive of the worst forms of that disease, as well as its complication with fever, of its most dangerous states ; and causes the former to assume a chronic and obsti- nate form. g. Laceration, or rupture of the 24* coats ofthe caecum, is generally fatal in its results. 31. vii. Treatment.—A. Inflammation of the internal surface of the caecum, and the chronic states of the disease (§ 17. 24.), require the application cf a number of leeches either near the iliac region, or on the inside of the right thigh, and a repetition of them according to the circumstances of the case. In robust or plethoric persons, general depletion may precede the local. After the leeches are removed, fomentations and a succession of poultices will be found service- able ; after which, a full dose of calomel with James's powder, and, a few hours subsequently, a mild aperient medicine, should be exhibited, and an aperient action promoted by the ad- ministration, and frequent repetition, of demul- cent, oleaginous, or saponaceous enemata (§ 13.). Drastic purgatives are seldom more efficacious than those of a milder kind, but are often attend- ed with risk. I have generally found the infusion of rhubarb, with tartrate of potash, and the elec- tuaries prescribed in the Appendix (F. 82. S9. 98.), most serviceable. In the majority of cases, the above means will remove all ailment. The treatment in other respects should be the same as is recommended in chronic Diarrhoza and in Dysentery. If functional disorder remain after the more inflammatory symptoms have subsided, a blister may be applied, or a deobstruent liniment (§ 13.) rubbed over the caecal region night and morning ; or a rubefacient and deobstruent plas- ter (§ 14.), worn for some months in this situa- tion. 32. B. In the more acute states of the disease, general blood-letting, repeated according to the circumstances of the case, or followed by local depletions, and the same treatment subsequently as described above, must be early and decidedly employed. If there be vomiting, or retchings upon taking substances into the stomach, a large dose of calomel,—generally from 10 to 20 grains given either alone or with one or two grains of opium,—will allay this disorder. If the symptoms still continue, or if they be but slightly mitigated, blood-letting, general and local, followed by fo- mentations, poultices, and oleaginous enemata, having been carried as far as may be deemed pru- dent, the turpentine embrocation, (flannel cloths wrung dry out of very hot water, and immediate- ly soaked with spirits of turpentine,) should be applied over the abdomen and retained there as long as it can be borne by the patient. If the tormina be severe, or if peritonitis have super- vened, this is, after depletions have been practised with decision, the most efficacious means we possess. In a case of this disease, which had be- come complicated with peritonitis, in a member of the family of a medical friend, this means gave almost instant relief, after other measures had been carried to the utmost limits, and the patient soon afterwards recovered. In another instance of extreme danger similarly complicated, which very recently occurred, the repetition of this treat- ment removed all complaint, although resorted to in despair of success from it. 33. C. I have stated that inflammation of the appendix caci, particularly when occasioned by hard bodies having passed into it, often does not extend to the caecum itself, or, at most, only to its peritoneal coat, in common with the adjoining portions of this surface; but that the supervention, 282 CANCER —Pathology of. the extension, and fatal termination of peritonitis in such cases are most rapid and dangerous, the appendix itself generally soon becoming gangren- ous. It therefore behoves the practitioner to "have recourse to the most decided measures, when he finds the symptoms of peritonitis originate in the raecal region, and when retchings come on. Vas- cular depletion, and all the remedies already no- ticed, must be energetically and early employed ; but premature attempts should not" be made to evacuate the bowels, otherwise their action will be inverted, and decided symptoms of ileus will be produced. Fomentations should follow the leeches ; and afterwards hot poultices should fol- low ; which in their turn ought to give place to the terebinthinate embrocation, if requisite. A large dose of calomel and opium should, how- ever, be given after the first full blood-letting ; this will generally be retained, even in the worst cases ; and it ought to be repeated according to circumstances, without fear of affecting the system by it,—an effect which it is even very desirable to produce. Little other medicine need be ex- hibited by the mouth, excepting draughts with nitrate of potash, or sub-carbonate of soda, or both, with agreeable demulcents and emollients, if the stomach will retain them. But the assidu- ous administration of enemata must not be neglect- ed. It is entirely by their agency in this state of disease, that the bowels are to be evacuated, when it is judged prudent to fulfil this intention, which should seldom be omitted as far as they are cal- culated to accomplish it; more especially after depletions have been practised. The enemata prescribed in the Appendix (F. .130—151.), as they may appear suited to particular cases, may be employed. Pain, tormina, nausea, or vomit- ing, having been relieved, gentle cooling aperients, and in the interval diaphoretic medicines, may be exhibited by the mouth. Warm baths are sel- dom of much use in this malady : but when they will not interfere with the treatment pre- scribed, they may be tried, particularly in the more advanced periods. After the disease has been removed, and merely functional disorder remains, the measures already advised may be put in practice. 34. D. The treatment now described is also applicable to the early stages of inflammation affecting the pericacal tissues. If suppuration takes place, the treatment recommended lor Abs- cess must be resorted to ; taking care to support the energies of life under it, particularly when the constitution or general health is in fault. If we suspect either the existence of ulceration or of thickening of the coats of the viscus (§27.), the assiduous employment of the liniments notic- ed above ; of gentle aperients and deobstruents, particularly the infusion of rhubarb with soda or potash ; of electuaries, with sulphur, cream of lartar and soda, or the sub-borate of soda ; small doses of blue pill or hydr. cum creta, with ipeca- cuanha, hyoscyamus, and camphor; repeated blistering, and subsequently the deobstruent plas- ters ; the frequent use of large oleaginous, sapo- naceous, and demulcent enemata, with the treat- ment recommended in chronic dysentery; are the measures most to be depended upon ; with strict attention to diet, which should be chiefly farina- ceous, to the state of the digestive organs general- ly, and to the secretions and excretions. 35. E. The complication of the disease with dysentery requires, in addition to the measures used for that disease, the application of leeches near the right iliac region, and the other external measures already noticed, with rhubarb aperients, combined with camphor, narcotics, and ipeca- cuanha ; laxatives, with demulcents and ano- dynes ; the frequent administration of oleaginous and emollient enemata ; and the usual means of correcting the secretions, and diluting and carry- ing off the acrid and excoriating fluids, and faecal matters in the intestinal canal. (See Di sentery —its Treatment.) A similar treatment to the above is necessary when the disease occurs in the progress of fever. Depletions, however, are generally not so well borne in this complication as in the former, and should therefore be carried to a less extent ; but all the external remedies, and the use of laxatives, particularly those im- parting a tonic effect to the intestinal mucous sur- face, should be often employed. Camphor, with hydrarg. cum creta and opium, or with ipeca- cuanha and rhubarb, terebinthinate injections, or even a terebinthinate draught in the worst cases, have proved most serviceable in this state of complication, in my practice. During recovery, the occasional use of the liniments and plasters above referred to, attention to the secreting and digestive functions, particularly to the state of the bowels, which should be occasionally assisted by emollient and laxative injections ; and a regula- ted diet, easy travelling, change of air and of scene ; are the chief measures requiring attention. (See the treatment of Fever.) Bibliog. and Refer.—Fabricius Hildanus, Cent. i. obs. 6.—Amyand, in Philos. Trans. No. 443.—Cantwelt, in Ibid. No. 446.—Heister, Wahrnehmungen, vol. i. n. 111.; Nov. Act. Curios. Nat. vol. ii. obs. 93.—Moreau, Journ. de Med. 1790, n. 4.—Salzmann, Observ. Anatom. p. 53.— ISacquart, Journ. Gtner. de Med. t. xxxi. p. 884.—Helm, Zwey Krankenc. kc p. 24.—Tiedemann et Gmelin, Rech. Experiment. Physiol, et Chimiques sur la Digestion, kc. 8vo. Paris, 182G.—Author, Appendix to M. Richerand's Elements of Physiology, p. 591. 2d edit. Lond. 1829.— Parkinson, in Mcdico-Chirurg. Transact, vol. iii. p. 57.— Copeland, in Ibid. vol. iii. p. 191.—Odier, in Ibid. vol. vii. p. 221.—Johnson's Medico-Chirurg. Review, vol. iv. p. 739. —Barlovj, in Ibid. vol. xii. p. 181.—Monro, Morbid Anato- my, S.r. 8vo. 2d edit. p. 26.—Emery, in Rivue Medic, t. iii. p. 273. 1825.—Louyer Fi/lennay, in Archives tfen. de Med. t. v. p. 246.—Blackadder, Edin. Med. and Surg. Journ. vol. xxii. p. 19.—Wilmot, Trims, of Assoc, of Iri*ii Coll. of Physic, vol. ii. p. 12.—Speer, Dublin Hospit. Re- ports, vol. iv. p. 349.—Bcezeley, in Philad. Med. and Phys. Journ. vol. vi. p. 350.—Kloekhoff, in Auserl. Abhandl. fur Pract. Aerit. b. i. st. ii. p. 124.—Anneslcy and Author, in Ueseart-h.es on the Diseases of India and Warm Climates, vol. ii. p. 54, et seq.—Ducos, in Archives tien. de Mid. t. xx. f>. 581.—Meniere, in Ibid. t. xvii. p. 188. 513.—Dup- let/, in Journ. Hcbdoin. t. ii. p. 302.—Shevard and Wul- dron, Midi. Med. Reporter, vol. ii. p. 50. 463.—Aber- crombie, On the Abdominal Viscera, kc. p. 237. CALCULI. See Concretions, Biliary and Intestinal; also Urinary Calculi, and Ultl.NE.) CANCER. Syn. Scirrhus, Carcinus, Schir- ro-Cancer, Carcinoma, Auct. Var. Cancer, Fr. Das Krcbsgesclavur, Ger. Scirro, Canchero, Cancro, Ital. Classif. 4. Class, Local Diseases ; 6. Or- der, Tumours (Cullen). 3. Class, San- guineous Diseases ; 4. Order, Cachexies (Good). IV. Class, IV. Order (Au- thor, see Preface). 1. Dffin. A disease often arising from he- reditary predhposition, in the middle or advanced periods of life; commencing with a local hardness, CANCER — Pathology of—Scirrhous Stage. 283 which subsequently softens in its centre, infects the adjoining parts, and ultimately contaminates the frame. 2. Cancer consists of two states or stages : the first, in which it presents the appearances usually denominated scirrhus ; the second, in which it softens, ulcerates, &c, and degenerates into true oancer, or carcinoma. I shall describe each of these successively. 3. I. Scirrhous Stage. — Occult cancer. It commences with a tumour, a limited local hard- ness; is usually single; is very rarely, at its com- mencement, detected hi different parts at once; and is not surrounded by a cyst. Several authors have stated the occurrence of a cyst; but Otto more accurately excludes it from this structure. It is of importance to attend to the appearances of the disease at its commencement, as serving to indicate its nature. It is distinguished, at this period, by hardness, coldness, whiteness or pale- ness, insensibility, and deficiency of red blood vessels; — a state indicating the low grade of vi- tal endowment of the part. 4. The scirrhous structure, when fully develop- ed, consists of a firm, hard, rugged, incompressible, and unequal mass, the limits of which are not distinctly defined. Its colour is generally of a light gray, and, when cut into thin slices, it is semi- transparent. Upon close inspection, it is found to consist of two distinct substances;—the one hard, fibrous, and organized; the other soft, and apparently inorganic. The former composes the chief part of the diseased mass, and consists of septa, which are opaque, of a paler colour than the soft part, unequal in their length, breadth, and thickness, disposed in various directions; sometimes forming a nearly solid mass; in other instances, a number of cells or irregular cavities, which contain the soft part. This latter is some- times semi-transparent of a bluish colour, and of the consistence of softened glue; at other times more opaque, softer, somewhat oleaginous, and like cream in colour and consistence. 5. The fibrous structure seems to be the cel- lular, or proper tissue of the part, in a state of induration and hypertrophy; assuming, in con- sequence of its increased density and bulk, an appearance similar to the fibrous or fibro-cartilagi- nous structures; whilst the softer portion, contain- ed in the meshes and cells of the former, appears to be merely a morbid secretion poured out by the vessels nourishing the organized fibrous tissue, and is probably the exhalation of the part, either secreted in a modified state, or accumulated and changed by the disease of its containing structure. If this view be correct, the former, or organized part, may be considered as chiefly resulting from an altered state of nutrition in the seat of disease; whilst the latter, or inorganized portion, may be viewed as proceeding from a morbid secretion, — the diseased structure thus being a product of a disordered state of both the nutritive and secreting functions, most probably in conse- quence of alteration of the vital influence exert- ed by the ganglial nerves on the capillaries of the part. 6. The proportion of each of those two sub- stances, and the modes of their distribution, vary very considerably in different scirrhous masses. This diversity seems to be owing to the different tissues in which they are developed, and to the modifications arising from temperament, local irri- tation, and various concurrent circumstances to which the patient may have been exposed. It has been attempted by Mr. Abernethy to ar- range these varieties of scirrhus into species, and to designate them according to the natural struc- tures which they most resemble. Thus he di- vides them into Mammary, Pancreatic, Tubercu- lous, &c; but these different states of structure glide so insensibly into each other, and are so perfectly similar as respects their origin and con- sequences, that little practical advantage is deriv- ed from thus distinguishing them. 7. In some scirrhous tumours, the fibrous part of their structure is both most conspicuous and abundant, and is condensed into a solid mass, having the appearance of a centre or nucleus, whence radiate numerous septa in every direction. This is the most common appearance of the dis- ease. In other instances, the tumour forms an uniformly hard mass, of an irregular shape, and of no very defined structure. In some cases, the organized part approaches more nearly to the cellular structure, its cells being filled with a soft matter which may be pressed out. Occasionally, cysts are formed within the tumour, of various sizes, containing a reddish, reddish brown, or a chocolate-coloured fluid. These cysts are lined by a smooth membrane, from which a fungous tumour sometimes sprouts out. In some instanc- es, portions of the scirrhous mass are converted into a hard substance resembling cartilage, in which bony or calcareous depositions are occa- sionally found. When the scirrhous structure is formed in the substance of a gland, its limits can- not generally be accurately determined, the two structures apparently being inseparably connected. In some cases, the scirrhous tumour condenses the cellular tissue surrounding it, and hence it acquires a somewhat sacculated appearance. (Wardrop.) 8. At the commencement of scirrhous disease, the structure of the tissue or organ in which it is seated preserves for some time its aspect and colour, being changed merely in volume and den- sity : sometimes, however, its volume is but little augmented, whilst its density is very much in- creased. As the disease advances, the proper tissue of the organ becomes more obscure, and verges nearer to that already described. 9. M. Hecht, of Strasbourg, analysed a por- tion of fully developed scirrhus of the mamma, and fouud 72 grains composed of 2 grains of al- bumen, 20 of gelatine, 20 of fibrine, 10 of a fluid fatty matter, and 20 of water and loss. He like- wise analysed, by a similar process, 72 grains of scirrhous uterus, and found it to consist of 15 grains of gelatine, 10 of fibrine, 10 of oily or fatty matter, and 35 of water and loss. (Lobstein, Anat. Path. t. i. p. 403.) 10. Scirrhous tumours do not always remain in the state now described; and the period during which they thus continue is not determinate. When once they commence, they seldom retro- grade, and the part affected never is restored to its healthy state. It is chiefly in this respect that the early stages of scirrhus differ from simple in- duration proceeding from chronic inflammation. Scirrhus may remain nearly stationary for several years, occasioning but little constitutional disturb- ance; but generally an important change takes 284 CANCER — Pathology of — Carcinomatous Stage. place in its structure, and the disease afterwards makes rapid progress. 11. II. Carcinomatous, or Cancerous Stage. — Open or ulcerated cancer. After a time, portions ofthe scirrhous mass begin to soft- en, and pass into a state of unhealthy suppuration and ulceration, — unhealthy as respects the cha- racters and progress of these processes, and their contaminating influence upon the whole frame. The soft or inorganic substance resolves itself into a thin ichorous matter, very different from pus; and disorganization commences, generally about the centre of the mass, and extending towards that part of it which is nearest either the surface ofthe body or any of the natural openings. When this process commences, it is in that state which has been denominated Carcinoma, orCANCER. When this change takes place, the diseased ma«s seldom increases much in bulk, but is destroyed by an ulcerative process. The disease now makes rapid progress, owing to the contamination of the adjoining structures by the morbid matter secret- ed by the ulcerating part, a portion of which matter is evidently absorbed, irritating the lym- phatic glands, and vitiating the whole frame. In consequence of this infection, the powers of life sink, the soft solids become cachexied, and the progress of the local affection accelerated. At last the patient sinks from the contamination of the circulating fluids, and the different textures of the body; the blood being diminished in quantity, as well as otherwise altered. 12. When the skin covering a scirrhous tumour ulcerates, a fungus of a cauliflower appearance, and hard gristly structure, sometimes proceeds from the surface ofthe mass. In some cases, ul- ceration destroys both the fungus and the primary tumour. It has been observed by Sir E. Home, that some cancerous sores have suddenly changed from a painful and malignant character, to a more healthy aspect at some part, and even have begun to cicatrize. This apparent amendment is never permanent, for, sooner or later, the ulcerative process is renewed, and the disease pursues its usual course. Dr. Parr (Diet. vol. i.) states, that he has seen several cases thus terminate spontaneously; but the patients were all soon af- terwards cut off by interna] disease; probably consisting ofthe internal developement, or metas- tasis of the malady, cases of which occurrence are not infrequent. (See Journ. Hebdom. t. i. p. 323. for a case wherein internal cancer appeared after the removal of the external disease by compres- sion.) 13. Cancerous tumours generally contaminate the glands in the vicinity, particularly after ulcer- ation has commenced. But these glands are sel- dom primarily affected. Mr. Wardrof states, in his excellent description of this disease, that he has only met with two cases of primary affection of the lymphatic glands. Besides these glands, various other organs and parts, sometimes far re- moved from the seat of the primary disease, be- come secondarily affected. This is most probably occasioned by contamination of the frame, from absorption of the morbid matter of the disease. Sometimes the existence of cancer in distant or- gans is not successive or secondary, but seemingly coeval. In this case the cause must be looked for in the originally morbid state of the system. Indeed, this state always obtains, to a certain ex- tent; the disease being strictly constitutional even in its origin; the consecutive contamination, aris- ing from the absorption of morbid matter from the primary tumour, merely augmenting the ori- ginal vice, and accelerating its noxious effects. 14. Scirrho-cancer most commonly originates in glands whose functions have been interrupted, or that have never performed the offices intended for them; or it affects parts which have been pre- viously diseased, or have received at some period an external injury. Thus it attacks the mammae, the uterus, the ovaria, the testes, the thyroid glands. It also very frequently commences in the tegumental, and the digestive, and urinogenit- al mucous surfaces; more particularly in the skin ofthe face; in the mucous membrane of the nose, lips, mouth, pharynx, and oesophagus; in the stomach, especially the pylorus and cardia; in the intestinal canal, the ileo-ca:cal valve, rectum, and anus, and in the urinary bladder. The vis- cera which are secondarily affected, are com- monly the lungs, bronchial glands, the liver, the omentum, the mesentery, the spleen, the pancreas, the brain, the medulla of the bones, and the skin. Several of these, particularly the liver, pancreas, mesentery, brain, &c. may also be primarily or coevally affected with other parts. Scirrhus af- fects the skin in two forms; — the one is that of wart, the other that of tubercle —the former be- ing primary, the latter secondary. 15. III. Diagnosis. — It is of great import- ance to be able to distinguish between this disease and various others, for which it is liable to be mistaken. For instance, the simple induration proceeding from chronic inflammation has, in several instances which have come to my know- ledge, been mistaken for scirrhus. This mistake not infrequently occurs in respect of induration of the neck of the uterus. 16. A. In simple induration, the part affected is redder, more injected, retains more of its ori- ginal structure, is less indurated, and less lobu- lated, than scirrhus. The parts also surrounding the indurated portion are frequently .slightly infil- trated with serum. Induration, the result "of in- flammatory action, admits of resolution, and en- tirely disappears, sometimes in consequence of a natural flux or evacuation, of active exercise, the return of accustomed discharges, or pregnancy. Thus the menstrual flux sometimes dissipates in- flammatory induration of the mammae, or of the neck ofthe uterus. 17. B. The fibrous production generally ap- pears in the form of a rounded body, implanted, but isolated, in the proper structure ofthe organ, and adhering to it merely by means of laminaled tissue. Upon dividing this structure, it grates un- der the scalpel; and it sometimes presents dilated vessels, which are never observed in scirrhous masses: moreover, it occasions little or no pain, and never passes into the cancerous state. 18. C. Compared with tubercular or lardaceous productions, scirrho-cancer offers remarkable dif- ferences :— 1st, 1 his latter is never found isolated in the cellular tissue, or in the parenchyma of organs, in the form of granulations, or of small rounded tumours, as the tubercular formations are; nor in largely diffused masses, as the lard- aceous substance : 2d, It is never enclosed in a cyst: 3d, It does not greatly increase the volume of the part it affects; sometimes the part is evea CANCER —Cancerous Cachexy — Causes of. 285 diminished, but much more dense: 4th, It is not susceptible of the same kind of softening as the tubercular and lardaceous productions; but rather of a peculiar rarefaction, passing into a peculiar form of fungus, followed by the developement of blood-vessels: 5th, Its vital properties are excited, and its sensibility becomes exalted, as the disease advances, — circumstances which are never ob- served in connection with these productions. 19. D. Cancerous ulceration is characterised by a jagged, thick, soft edge, which is turned out- wards. The surface of the ulcer is grayish, or grayish brown, sometimes livid brown, elevated into loose, fungous vegetations, discharging a foetid, corroding sanies or ichor, and bleeding slightly upon irritation, a. Chronic inflammatory ulcers differ from the former in the absence of a fa'tid corroding ichor; in the hardness of their margin, which turns inwards; and in the reddish ;ind more healthy appearance of their bottoms, which in cancer is colourless, or a livid brown, hard, irregular, fungous, sometimes with cauliform excrescences, and extremely offensive, b. Local tumours sometimes appear, particularly on the tongue, originating in irritation, and exasperated by the continuance of this cause. These usually commence with a small pimple or wart, becoming more and more hard and irritable as they increase, until they assume a scirrhus-like induration. They seldom endanger the constitution, yet appear sometimes to assume a malignant character. (Mr. Earle, in Trans, of Med. Chir. Soc. vol. xii. art. 22.) 20. E. As soon as the carcinomatous change takes place in the scirrhous mass, the disease in- volves adjoining parts, and the system generally. The local suffering is more fully developed, and the vital actions of the part are changed greatly from the healthy course. The sensibility is mor- bidly augmented in short paroxysms ; the pain being violent, and what is usually called lan- cinating or stinging during the exacerbations, but often slight, or almost altogether absent in the intervals. If the surface be exposed, the pain is burning, and the part is always sore. As the dis- ease advances, and particularly as the ulceration proceeds, the paroxysms of lancinating and burn- ing pains increase in violence, and the remissions become more imperfect, and of shorter duration. The cancerous sanies is generally very fluid; but its appearance varies with the treatment, the situation of the disease, and with the diet of the patient. It is generally of a grayish white, or reddish gray; it slightly effervesces with sulphuric acid, and turns syrop of violets to green. 2 f. F. The extension and contamination of the system characterising cancerous ulceration appear to be owing, 1st, to the corroding influence ofthe secretion on the parts with which it is in contact: 2d, to the absorption of a portion of the morbid secretion by the lymphatic vessels: this is evinced by the swelling and affection of the glands in the vicinity ofthe primary disease. But the affection of the glands may not be altogether owing to the absorption of the morbid matter, but partly to the irritation of the lymphatic vessels occasioned by the disease of the part in which they originate : and, 3d, to the absorbing function of the veins, according to the researches of Mayer, Magen- die, Tiedemann, Gmelin, &c. These different sources of contamination seem more than sufficient to account for the general cancerous cachexia characterising the advanced stages of the disease. 22. G. The characters of this cancerous ca- chexia are, emaciation; softness and flaccidity of the soft solids; cedema of the extremities; hectic fever; a peculiar change of the complexion and colour of the whole surface of the body, which become of a pale leaden, or pale straw colour, or waxy hue ; and general depravation of the functions. This state of cachexia increases with the progress of the disease, and augments at the same time the primary local change. It is rapidly developed and increased when the scirrhous mass ulcerates, when also carcinomatous tumours fre- quently manifest themselves in various parts of the body. Ultimately the circulating fluid is de- ficient in quantity, and is poor and morbid; and the vital cohesion of the soft solids, and even of the bones, is diminished. 23. IV. Causes. — Scirrhus, like scrofula, is undoubtedly an hereditary malady. Instances are numerous of several individuals in the same family having been affected by it. It is almost altogether confined to persons advanced in life. Cases of the disease are very rare before the age of thirty. Sir A. Cooper met with it only twice previously to this age. Mr. Wardrop has seen one instance of it in the skin of a girl of twelve years. Females, owing to the liability of their appropriate organs to be attacked, are more sub- ject to it than males; especially those who have not borne children, the disease generally appear- ing in them upon the cessation of the catamenia. The disease seems commonly to result from an original or acquired diathesis, existing previously to the developement of morbid structure, and very often connected with the lymphatic temperament. MM. Breschet and Ferrus found 23 instances of this temperament prominently marked, out of 44 cases of the disease. Anxiety and distress of mind, and all the depressing passions, are most disposing causes, particularly to cancer of the breast. An inactive state of the part for a con- siderable time previously; a poor, unwholesome diet; laborious and exhausting occupations, and an unhealthy locality; also dispose to it. 24. It is generally excited by blows and exter- nal injuries; by repeated or continued irritation; the abuse of spirituous liquors; and by low and poor diet. It is not liable to be propagated by contagion; the experiments of MM. Alibert, Biett, and Dupuytren,having shown that the matter discharged from a cancerous ulcer cannot produce the disease in another person. Although irritating agents of any description may give oc- casion to its appearance, yet there must have pre- viously existed cancerous diathesis, or constitutional disposition, in which it almost always originates. 25. The proximate cause of this dreadful disease is extremely obscure; and opinions respecting it have consequently been numerous. Schaefker and Gamet consider it to be caused by a singular depravation of the nervous fluid. Dr. Adams and Dr. Baron impute it to the existence of an hy- datiform body, which they call the hydatis car- cinomatosa; and Mr. C arm ich a el, to a body enjoying an independent state of existence de- veloped in those parts of the frame, the vitality of which is enfeebled, and the organized matter of which begins to be decomposed. He supposes that, at first, this constituent of cancer occupies 286 CANCER—Treatment of. but a minute spot, consists of a substance nearly similar to cartilage; and that it afterwards extends itself in the form of radiations, resembling liga- ments formed by thickened cellular tissue. These opinions, which are not essentially different from each other, have been completely refuted by Burns, Cleri, and Himly. According to M. Broussais, scirrho-cancer is the result of an inflammatory or sub-inflammatory state of the vessels (Examen des Doctrines Med. t. i. prop. 93 — 95.); and the opinions of M.M. Begin, Brf.schf.t, and Ferrus (Diet, de Mid. t. iv. p. 133.), differ but little from that of M. Brous- sais. They impute the disease to irritation of an inflammatory nature, occasioning the secretion of a coagulable lymph that becomes condensed into a scirrhous substance, which may remain sta- tionary for a longer or shorter period, but which sooner or later undergoes a secondary inflamma- tory process, and experiences softening and dis- organization, with various other changes, as these processes proceed. To this doctrine of the mod- ern French pathologists it may be objected, that scirrhus furnishes no sign, local or general, of in- flammation, and yet it goes on increasing; and if it can increase rapidly without inflammation, may it not also originate independently of this cause ? Where, therefore, neither the local appearances, nor the usual consequences, nor the constitutional symptoms, of inflammation can be perceived, ought we to impute disease to this state of vascular ac- tion ? The inference is obvious; but it is only one of many arguments, which, if they were not su- perfluous, might be adduced against the doctrine. 26. According to M. Andral, cancer is not a specific alteration, but a state of disease arising from lesions of nutrition and secretion, which have reached the period of their termination in ulcera- tion; the ulcer thus arising, constantly increasing either in depth or extent of surface, without any disposition to cicatrisation. Thus, M. Andral considers cancer in a generic acceptation, and com- prises under it the ulcerative process in various species of disease of a constitutional origin and malignant nature, which, although always consid- ered as closely allied, in their origin, nature, and tendency, to scirrhus, have usually been viewed as distinct maladies. This opinion is more in ac- cordance with the wide signification of the term cancer, in the writings of French pathologists, but is very deficient in precision and applicability; in- asmuch as it embraces the advanced states only of several organic changes, which, in their earlier periods especially, are very distinct from one another — distinct in causes, origin, the structures they principally attack, and in their appearances and properties. I have, therefore, adopted the more accurate views of British pathologists re- specting this disease, which I consider in relation to its predisposing and exciting causes, to the states of the system in which it occurs, to its local ap- pearances, and constitutional effects, to the results of treatment, and to the ultimate changes produc- ed in the blood, and in the various structures, as essentially depending upon a weakened and other- wise morbid state of the system generally ; and arising from depravation of the vital conditions of the part affected, whereby its nutrition, ner- vous sensibility, and secreting function, become specifically clianged, und all the fluids and solids ultimately contaminated. 27. V. Treatment.—The conclusion now drawn respecting the nature and morbid relations of scirrho-cancer must render very apparent the futility of various measures which have been em- ployed to remove it. Some writers have too ex- clusively viewed the disease as local; and thus, even in its advanced stages, resorted to most dan- gerous and painful operations to extirpate an evil, which, instead of being local, proceeds from the morbid state of the system generally, and which all depressing causes (the surgical operation itself being one) rapidly increase, disposing not only to its extension in its primary seat, but also to its ap- pearance in new situations and more vital organs. The means of cure, therefore, should have especial reference to the state of the constitution favouring its developement and progress ; for, when the malady is advanced, local measures can, at the best, only be palliative, and are therefore subsidi- ary to judiciously devised means employed inter- nally, and assisted by suitable diet and regimen. 28. Before I proceed to state the indications which should guide the treatment of this disease, and the medicines which seem best calculated to fulfil them, as far as this is possible, I will take a brief view of the means which have been recom- mended or tried by preceding writers. The real importance of this subject to the physician will be the more obvious, when he reflects, that cancerous diseases are often—indeed most legitimately on all occasions—within his province, more particularly when they invade, as they frequently do, internal organs; and that the life of the patient may be greatly prolonged, and his sufferings much allevi- ated, by judicous medical treatment. 29. A. At the commencement of the scirrhous stage, various means have been employed, and sometimes with some advantage, according to the showing of those who employed, them. Conium has, upon the whole, found the greatest number of supporters; and I think that, when it has been combined with the alkaline tonic and stomachic preparations, it has been often of considerable benefit. This seems to be nearly the opinion of several writers, and amongst others, of Ges.ner (Beobacht. b. i. p. 213., iii. p. 242.), Girard, Hufeland, (Journ. der Pract. Heilk. b. ix. 3 st. p. 86.), Hahnemann (in Ibid. b. ii. p. 473.), and Thilenius (Med. und Chir. Bemerk. p. 100.). Electricity and Galvanism have been employed by Brisbane (Select Cases, fyc. p. 36.) and Walth e r (Ueber die Ther. Ind. der Galv. Oper. fyc. c. 12.); the muriate of baryta, by Hufeland; antimonials, by Rowley and Dowmann; aconitum, by Greding; digitalis, by Mayer (Richter's Chirur. Bibl. b. v. p. 531.); laurel-water, by Thilenius; mercury, particularly the corrosive sublimate, by Ruysch, THiLFNius,and Harris; sal-ammoniacum,by Justamond; belladonna by Gataker; and the mezereon, by Home (Clin. Exper. and Hist. p. 428.), with more or less benefit, chiefly of a tempo- rary kind in those cases which were obviously scirr- hous, and with permanent service in those which were only supposed to be of this description. 30. B. In the more fully developed and less doubtful states of the disease, as well as in its earliest stage, a number of medicines have been recommended, and for awhile have obtained some credit, which few of them have long retained. The great majority, however, of them have been CANCER—Treatment of. 287 brought forward rather as palliatives, and with the view of keeping the disease in check, than as pos- sessing the power of curing it; yet some have been exhibited with more sanguine expectations, par- ticularly arsenic, conium, hyoscyamus, and bella- donna, a. That conium is productive of benefit, when judiciously combined with other remedies, is manifest, notwithstanding the contradictory evi- dence respecting it. While we find Stoerck (Lib. de Cicut. Vind. 1761. 8vo.), Fothergill (Works, vol. ii. p. 47.), Hamilton, Francke (De Cancro. len. 1778.), Nicolson (Med. Obs. and Enquir. vol. iv. n. 31.), Quarin (De Cicu- ta, ch. 4. 5.), Fearon, Bell (On Ulcers, pt. ii. sect. 8.), Gruelmann (De Usu Cicuta, 8fc. Goet. 1785.), Renard (Journ. de Med. t. xxiii. p. 411.), Schaeffer, and several other writers, in favour of it, we observe, Siebold (Chir. Tageb. n. 74.), Lange, Hill (Ed. Med. Com- ment, vol. i. p. 146.), Akenside (Trans, of Col. of Phys. vol. i. n. 6.) Oberteuffer, (Hufe- land's Journ. b. ix. st. 3. p. 81.), Schneider Chirurg. Gesch. b. iv. n. 19.), and Burns, ex- pressing opinions as to either its little efficacy, or its entire want of effect. This discrepancy may be accounted for upon the supposition of want of virtue in the preparations prescribed; the extract generally losing the virtues ofthe plant during the modes of preparing it formerly in use: and I find, upon referring to most ofthe authors now quoted, and to others not referred to, that the extract and decoction were usually employed by those who found it productive of no benefit; whilst the powdered leaves, the expressed juice of the plant, or an infusion of it, had been preferred by those who have expressed themselves in favour of it. I have prescribed the inspissated juice and powdered leaves of this plant, in several cases of internal scirrho-cancer, in combination with the alkalies and tonics, and have always found them much more beneficial when associated with it. 31. b. Belladonna was first exhibited by Al- berti (De Bellad. tanquam Specif, in Cancro, 4rc. Halae, 1739.), who highly praised it in the occult stage ofthe disease. It w;is afterwards re- commended by Lamb erg en (Haller's Disp. Pract. ii. n. 41.), Bellot, Lentin (Beobacht. &rc. n. 2. and 3.), Amoureux (Journ. de Mid. t. xiiL p. 47.), Camperdon (Ibid. t. Iv. p. 312. 423—502.), Sulzer (in Ibid. t. xxiv. p. 68.),and by Grandvilliers (Ibid.t. xvi. p. 449.); and declared of little use by Zimmermann and De IIaf.n (Rat. Med. pt. ii. p. 37.). I believe, how- ever, that some advantage will be procured from its internal and external use, particularly as a pal- liative, and when combined with medicines which are calculated to support the energies of life, and improve the secreting and digestive functions. A similar opinion may be offered respecting hyoscy- amus. 32. c. There is, perhaps, no medicine which has been so commonly prescribed in this malady as arsenic. It forms the base of the several secret remedies, internal as well as external, employed by empirics; and has been very generally used by them as an escharotic, sometimes with very inju- rious effects, from being absorbed 'argely into the system. There can be no doubt, however, of its beneficial influence, in many cases, when cau- tiously prescribed, and judiciously combined with other medicines; but chiefly as a most energetic tonic and excitant of the capillary vessels, and powerful detergent in the ulcerative stage of the disease. Justamond prescribed it both internal- ly arid externally, with opium and various other medicines; Stark (Archiv. f d. Geburtsh. b. ii. p. 673.), Rush (Edin. Med. Comment, vol. xi. p. 312.), and Odhelius, state that they have found it cure incipient cancer, when applied in solu- tion to the part; Collenbusch (in Hufeland's Journ. d. Pract. Arzn. fyc. b. iii. p. 103.) found it beneficial when employed externally, tonic ex- tracts having been given internally at the same time; Fischer (in Richter's Chir. Bibliog. b. viii. p. 76.), Michaelis (in Ibid. b. v. p. 132.), and Reusner, prescribed it in the form of the powder of Guy * (composed of arsenic, sulphur, ranunculus sylvest., &c), with marked benefit; Salmade (Mem. de la Soc. d'Emulat. t. i. p. 152.) cured a case with the powder of Rousselot, the twenty-fifth part of which, he says, consists of arsenic; Bala scon deTarare gave it with the expressed juice ofthe solanum, and Hornung with serpentary and soot. This evidence, how- ever, in its favour, is not without powerful oppo- sition. Fabricius Hildanus (Cent. vi.obs.81.) says, that arsenic was introduced into practice by a monk named Theodoric, in the tenth or eleventh century (having probably been made acquainted with it in the West), and details cases in which he considered it detrimental. A similar opinion has been entertained of it byScHNEiDER, Thilenius (Med. und Chir. Bemerk. p. 101.), Acrel, Murray (Med. Pr. Bibl.h.iii.p.485.), Adams, Oberteuffer (Stark's N. Archiv, b. iv. p. 673.), and Delius. Mr. Hill, however, expresses a very favourable opinion as to the ef- fects of this mineral, and states that it will retard the progress of the true scirrhous tumour, in the great majority of cases, and often prevent it from becoming cancer (Ed. Med. and Surg. Journ. vol. vi. p. 58.). I believe that, when this medi- cine is cautiously employed, both internally and externally, in conjunction with narcotics and al- kalies, or otherwise judiciously combined, Mr. Hill's opinion in its favour is not much too highly coloured. 33. d. The preparations of mercury are always injurious in this disease, when exhibited in any other manner than as an alterative, and, externally, as an astringent and stimulating wash. The oxy- muriate, in minute doses internally, with the mu- riate of ammonia, or the compound sarsaparilla decoction, the tinctures of cinchona, with guiacum, &c, is often of service, at least in retarding the progress of its early stage; and when the disease has advanced to ulceration, the external use ofthe oxymuriate, with the muriate of ammonia, lime water, &c. may occasionally be of some service. Reidlin (Cur. Med. Millen. n. 408.), states, that the preparations of this mineral are always injurious when productive of salivation. Of the accuracy of this opinion, there can be no doubt. Prescribed, however, as now recommended, it has received the approbation of Moseley, Gooch, Gmelin (Method. Cuncrum Sanandi, Tub. 1756.), Hagen, Gataker, Chapuis, Buchner (De Med. Met cur. Usu in Cancro. Hal. 1755.), Champei.le (Sur le traitem. du * A secret remedy, recommended by Richard Guy, in a production, entitled Essays on Scirrhous Tumours and Can- cers, Svo. Lond. 1759. 288 CANCER—Treatment of. Cancer. Par. an viii.), and by Sir A. Cooper (Lectures, in Lancet, vol. iii. p. 190.) 34. e. The preparations of iron have been recommended by Justamond and De Mare ( Tract. Med. Chirurg. de Cancro, 8fC. Men. Svo. 1767.), who gave them variously combined, par- ticularly with muriate of ammonia, and in the state of neutral salts. Mr. Carmichael strenu- ously advises the sub-phosphate, combined with a little pure fixed alkali, lie prefers this prepara- tion, but occasionally also employs the carbonate, the tartrate of iron and potash, the phosphate and oxyphosphate of the metal. If it occasion cos- tiveiiess, he combines with it a little aloes; and, if it produce headach, fever, or full pulse, he leaves it off, and gives four grains of camphor every five hours. He prescribes it as follows; directing externally to ulcerated cancers, the carbonates, phosphates, or arseniate of iron, made into a thin paste with water; and to occult cancer a lotion constantly applied, consisting of a strong solution of some one of the salts of this metal. No. 85. R Sub-phosph. Ferri gr. xxx.— >) ij.; Potassae vel Sod* Pura> gr. iij.—v.; Extr. Aloes gr. iv.; Pulv. Gly- cyrrh. 9 j. ; Albiimenis Ovi q. s. ut fiant Pilulae xij. Capiat binas terliu vel quartis horis. Besides these preparations, the ferrum ammonia- turn is entitled to notice. It was considered the best medicine that could be directed against this disease by Dr. Den man (Observ. on the Cure of Cancer, p. 77.). 35. /. The preparations of lead have also been used, chiefly externally, when the disease has ad- vanced to ulceration. Gesnf.r (Beobach. b. v. p. 141.) recommends the acetate in the form of liniment with turpentine, and Schoenheyder (Soc. Med. Hann. Coll. vol. i. n. 4.), advises the continued application of lotions of this salt in a decoction of conium. It has also been used in thin sheets constantly pressed upon the scirrhous tumour. Of the various other remedies brought forwards by authors at different periods, and stated by them to have proved serviceable, I may briefly notice the following:—Horstius (Observ. 1. ix. ob. 3.) prescribed internally, and externally, sul- phur, with spirit of turpentine; Rui.and (Cur. Ampir. i. n. 92.), the balsamum sulphuris; and various other writers, the oleum sulphuris (F. 21.). The sulphurets have also been employed, both internally and externally, either alone, or with narcotics, and sometimes with benefit. Gata- ker (Obser. on the Intern. Use ofthe Solanum. Lond. 1757.) used the solanum nigrum; and Paulus.KginjE (1. iv.c.25.),ORii)ASius (Syn- op. 1. vii. c. 13.), and Carerf, the expressed juice of the solanum dulcamara, externally; the last-named author exhibiting it internally at the same time. Opium, as well as other narcotics, is often necessary in order to alleviate the patient's j sufferings, and with this view has chiefly been ; employed. I believe, however, that, when com- bined with suitable remedies, it is otherwise pro- ductive of benefit. The volatile and fixed alka- lies have been exhibited by Bark e r (New York Med. Repos. vol. iv. n. 4.), Martinet and Bar- bette (Journ. de Med. t. lvi. p. 559.); antimo- nials, by Rowley and Theden (Bemerk. b. ii. p. 86.) ; barytes, by Crawford (Duncan's Med. ' Comment, vol. xiv. p. 433.); cinchona, by Hom- j burg, Vikussknn, and Plenk (Samml. von Beobacht. L n. 6.); the expressed juice of the che- j lidonium and the sulphate of zinc, by Berchel- mann; lime-watcrhy Vogel (De Curat. Cancir. per Aquam Calcis V'iua potam, 8fc. Goet. 1769.); the orobanche Virginiana, by Barton and Ben- sell (Philad. Med. Journ.); an ointment with the juice of the bardana and acetate of lead, by Percy (Hufeland N. Annalen, i. p. 3SL); cam- phor, by several authors; the sedum acre, by Bu- choz and Quf.snai; the onopordum acanthium, bvGoEi.iCKF. (De Onopordo Carcin. Aver.fyc. Fr. 1739.), Handel, Juncker, and Ross; myrrh, by Nicolas (Hufeland N. Annalen, i. p. 362.); fixed airs, by Beddoes, Percival (Essays, ii. p. 73.), Ingenhousz, and Peykii- he (De Cancro, p. 75.); digitalis, by Richter (Chirurg. Bibl. b. iv. p. 591.); the hydro-sul- phuret of ammonia, by Burns; petroleum, by Ramma/.zini and Pierce; the rhododendron chrysanthemum, by Pallas; and aconitum, sar- saparilla, guaiacum, the beccabunga, the phellan- drium aquaticum, &c by various writers. All these have been prescribed both internally and externally, with little or no advantage, or with very temporary benefit only. 36. g. Of the numerous external remedies re- commended at various periods, the preparations of arsenic and quicksilver; charcoal and carrot poultices; the mineral acids, particularly the oxy- muriatic and chloric acids; the chlorurets, and many ofthe metallic salts; camphor, the balsams, and the terebinthinate substances; ammoniacum, galbanum, and myrrh; and the greater part of the astringent, antiseptic, detergent, and stimulating vegetable medicines, have obtained a greater de- gree of reputation; and, when some of them are judiciously combined with one another, and with narcotics, they are deserving of notice as discu- tients in the early stage of the disease, and as pal- liatives in its ulcerating state. 37. Frictions of the part were advised by Pon- teau, and Young entertained sanguine expec- tations ofthe result of pressure,—a practice which, very recently, has received the support of Reca- mier, and several French physicians. M. Jou- bert states, that he has found small local blood- lettings, and the following pills, most serviceable in the different stages of cancer. (Archives Gin. vol. xvi. p. 282.) No. 86. R Sapoius Medic. ^ iv.; Gum. Ammoniaoi ~ ij.; Kxt. Conii et Ext. Aconiti Nap. 5 jss.; Mass;e Pilul. Kuli ~, j. M. Contunde bene simul, et divide in Pilulas gr. v. He directs two of these to be taken night and niorniug, increasing the dose by an additional one daily, until twelve, fifteen, or even twenty, are taken, morning and night. The rest ofthe treat- ment consists in applying poultices of the recent conium; using deobstruent and solvent beverages, a mild diet and regimen, and wearing an issue or setou in the arm or thigh. This plan has likewise been advised by Dr. Low assy, by whom it was first practised. 38. h. Sir A. Cooper expresses himself very strongly against low diet in this disease,—a practice which had been much insisted on by Mr. Pear- son, Dr. Lambe, and Hufeland (Journ. der Pract. Arzueik. b. i. p. 289.) The opinion of Sir Astley is certainly in accordance with accurate observation, and rational induction. This very emi- nent surgeon states, that he has seen most benefit derived from Plummer's pill given at bed-time, CANCER — Treatment. 289 and stomachic tonics in the day, consisting chiefly of the bitter infusions, with ammonia, and the sub- carbonates of the alkalies. Some advantage was also derived from a pill, consisting of half a grain of stramonium, with two grains of camphor, given twice or thrice a day. 39. Since the introduction of iodine into prac- tice, the preparations of it have been tried in the different stages of cancer by several physicians. The results of the trials which have been made of this substance are certainly such as ought to war- rant the use of it in the early states of the disease. The cases recorded by Dr. Wagner (Rev. Med. Juin, 1823.), and by Mr. Hill, of Chester, are much in favour of it. I have been consulted in two cases occurring in females between thirty and forty, for what was considered, by the attending practitioners, scirrhus mamma, owing to the lan- cinating and remitting pains, and the diseased state of the nipple and axillary glands. They were both put upon a course of iodine (F. 328, 329.); and conium, with the sub-carbonates of potash, was given internally; a light nutritious diet, and strict attention to the state of the uterine functions, were also observed. Perfect recovery has taken place in both; but it appears doubtful whether or not they were genuine cases of scirrhus, notwith- standing the signs now alluded to were present. They had, however, withstood other means of cure for a long time. The treatment, in one ofthe cases, was chiefly conducted by Mr. Faxon, according to the above suggestions. 40. C. Conformably with the opinion stated above (§ 26.), I conceive that the treatment of this disease should be directed to the fulfilment of the following intentions : — 1st, To support the energies of life, by exciting the digestive functions, and the abdominal secretions and excretions; 2d, to soothe the morbid sensibility of the part, and promote the absorption of morbid depositions in its tissues, by means of anodynes combined with deobstruents and discutienfs ; and, 3d, to impart vigour to the frame by suitable medicine, diet, and regimen. The remedies which are calculated to fulfil the first indication, may be often conjoined with those intended to accomplish the second and third; and both internal and external means may be simultaneously used, with those views. The medicines already enumerated comprise nearly all that have been found of any service in this dis- tressing malady. But the advantage to be derived from them will mainly depend upon their combi- nation and exhibition appropriately to the circum- stances of individual cases. 41. The preparations of iodine given in very small and frequently repeated doses, with potass, and conium, or opium, will be found amongst the best remedies that can be used; inasmuch as, when exhibited in this manner, they are both tonic and deobstruent. They may also be used externally in the form of ointment; but one third of the proportion of hydriodate to the ointment usually employed should be prescribed, and friction with it ought to be of much longer continuance than commonly directed. Either stramonium, conium, opium, belladonna, hyoscyamus, or aconitum, may be given in various forms in the intervals between the exhibition of the iodine ; and be combined with tonic infusions or decoctions, with the fixed or volatile alkalies, or with camphor in doses of from two to six grains. They may also be tried | 25 in conjunction with the preparations of arsenic, or of iron, or the chlorates of potash, soda, or lime, and as external applications also, when the disease has gone on to ulceration. In females, scirrho- cancer is generally connected, at its commence- ment, with disorder or the cessation of the men- strual discharge. In such cases, the preparations of iron with ammonia, or the fixed alkalies, and aloes, are sometimes of service. I have observed most advantage in these cases from frequent and full doses of conium, in the form of powder, given with the sub-borate of soda. 42. Tonic infusions, or decoctions, with liquor ammoniae acetatis, or with the carbonates of the alkalies, and extract of conium, or the tincture of hyoscyamus; the oxymur. hydrarg. in the com- pound tincture of cinchona, or compound decoc- tiou of sarsaparilla; or small doses of blue pill, or hydrarg. cum creta, with camphor, and either of the narcotic extracts; the preparations of sulphur, and the sulphurets ; the phosphates of iron, or this metal combined with ammonia, and conium; the sulphates of quinine and zinc; and the balsams and terebinthinates ; may severally be employed. No. 87. R Decccti Cinchona J j- i l"'1}- Ammon. Acet. 3 ij. j Liq. Ammon. TTJ xx.; Extr. Conii gr. vj.; Tinct. Capsici Annui TT) viij. M. Fiat Haustus, ter die sumen- dus. No. 88. R Potassae Sulphureti 3 jss.; Pulv. Fol. Bella- donna: 9 jss. j Saponis Castil. J j- i Gum. Ammoniaci 3 j- Syrup. Simp. q. s. Simul contunde, et divide massam in Pilulas lx. quarum capiat tres ad quatuor ter qtiotidie. No. 89. R Infus. Anthemidis 3 jss.; Liq. Potassae TT) x.; Tinct. Hyoscyami 3 »• M. Fiat Haustus, ter die capieudus. No. 90. R Hydrarg. cum Creta er. j. 5 Camphors rasae gr. iij.; Extr. Aconiti (vel Belladonnas, vel Stramonii) gr. ss. ad gr. j.; Soda; Sub-carbon, exsic. gr. viij.; Bals. Peruvian, q. s. ut fiant Pilulae iij. mane nocteque sumen- dae. No. 91. R Arseniei Albi gr. vj. — x.; Opii Puri gr. xij. —xx.; Oxydi Zinci 5 ss. j Butyr. Recent. J j. ; Ceras Flavae Liquef. 3 jss.; Longe triturat. inisceantur exac. tiss. et f. Unguentum parti aftectae applic. (HARLESS, De Arsen. Usu in Med. Norim. 1811.) No. 92. R Extr. Conii mac, Balsam. Peruv., aa 3 )• 1 Plumbi Acet. 9 j.; Tinct. Belladonna; TT) xii.; Tinct. Opii Comp. (F. 729,) 9 j.; Unguent. Ceras 5 j. M. Fiat Unguentum. No. 93. R Ferri Ammoniati 3 jss.; Extr. Conii, 3 j- i Pulv. Capsici Annui 3 ss.; Extr. Aconiti gr. iv. Camphorae rasae gr. xv.; Extr. Aloes purif. 9 j.; Syrup. Simp. q. s. M. Contunde bene simul, et divide in Pilulas xlviij. quarum capiat tres, ter, quaterve quotidie. No. 94. R Herbas Beccabungae contus. "i, ij.; Pulv. Capsici Annui 3 jss.', Aquae Ferventis O J. Macera bene et cola. Dein adde Liq. colat. Solut. Arseniei 3 'j- (vel Chlor. Calcis 3 jss.); Extr. Opii Aquos. 3 j, M. Fiat Lotio, pro parte aiTecta. No. 95. R Balsam. Canad. 3 jss. j Oxyd. Zinci 9 ij., (vel Sub-carb. Potassae exsic. 3j-)i Pulv. Folii Conii 9 ij.; Pulv. Capsici 9 j,J. ; Pulv. Tra^acanth. Comp. q. s. ut fiat Massa Pilularis, quam divide in Pilulas xlviij. Capiat tres ter die ; et augeatur dosis ad quatuor quater quo- tidie. 43. D. Although the malady obviously has a constitutional origin, yet the propriety of extirpat- ing the affected part, as soon as the true scirrhous character becomes manifest, may be conceded. After this is accomplished, the constitutional vice may be .more successfully combated, and the re- appearance of the local disease more probably pre- vented than at a later period. When, however, the system exhibits any of the symptoms of the can- cerous cachexia, whether the adjoining glands be enlarged or not, nothing will be gained by an oper- ation ; but some advantage may still accrue from judicious and energetic medical treatment, par- ticularly from tonics combined with anodynes, alteratives, and deobstruents. Whilst medical 290 CATALEPSY —Pathology. measures have often obtained the credit they by no means deserved, from the circumstance of local diseases mistaken for scirrhus having been re- moved by them; so I believe that surgical opera- tions have sometimes acquired reputation from the same cause. 44. During the treatment of this malady, atten- tion must be especially directed to the secretions and evacuations. The bowels ought to be kept freely open, with deobstruent laxatives, combined with tonics and vegetable bitters. The diet should be nutritious, and easy of digestion. Pork, in every state, ought to be avoided, as well as other indi- gestible kinds of meat. Change of air, and of scene, with agreeable amusements, serve essentially in assisting the influence of a judiciously devised method of cure, and should, therefore, not be over- looked by the practitioner; and several of the tonic and deobstruent mineral waters are of use, particu- larly those of Bath, Tunbridge, Buxton, Spa, &c. Bibliog. and Refer.— Le Dran, Mem. de 1'Acad. Roy. de Chirurg. t. vii. p. 223.—B. Peyrilhe, On Cancerous Diseases, translated from the Latin, with Notes, kc. Lond. 1777.—M. Akenside, On Cancer, in Transac. of Coll. of Physic. Lond. vol. i. p. 45. — Johnson, Practical Essay on Cancer, 8vo. Lond. 1810. — Himly, in Hufeland's Journ. der. Prakt. Heilk. 1809, par. xii. p. 126. — Home, Observations on Cancer, &c. Lond. 1805. — Adams, On Morbid Poisons, 2d edit. 1807. — Howard, Pract. Obser- vat. on Cancer, 8vo. Lond. 1811. — Young, Cases of Can- cer aud Cancerous Tendency, vol ii. Lond. 1816.—Rouzet, Recherches et Observations sur le Cancer, 8vo. Paris, 1818. — Bayle et Cayol, in Diet, des Sciences Med. t. iii. p. 555. — Wenzel, Ueber die Induration und das Gcschwur on Indurirten Theilen, 8vo. Mainz, 1815. — Baumann, Ueber den Krebs, kc 8vo. Leips. 1817. — Hill, in Edin. Med. and Surg. Journ. No. lxxxvii. p. 282. — Wardrnp, in Introduction to Dr. Baillie's Morbid Anatomy, vol. ii. p. 36. — Scarpa, Sullo Scirro e sul Cancro Memorie, 4to. 1822. — Cruveilhier, Essai sur l'Anat. Patholog. t. i. p. 127. — Velpeau, in Revue Medicale, t. i. p. 217. 1825. — Lambe, On tie Effects of a peculiar Regimen in Cancer- ous Complaints. Lond. 1815. — Carmichael, On the Effects of the Preparations of Iron upon Cancers, kc. 2d. ed. 8vo. Dub. 1809. — Abernethy, Surgical Works, vol. ii. Lond. 1811.—Rodman, On Cancer of the Breast, 8vo. Lond. 1815.— C. Bell, On Carcinoma, in Trans, of Med.-Chirurg. Society, vol. xii. p. 213. — A. Cooper, Lectures, in Lancet, vol. ii. p. 559. —Breschet et Ferrus, in Diet. deMed. t. iv. p. 131. — Ultmann, in Encyclopad. Worterb. der Med. Wissen. b. vi. p. 559. — Recamier, Sur le Traitement du Cancer, kc t. l. Paris, 1826. — Begin, in Diet, de Med. et Chirurg. Prat. t. iv. p. 425. CARCINOMA. See Cancer. CARDIALGIA. See Indigestion. CARDITIS. See Heart, Inflammation of, &c. CATALEPSY AND CATALEPTIC ECSTASY. Classif. 2. Class, Nervous diseases; 1. Order, Comatose Affections (Cullen). 4. Class, Diseases ofthe Nervous Function; 4. Order, Affecting the Sensorial Powers (Good). II. Class, III. Order (Author,see Pre- face). 1. Catalepsy and Ecstasy, although treated of by some writers as distinct affections, generally present very nearly the same pathological con- ditions, as respects the presumed states of circu- lation in the brain, of vital energy, and of nervous influence ; manifest similar morbid relations and complications, in their origin and progress; are so far modified in their symptoms, as frequently to pass insensibly into each other; and therefore re- quire, according to such manifestations, a treat- ment in all respects the same. For these reasons I shall consider them, in this article, as varieties of the same species of disease ; and, if nothing more be gained by thus connecting them, repetition will be, at least, avoided. I. Catalepsy—Trance (from yaTaXnrpic, the action of seizing, and that from y.ara- ?.au§urei. I seize). Syn. /fuTu/.f^i/'c, Greek. Catalepsia, Catalepsis, Catochus, Prehensio, Congelatio, Auct. Lat. Caru* Ecstasis, Ca- ms Catalepsia, Good. Entonia Catalepsis, Young. Catalepsie, Fr. Die Starrsucht, Katalepsis, Ger. Catalepia, Ital. Trance. 2. Defin. A sudden deprivation of sense, intel- ligence, and voluntary motion, the patient retain- ing the same position, during the paroxysm, in which he was at the moment of attack, or in which he may be placed during its continuance; the pulse and respiration being but little affected. 8. This disease is very rare; so much so, that its existence has been doubted by many writers, who consider it to have been feigned. Its occa- sional occurrence is, however, well ascertained. I have seen one case of it in my own practice, and been consulted by letter respecting a second. I recollect, also, an undoubted example of it in an hospital, the practice of which I attended when a student. It presents no precise or undeviating train of symptoms, but varies in many particulars; the phenomena noticed in the definition being those most uniformly present. This varying char- acter of the disease, according to the description given of it by authors, is owing to two circum- stances;— 1st, to the modified state which it actually assumes, from the circumstances con- nected with its origin; and, 2dly, to certain of its phenomena having been more particularly noticed by some authors than by others, who have either mentioned them incidentally, or entirely overlook- ed them. 4. Symptoms.—This is an intermittent and apyrexial disease, occurring in paroxysms of vari- able duration ; and generally after very irregular intervals. The seizure is occasionally announced by premonitory symptoms,—by headach, mutabi- lity of temper, yawning, tinnitus aurium, vertigo, palpitations, lassitude, pain or slight spasm of the limbs or neck, confusion of mind, &c. ; but it is commonly sudden, — the patient retaining the same expression of the countenance, and posture of the body, as at the moment of attack. The eyes are fixed, are open or shut, the pupils usually dilated, but contractile from a strong light; and, from their unvarying expression, and the un- changed attitude, the body has the appearance of a statue. Any position, in which the head, trunk, or limbs are placed, is retained without deviation; the passive contractility of both the flexor and extensor muscles being such as to admit of a change as well as retention of the position during the paroxysm. The evacuations are either suspended during the fit, or passed involuntarily. 5. After a very indefinite duration—sometimes of only a few minutes, at others of several or even many hours, but rarely of days — the pa- tient is restored to consciousness. In a remarka- ble case,however,detailed by Dr.BuRuows, the fit lasted many days. Restoration is usually in- stantaneous, accompanied with sighing, and fol- lowed by pain or confusion in the head, and a sense of fatigue and lassitude. The patient has no recollection of what has passed during the fit: and the same ideas, and, according to some, even the same sentences, which had been suspended by the seizure.have been pursued.the moment of recovery CATALEPTIC ECSTASY—Pathology. 291' 6. The countenance, during the paroxysm, is sometimes little changed; at other times, it is [>aler than usual; but it is more commonly slight- y suffused, and the pulsations of the carotids more forcible than natural. The respiration is variable, sometimes it is embarrassed: the tem- perature of the surface is also unequal; being generally depressed in the extremities and in- creased in the head, evincing an irregular distri- bution of the circulation. The pulse is occa- sionally very slow: Sauvages found it only 50; but it is more commonly quick and small. The senses are so entirely abolished, that the patient may be pinched, without feeling it; and he can- not hear the loudest noises. The state of the muscles, during the attack varies somewhat in different cases. They are often slightly rigid, but not to the extent of preventing the easy change of position of the limbs; and sometimes the po- sition so permanently retained is one, which no person in health could so long preserve. M. Georget states, that the muscles often present a degree of tetanic rigidity; but this is only some- times the case, particularly when the disease is more nearly allied to Ecstasy. In some cases, it would seem as if a partial state of volition exist- ed, of which the patient either had no conscious- ness, or a very imperfect consciousness at the time, and consequently, no recollection ofthe act subsequently, as in some states of sleep. 7. In the more complete seizures, sense, intel- ligence, voluntary motion, and consciousness, are entirely abolished; but, in some instances, the abolition is only partial; the patient being con- scious, but incapable of moving or speaking. This imperfect form of the disease has very gen- erally received the appellation of catochus from nosologists; and numerous instances of it are on record. A very marked case, and nearly ap- proaching to fully formed catalepsy, is recorded in the Edinburgh Medical Commentaries, by Dr. Fitzpatrick; and slighter grades of it have been met with as a subordinate symptom of chronic nervous diseases, particularly of the severe and obstinate forms of hysteria. In a case, how- ever, of well marked catochus, in a female, de- tailed by Dr. Lubbock, no hysterical symptoms existed; and, instead of unusual susceptibility of the system having been observed, in this and other cases which he had met with, more than common torpor was apparent. M. Pete tin and others, who believed in animal magnetism, conceive that sensation, instead of being lost for the time, is con- centrated towards the epigastric region; and that the intelligence, so far from being altogether abolished, is exalted to^a degree to amount almost to prophecy. But these opinions can only be applicable to ecstasy. II. Cataleptic Ecstasy. Ecstasis, Ecstasy (from sxaraatc, from tiiarrui). Syn. Ex- tase, Fr. Entziickung, Begeisterung, Ger. Estasi, Ital. Ecstatic Trance. 8. Defin. Suspension of consciousness of external objects, and of voluntary motion, arising from, and attended by, a high degree of mental excitement and abstracted contemplation, the muscles continuing more or less rigidly contract- ed, or only partially relaxed. 9. Under the term ecstasy, Dr. Good has described a variety of catalepsy, but little dif- ferent from the usual appearance of that form of' seizure, instead of the particular modification of disease to which the name ecstasy has usually been applied. This variety of cataleptic disorder is generally induced by mental excitement and sustained contemplation of some particular sub- ject, most generally of religious topics, and of those exciting the affections and passions. The patient suddenly seems mentally struck, or car- ried away from all external objects; either stand- ing or sitting ia a most excited and impassioned position, with the eyes fixed and open; and some- times uttering either the most enthusiastic and fervid expressions, or the most earnest denuncia- tions and warnings, or the most absurd exclama- tions, with the feeling or belief of their reality; and total abstraction from, or unconsciousness of, all surrounding objects or persons. 10. This affection is variously modified. In some cases it very nearly approaches to pure ca- talepsy; in others, to a sort of maniacal excite- ment. Dr. Chisholm records an instance of this latter state in a young female, in whom it alternated with mania; and I was consulted by a practitioner in the country, respecting a most marked case occurring in a religious young lady, where it was evidently connected with, if not consisting of, an exalted form of hysteria. During the attack, she sung and composed long doggerel strains. Many of the cases which have lately made so much noise in this metropolis, under the idea of inspiration with " unknown tongues," evi- dently belong to this affection; at least, such of them as have not been feigned. The effects pro- duced by the practisers of animal magnetism, upon nervous persons, sometimes appear allied to this affection. Many of the Italian impro wisatori are possessed of this faculty only whilst they are in a state of ecstatic trance, similar to this disease. And few of them enjoy good health, or consider their faculty otherwise than a morbid one. 11. The Terminations of Cataleptic and Ecstatic Seizures are generally either in health, or in disease of the cerebral functions. They may pass into mania, epilepsy, or confirm- ed insanity. Dr. Burrows's case, already al- luded to, was complicated with mania, following excited and ungratified passions, and interruption of the menses. Recovery, however, took place, and the patient afterwards bore children. Dr. Gooch met with a case which supervened on, and was followed by, melancholia. J. Frank treated a case of catalepsy, that terminated in mania, of which the patient at last recovered; and Behrends details the history of a case com- plicated with mania. Pinel records a case of catalepsy which terminated in apoplexy. Ros- tan states, that he has observed a case in which inflammation of the lungs was associated with it. In many instances, these affections terminate, as they commence, in most severe hysteria; with which a very large proportion of them are more or less intimately allied. 12. But little is known of their relation to morbid states ofthe brain or viscera. Holier, however, informs us, that he found the vessels of the brain and cerebellum distended with black blood, and slight extravasation in a case which terminated fatally. Lieutaud and Ab Heers make mention of fibrinous concretions formed in the longitudinal sinus, with disease of the lungs 1 and liver. According to the state of the counte- 292 CATALEPSY—Treatment. nance, temperature of the head, and action of the carotid arteries, during the fit, it may be in- ferred that active congestion, or an efflux of blood, far beyond what obtains in health, takes place to the brain, and is instrumental in the production of the disease. 13. Prognosis.—These affections do not ap- pear to be attended with much danger. The fully formed cataleptic seizure is, however, a seri- ous disease. The cases already adduced in illus- tration of its termination are sufficient to indicate this. Fatal cases are, however, noticed by Ho- lier, Dodono:us, and the authors just quoted. Aetius, De la Tour, Fahr, and Sauvages, state that they have seen it disappear after copi- ous epistaxis, and return of the menses. 14. Causes of Cataleptic Seizures.— A. The predisposing causes are, whatever di- minishes vital power, and increases the suscep- tibility of the nervous system, particularly the depressing passions, violent and continued sorrow, great anxiety, unrequited affection, intense and sustained mental applications, religious contem- plations, exhaustion from repeated miscarriages or severe confinements, and excessive venereal indul- gences and manustupration. The hysterical, hypo- chondriacal, and melancholic temperaments, are evidently most disposed to these attacks. They occur at all ages, from six or seven years till old age; but they are very rare before puberty; and are much more frequent in females than in males. 15. B. These affections are most commonly ex- cited by some violent mental impression; by cer- tain of the above predisposing causes, when acting intensely, particularly religious enthusiasm; great mental application, and the passion of love; frights, terror, or uncommon dread; the irritation of worms in the prima via ; suppression of the menses, of eruptions and accustomed discharges; injuries of the head (Stark); concealed mental emotions, and ungratified passions; and disturbance of the uterine functions. Renard (Hufeland's Journ. die Pr. Heilk. June, 1815.) relates a case which was occasioned by disease ofthe ovaria. Spren- gel states, that these seizures are induced by onanism. J. Frank remarks, " nunquam cata- lepsin in Judreis observavi, ac onaniae vitium rarius inter eos, quam alias apud gentes inveni." (Prax. Med. Univ. Pracip. v. ii. p. 487.) I believe that many cases in females are chiefly exalted or more severe states of hysterical affection; and more or less connected with disorder of the nerves and cir- culation in the uterus and ovaria. 16. Diagnosis and Prognosis.—The prac- titioner must not overlook the fact of all those affections being frequently feigned, particularly by females, even by those in good circumstances, and when there can be no end to serve by the imposture further than to create interest in their behalf. Although cataleptic and ecstatic seizures pass insensibly into each other, and are in their nature obviously very intimately related, yet their more extreme and distinct forms are very differ- ent. In the former affection, the patient resem- bles a statue, is entirely deprived of voluntary motion, and is perfectly mute: in the latter, the countenance is animated and earnest; the muscles are more or less rigid; the patient talks, exclaims or even sings with the utmost ardour; and the character of the whole frame is that of the most abstracted and intense contemplative excitement- I consciousness of all other objects and ideas, ex- cepting of the particular subject by which the mind is excited, being abolished: but the consci- ousness is often of a morbid or imaginative kind; the patient conceiving, as in the instances adduced by Tissot, that he has seen wonderful visions, and heard singular revelations. Ecstasy may be confounded with somnambulism and reverie. The excited, and, as it were, inspired appearance of the patient, in the former affection, is sufficient to distinguish it from the more passive character of the latter, in both of which he resembles a person half asleep, or sleep-walking. The statue-like appearance and muteness of the cataleptic are alone sufficient to distinguish this disease from these latter affections. (See § 4—6.). 17. Catalepsy may also be mistaken for as- phyxia, syncope, apoplexy, and even for death itself. The total suspension, however, of re- spiration and circulation, the deep colour of the lips and countenance, in asphyxia; the flexi- bility ofthe limbs, great paleness ofthe face, and the scarcely perceptible performance of the re- spiratory and circulating functions, in syncope; and the congestion of the head and face, the stertorous breathing, relaxed and flexible limbs, and the attendant paralysis, in apoplexy; are suffi- cient of themselves to distinguish it from any of the modifications of the affection now under con- sideration. It is possible, also, that a cataleptic patient may be considered as being dead. There are many instances on record, where persons in a state of trance have narrowly escaped being buried alive; and there is even reason to suppose that, in countries where burial usually takes place much sooner after dissolution than in this, such a circumstance has actually occurred. But this could never have occurred, unless the respiration and pulse had been suppressed, and the counte- nance pale. The stethoscope may now possibly prevent such an occurrence from taking place, by detecting the feeble action of the heart, which can never be altogether extinct in catalepsy. The states of the sphincters, and of the cornea, and the temperature of the trunk of the body, will further serve to prevent so distressing a mistake from ever occurring, even independently of due reservation of the body from inhumation, till in- dubitable proofs of death show themselves. As to discovery of feigned seizures of these affections, the general characters of the case, and the prac- titioner's own acumen, must be the chief guides. 18. Treatment.—When we consider that evidence of determination, or of active congestion, of blood in the head, has generally been furnished in these affections, the propriety of vascular deple- tion will not be disputed. If the signs of*general or local plethora be very manifest, and if the disease have any relation to suppression of the menses, cupping between the shoulders, the ap- plication of a number of leeches to the nape of the neck and behind the ears, stimulating pedi- luvia, and bleeding from the feet, should be em- ployed. If the temperature of the head, and the action of the carotids be increased, the affusion of cold water on the head, or the use of cold or evaporating lotions in this quarter, whilst the low- er extremities are plunged in warm water, will be of service. In addition to these, purgatives should be given by the mouth, and repeated; a constant, but moderate action, being thereby exerted upon CATARRH. 293 the bowels ; and antispasmodic or turpentine enemata should be administered from time to time. (See F. 130. 135. 150. 152.). The aloe- tic purgatives (F. 450—455. 470. 518.), are par- ticularly eligible, when the affection is connected with irregularity of the menstrual evacuation. Diedier advises active hydragogue cathartics. 19. The above means are equally applicable to the paroxysm, and the interval, or suppression of accustomed evacuations, in cases characterised by plethora, or local determination of blood. If resorted to in the fit, they may be conjoined with various antispasmodics, as valerian, musk, ether, assafcetida, camphor, ammonia, &c, and volatile stimuli may be occasionally held to the nostrils, when the face is pale, and signs of determination of blood to the head are wanting. 20. The utmost attention should be directed, during the intervals, to the state of the uterine organs. If signs of congestion or of irritation are detected in this quarter, cupping on the loins, the application of leeches to the groins and tops of the thighs, and the internal use of the boracic acid, or of the sub-borate of soda, combined with re- frigerants and anodynes, should be resorted to. The frequent association of these complaints with hysteria indicates the propriety of having recourse to a nearly similar treatment to that recommend- ed in it, and to the same appropriation of medi- cinal means. Behrends attaches considerable importance to the state of the stomach and prima via in cataleptic seizures. There can be no doubt of the functions of these organs being often im- peded or disordered, and of the propriety of res- toring them to a healthy state. This can be done only by a judicious combination of tonic and aperient, or of deobstruent medicines. 21. When these affections have arisen, as they not infrequently do, from depressing or exhaust- ing causes, the judicious combination of tonics with gentle aperients and antispasmodics, will be of much service. The shower-bath, salt water bathing, change of air, tonic and deobstruent min- eral waters, regular exercise, early rising, and mental amusement, will be most advantageous in ■uch cases. Several of the causes of the disease are both of an exhausting nature, as respects the constitutional energies, and of an exciting kind, in regard of the cerebral organs, particularly some of those which induce the ecstatic form of seizure (§ 8—10.). In these, it will be necessary to di- minish the local determination to the brain, which is generally present, by the means indicated above (§ 18.), whilst we soothe the nervous system, and restore the digestive functions and the ener- gies of the frame. To accomplish these ends, we must resort to a combination or alteration of tonics with anodynes, antispasmodics, and ape- rients (F. 453. 572.), keeping at the same time the head cool, the secretions and evacuations free, the mind amused and disengaged, the feet warm, and the blood as regularly distributed throughout the body as possible. 22. When the disease is complicated with mania, melancholia, or epilepsy, similar means to those already stated may be employed, appro- priately to the state of vascular excitement and vital powers, and to the symptoms more imme- diately connected with the brain and the uterine organs. In several cases of these complications, full and frequent doses of calomel will be of ser- 25* vice, and, under careful supervision, it may be judicious to exhibit, in conjunction with anodyne, nervine, or antispasmodic remedies, the milder preparations of mercury, until the mouth is slight- ly affected. In all cases where the above means fail of producing the expected effect, and parti- cularly in these complications, issues, or setons, perpetual blisters, or the tartarised antimonial ointment, or moxas, should be directed to the nape of the neck, the occiput, or behind the ears, and perseveringly continued. In most instances, whether simple or complicated, after the affection of the mouth by mercurials, or the long continu- ed use of setons, &c, the more tonic and restor- ative means advised above should be prescribed. Amongst the various antispasmodic medicines recommended by authors on these affections, I may notice the different antispasmodic gums, by Stark (Klin. Instit. p. 172.) ; the ammoniated copper, byTHEUSSiNK (Samml. Auserl. Abh. fiir Pract. Aerzte, b. xvii. p. 279.); electricity, by Ledra and Sigaud la Fond (De I'Elect. Med. p. 396.) ; the-cautery to the occiput, by" Blankard (Collect. Med. Phys. cent. v. No. 18.); and cinchona combined with valerian. The different preparations of iron, and various anti- spasmodics, have been recommended by Dr. Lubbock, and exhibited by him in a case where, however, they appeared of little service, most ad- vantage having been derived from travelling, pure air, and agreeable mental occupations. (Edinb. Med. and Surg. Journ. vol. i. p. 61.). During the whole course of treatment, the strictest refer- ence ought to be had to the nature of the predis- posing and exciting causes, the habits and prac- tices of the patient, and to his diet, and physical and moral regimen. Bibliog. and Refer.—Schenk, De CatalepsL Jens, 1671. — F. Hoffmann, De Affectu Catalept. raris. Francf. 1692. — Boerhuave, Aphorismi, &c. § 1036. — Dionis, Diss. sur la Mort. subite et la Catalepsie. Paris, 1718. — G. W. Wedel, Diss, de Catalepsi Affect, raris. Jen. 1711. —Roe- der, Diss. Raro Affect. Catalepsi. Erf. 1721.—Reynell, in Philos. Trans. No. 437. — Delins, Diatribe de Cata- lepsi. Ed. Secun. Erl. 1754.— L. E. Hirschel, Gedan- ken von der Starrsucht oder Catalepsie. Berl. 1769. — Home, Principia Medicine, ed. Amst. 1775, p 232. — Gun- dramm, Disser. de Catalepsi. Helms. 1776. — Schilling, Diss. Mgr. ex Amore Catalep. factum exhibens. Geiss. 1776. —Baumer, De Differ. Extas. et Catalep. Geiss. 1776.—Sauvages, Nosol Method, t. ii. p. 418. — Fitzpa- trick, Edin. Med. Comment, vol. x. p. 242. —Tissot, Traits des Nerfs et de leurs Malad. kc. ch. 21. — G. L. Fabri, . Tract. Pathol, de Catalepsi. Hal*, 1786. — H. Gerson, Diss, de Calepsi. Gott. 1797. — Ossius, De Catalepsi. Marb. 1799. — C. A. Illinger, De Catalepsi. Francf. 1800. — W. F. Dreysig, Handworterbuck der Medic. Kinder, b. iv. abth. 2. p. 360.—Petetin, Elect. Animale prouvee par le Decouv. des Phenom. Physiq. et Mor. de la Cata- lepsie, Ire. Paris, 1808. — K. Sprengel, Handhuch der Pathol, b. iii. p. 225. — Dufour, in Journ. de Med. t. lxx. p. 418. —Savery, in Journ. de Med. Contin. Dec. 1811. p. 419. — Gilibert, in Actes de la Societ. de Montp. Ann. xiii. No. vi. — Vyan et Lenarmand, in Revue Medicale, t. iii. p. 52. 1825. — Handtwick, Diss, de Ecstasi. Rost. 1755. — Eber, in Halleri Biblioth. Med. par. ii. p. 131. — Bang, in Act. Reg. Societ. Med. Havn. vol. i. p. 10T. — Rett, Fieberlehre, b. iv. p. 572. — Zwinger, Theatrum Vita Hu- man*, p. 223.— Sauvages, Nosol. Meth. 1. iii. p. 422., et 1. iv. p. 397. — J. Frank, Praxeos Med. Universa Prscepta, t. ii. p. 475.—Robert, in Journ. de Med. Contin. Dec. 1811, p. 415. — Sarlandiire, Histoire d*un Cataleptique, kc. Paris, 1816.— D. A. G. Richter, Die Specielle Therapie, kc bd. viii. p. 465. — Bouillaud, in Diet, de Med. et Chir. Pratiques, t. v. p. 15. CATARRH. —Simple Catarrh. Syn. Ca- tarrhus (from xaraiqiut, defluo). Gravedo, Coryza, Bronchos, Catarrheuma, Fluxio, Rheuma, Capiplenium, Auct. Var. Catarrhus 294 CATARRH—Causes. simplex, Richter. Phlegmhymenitis ( from tpXiyua, mucus, and run; a membrane), Hil- denbrand. Catarrhe, Rhume, Fluxion, Fr. Ein Fluss, Schnupfen, Katarrh, Ger. Catarro, Reuma, Ital. A Defluxion, a Cold. Classif. 1. Class, Fevers; Order, Flux- es (Cullen). 3. Class, Sanguineous Func- tion; 2. Order, Inflammations (Good). II. Class, I. Order (Author, see Preface). 1. Defin. Sneezing, watery discharge from the nostrils; lachrymose state of the eyes; slight gravative headach, chillness, evening fever, some- times accompanied with sore throat, hoarseness, and cough. Path. Defin. Specific irritation of the mu- cous surface of the nostrils, extending to the frontal sinuses and eyes, in one direction ; to the posterior nares, fauces, and throat, in an- other; and occasionally also to the pharynx, (esophagus, glottis, and trachea, thus terminating in catarrhal bronchitis. 2. Although the most common of all diseases, there are few which are less understood, or have called forth a greater diversity of opinion, than catarrh. This uncertainty is chiefly owing to its varying characters, arising from the limitation or extension of its seat, the temperament and habit of body ofthe patient, the causes which occasion it, and the severity of the attack. If the affection be not extended much beyond the Schneiderian membrane, it very generally receives the name of coryza, or catarrhal coryza; if it be seated in the frontal sinuses it is called gravedo, or catar- rhal cephalalgia ; if in both these situations, a cold in the head ; if the fauces be its principal seat, catarrhal cynanche, or catarrhal sore throat; if the glottis and pharynx, catarrhal cough and hoarseness ; if it advance to the trachea and bronchi, catarrhal bronchitis; and if the eyes be primarily affected, catarrhal ophthalmia. It may thus be limited to any one of those situations, or be extended to two, or more, or even all of them, according to the predisposition of the parts and of the person affected. It may even pro- ceed further, as to the air-passages on the one hand, or to the oesophagus and digestive organs on the other, after having subsided in, or disap- peared from, its primary seat; and it may even be coexistent in several, or even all of these situations. 3. If we consider the origin and phenomena of catarrhal affections, we shall observe many characters warranting an analogy between them and rheumatism on the one side, and erysipelas on the' dther. Catarrh is a disorder proper to mucous membranes, and is not limited to the parts of this tissue above specified. The same causes which occasion it in them, will sometimes, although much less frequently, excite it in other parts of this system, according to morbid predis- position of the organs. Rheumatism is an affec- tion of the fibrous, sero-fibrous, and aponeurotic structures, and generally proceeds from the same or very similar causes to those which produce catarrh; they are both also often present at the same time, and in the same person, and the epi- demic prevalence of both is not uncommon. Erysipelas is an affection of the skin, also often depending upon similar causes to those which produce catarrh and rheumatism, particularly those connected with the states of the atmosphere; and all of them are benefited more or less by a nearly similar treatment. Neither of these dis- eases is the same as true inflammation, although presenting more or less of the inflammatory cha- racters, but also some which are proper to each. On this account, therefore, should they be view- ed, even when approaching the nearest to inflam- mation, as essentially specific diseases; possessing, however, certain symptoms in common with one another, and with inflammation; the same causes acting on a certain number of individuals, pro- ducing catarrh in many, rheumatism in some, erysipelas in a few, and true inflammation in others, according to die diathesis, habit of body, state of the abdominal functions, previous disor- der, &c. of the affected. 4. I. Causes.—A. The predisposing causes of catarrh are referrible chiefly to original con- formation and diathesis, and to previous disorder, particularly as respects the state of the digestive and assimilating organs. It most frequently af- fects persons of a phlegmatic temperament, relax- ed habit of body, and delicate constitution, or who are weakened by any cause, particularly by morbidly increased secretions and discharges; also those with long necks and narrow chests, or who indulge in warm apartments and beds, who rise late, and take little exercise in the open air. It is very common among the inhabitants of cold, moist, and changeable climates, more particular- ly during spring and autumn, and in variable or wet seasons; and in persons whose digestive or- gans are deranged, the functions of the liver tor- pid, and whose biliary organs and alimentary canal are loaded by morbid or accumulated secre- tions. 5. B. The exciting causes of catarrh are most commonly cold and moisture, or other states of the air, which either are or are not perceptible to the senses, but which impede or check the insen- sible cutaneous perspiration, and change the func- tions of those parts of the mucous surfaces most obnoxious to their first impression. That there is something in the air, often producing catarrh, be- yond what is perceived by our senses, is shown by the very general or even epidemic prevalence of the affection during states of the weather and of the air, in which nothing peculiar can be observed. Its great frequency, particularly in certain localities and seasons, has induced some authors, amongst whom Dr. Macculloch is pre-eminent, to impute it to a diluted or generally diffused malaria proceeding from the usual sour- ces of this active agent of disease. 6. Change of locality, whilst it will often re- move a cold, will also frequently occasion it, especially in some constitutions; and a current of air, particularly if it come directly on the face, is a very common cause. The occurrence of ca- tarrh on travelling and visiting places at a dis- tance has been attributed to malaria; and this may very possibly be the case in many instances. Whenever I have gone any distance into Essex, I have returned with catarrh. It is very com- monly believed by unprofessional persons, that the disease is infectious; from the circumstance of its commencing in one member of a family, and attacking others successively. This spread of the ailment, however, may be in a great measure owing to the diffusion of the same cause in the atmosphere, whether it be a much diluted or weak local malaria, or a more widely CATARRH — Progress and Terminations. 295 spreading epidemic influence. Still I believe that there are some grounds for the popular be- lief. Although these causes will explain much of what is imputed to infection; still, it may, either of itself occasion the disease, or, when superadded to them, induce an attack in those whom the states of the air, without such aid, might have spared. When catarrh is occasioned by local or generally diffused influences, it may not only thereby assume an infectious character, but really possess it; thus countenancing the opin- ion of Dr. Cullen, that the epidemic prevalence ofthe disease only is infectious; yet, still, I ques- tion if this limitation be just. There can be no doubt, however, that when it arises from epidem- ic, malarial, or infectious sources, it is usually febrile and severe, and very prone to extend along the air-passages on the one hand, and to the digestive mucous surface on the other, par- ticularly the former; while catarrh, arising from the more common causes of cold and moisture merely, in any one of the many ways in which these causes are applied to, and affect either the whole or parts only of the frame, is more com- monly seated in the cephalic mucous surfaces, as- suming the form of cold in the head, coryza, or aore throat, and quickly subsiding. It should not be overlooked, also, that sudden change from a low to a high temperature, or from a very dry to a very moist air; and even the being more than commonly overheated, without any very apparent chill, or exposure to cold in any form subsequent- ly; will often produce catarrh. This is especial- ly the case, if the exposure to warmth be sudden, after an impression of cold of some continuance, as the coming into an overheated apartment out of a cold and moist atmosphere,—the instantane- ous transition from a raw air of about 32s to a dry air of upwards of 70°. 7. II. Symptoms. —Owing to the circumstan- ces already alluded to (§ 2.), catarrh manifests itself in various forms; but most commonly in the following manner : — A. Its slighter states. At a period generally varying from a day or two, to six or seven, but occasionally after even a shorter or longer time, from exposure to the cause, this affection commences with a sense of chilli- ness or coldness, lassitude, and heaviness of the head, followed by dryness, fulness or stuffing of the nasal passages, frequent sneezing, a dull pain and sense of weight in the forehead, and stiffness, or rather uneasiness, in the eyes. To these is more or less quickly added a distillation of a wa- tery fluid from the nose and eyes, with slight redness and tumefaction of the mucous surfaces of these parts. Occasionally the above symp- toms appear nearly simultaneously. The deflux- ion is generally somewhat acrid and saline, pro- ducing slight excoriation of the parts over which it passes. These phenomena constitute the gra- ved/) of Celsus, and the coryza or defluxion of various authors. They may be the only ail- ment, and not proceed further, or they may have others rapidly superadded to them, depending upon greater constitutional disturbance, and the extension of the affection to a larger surface. In the former case, the general lassitude and chilliness ushering in the complaint are often so slight as to be overlooked ; but, in the latter case, and in the severer states of the disease about to be noticed, they are commonly more marked from the commencement and amount even to slight shiverings, followed by white tongue, acceleration of pulse, and increase of heat in the evening. The posterior nares and fauces, as well as the nose and eyes, are affected; and the patient complains of a sense of rough- ness, or soreness of the throat; loss of the sense of smell; sometimes of dulness of hearing, with soreness or pain extending along the Eustachian tube to the ear, with slight redness of the fauces and mouth, hoarseness, frequent tickling cough and efforts to excrete a mucous fluid abundantly secreted from the posterior nares, fauces, pha- rynx, and trachea; and sometimes with a loss or suppression of voice, from slight oedematous fulness about the glottis. To the foregoing are very commonly added, pains resembling those of rheumatism in various parts of the body, particularly about the neck, head, and limbs, loss of appetite, costive bowels, and slight thirst. 8. B. Its severe forms.—The above symp- toms constitute the usual form of simple catarrh, which frequently subsides in from three, to seven or eight days; the fluid secreted becoming grad- ually less copious, more opaque and coloured, and, at last, thick, small in quantity, and yellow- ish white, or yellowish green; all disorder quick- ly disappearing. But in very many other instan- ces, as the coryza and watering of the eyes sub- side, straitness, oppression, and uneasiness in the chest, supervene; with fits of coughing, and all the symptoms described under the catarrhal form of Bronchitis. In other cases, the symptoms indicate, from the beginning, a more severe af- fection, and a more evident constitutional disturb- ance, approaching more nearly to a state of in- flammatory irritation of the mucous membrane of the cephalic passages, than the preceding form. In this case, the coryza and watering of the eyes are attended by much soreness and heat of the eyes, nostrils, fauces, and throat; by frequent sneezing; and by the secretion of a very copious, watery, and colourless fluid, excoriating the parts over which it passes. The fauces are red; the tonsils somewhat inflamed and enlarged; and there is a short, dry, tickling cough. The fever, which, in the slighter state of disease, was scarce- ly noticed, is much more evident in this, particu- larly towards evening; and is ushered in by chills, or shiverings, the chills often continuingnhrough- out, and preceding the evening febrile exacerba- tions; catarrhal fever usually thus assuming a re- mittent type. The pains felt in different parts of the body, and the general lassitude, cough, anor- exia, sluggishness of the bowels, and thirst, are also greater in this, than in the preceding state of the affection. 9. Throughout the disorder, the patient is un- usually susceptible ofthe impression of cold, even although the skin be warmer than natural. He is also inordinately disposed to experience an ac- cession of, or to contract a fresh cold, upon the slightest exposure to its causes, or even to the least depression of temperature. Owing to this circumstance, catarrhs are often very much pro- longed, and either assume a chronic form, or in- duce chronic bronchitis, and other serious affec- tions ofthe air-passages and lungs. 10. C. Progress and terminations. — Thia form of catarrh either disappears, as in the slight- 296 CATARRH — Complications or. er states of the disorder, with a diminished and thickened secretion, less frequent and less severe fits of coughing, and subsidence of fever, in from four, to seven or nine days ; or it affects, in a much shorter period, — sometimes almost from its commencement,—the pharynx, trachea, and large bronchi, producing slight or severe bron- chitis; or it terminates in this disease, or in pneu- monia, or even in pleuritis. But most commonly, under proper management, it is attended merely by a moderate catarrhal affection of the trachea and bronchi; with fits of coughing, increased mucous expectoration, &c, constituting catarrhal bronchitis. It also sometimes extends down the oesophagus, and affects slightly the stomach, in- ducing numerous dyspeptic symptoms; and, in persons with an irritable state of the digestive tube, occasionally passing off at last with mucous or serous diarrhoea. 11. III. Prognosis. — In general, catarrh is a very slight ailment, and attended with no danger as respects itself. But, in aged persons, in those disposed to pectoral diseases, particularly those who may have tubercles already formed in the lungs, who have had haemoptysis, or who are asthmatic, or have experienced attacks of bron- chitis, pneumonia, or pleuritis, catarrhal affections require strict attention, as they very often quickly produce, or terminate in, these maladies. In many persons, also, they are very prone to be- come chronic, either in the form of a chronic co- ryza, with continued irritation, and slight redness ofthe posterior nares and fauces, and an abundant muco-puriform discharge; or in some one of the states of chronic bronchitis. In the aged, and in those of a phlegmatic temperament, or lax habit of body, catarrh often passes into a chronic bron- chial flux, when it has been neglected, or renew- ed by incautious exposures during the treatment. Children of a lymphatic and flaccid habit of body are very liable to catarrh in the form of coryza; and in them it very frequently assumes a chronic form; the thick muco-purulent secretion filling up the nares, and, in infants, preventing them from taking the breast, and rendering them irritable, each attempt at sucking disordering the pulmonary and cerebral circulation in such a manner as even to occasion convulsions. In children also, the coryza, when allowed to become chronic, some- times degenerates into ozana, with ulceration. 12. IV. Complications. — Catarrh very commonly ushers in the febrile exanthemata, par- ticularly measles ; and even accompanies them through their course, especially in the form of bronchitis. It is also very liable to appear dur- ing convalescence from them. Its connection with rheumatism has already been noticed (§3.), both disorders evidently springing from the same causes. Continued fevers, as well as some epi- demic visitations of fever, are not infrequently complicated with catarrhal affections. The as- sociation of catarrh with biliary and gastric de- rangements is very common, sometimes in con- sequence of the disposition to be affected by its causes during biliary disturbance, and occasional- ly owing to the circumstance of simultaneous dis- order of the digestive, cephalic, and respiratory mucous surfaces, having arisen from the impres- sion of the same exciting causes. These com- plications have especially characterised the various occurrences of epidemic catarrh, which have been observed. (See art Influenza.) 13. V. The Nature of Catarrh is deserv- ing of some notice. Many pathologists, particu- larly those of the modern Parisian school, — the followers of Laennec and Broussais, — con- sider it as ordinary inflammation of the cephalic mucous membranes, or parts of this tissue which it usually affects. Other pathologists, more espe- cially Richter and Hildenbrand, view it, with stricter propriety, as an inflammation of a specific kind. I believe, although it very often terminates in true inflammation when it extends to the bronchial tubes, that it chiefly consists of a specific irritation of that portion of the mucous surface primarily affected by it, nearly allied to inflammation, and soon followed by, or accom- panied with, great increase of the secreting func- tions ofthe part; or, in other words, that it is not pure inflammation, but an irritation of a specific or peculiar kind, attended by slightly increased vascularity, afflux of the circulating fluids, and augmented secretion. Since the time that Van Helmont ridiculed, in his Catarrhi Deliramenta, the opinions then entertained respecting catarrh, enquiries into its nature have been more rational, although, up to the present time, ideas have still continued very vague as to the extent of surface affected by it, many even of modern writers com- prising under catarrh, not only bronchitis, but even all affection of mucous surfaces, attended with a copious serous or sero-mucous discharge. 14. One of the most interesting questions con- nected with this subject, and one which has been agitated by J. P. Frank and others, is, whether the defluxion is a consequence of the suppression of the cutaneous perspiration, arising out of the irritation which the secretion retained in the cir- culation produces upon the cephalic and pulmonic mucous surfaces; or of the specific irritation and morbid impression of those parts by the exciting causes of the disease. The former opinion was very generally received by the followers of the humoral pathology ; and the latter by Hoff- mann, and subsequently by Cullen, Pinel, and other disciples of his school. Pinel consid- ered the febrile phenomena merely as symptom- atic of the inflamed mucous membrane, discarding the plausible opinion advanced by Botal, that whatever of inflammation exists is caused by the acrimony of the catarrhal discharge, and that the local ailment is consecutive of the constitutional disturbance, — a doctrine which is in strict ac- cordance with the description ofthe disease given by Richter, and with the more usual succes- sion of its phenomena. In some cases, however, it is very difficult to determine the priority of the general disturbance, the local ailment being equally early. Upon the whole, I believe it is not proved that the constitutional affection is the consequence of the local, although the former is generally increased in proportion to the severity of the latter; nor does it appear that the de- fluxion is caused by the suppression of the cuta- neous perspiration, even granting that suppression is actually produced, — a position by no means established. I would thence infer that the causes of catarrh affect primarily the organic nerves supplying the surface principally disordered, and, through them, the system generally ; and that, CATARRH —Treatment. 297 owing to this change, the secreting functions and circulating actions of the part primarily or spe- cifically impressed, are altered, and the disease fully developed; its chief modifications arising out of the degree to which the constitutional actions are disturbed, of the extent of surface affected, and of the grade of irritation produced in the capillaries of the part. 15. VI. Treatment.—The treatment varies much according to the symptoms and periods of the disease. Immediately upon the approach of catarrh, before febrile exacerbation has appeared, and whilst ailment is limited to the cephalic mu- cous surfaces, very opposite means to those re- quired when fever is present, or when the affection has extended to the trachea, and threatens to pro- duce bronchitis, are generally most serviceable. Under the former circumstances, a judicious ex- hibition of stimulants of any kind, but especially stimulating diaphoretics, will either cut short the disorder, or render it much shorter and more mild; whilst, in the latter state, particularly when any pectoral symptoms have appeared, considerable risk will be incurred in some constitutions, al- though either little or none in others, of inducing inflammatory action by the same measures. 16. Early in the disease, therefore, and while a copious defluxion has not come on, the patient may inhale through the nostrils the vapour of warm water, or of any emollient and anodyne decoction or infusion: if the ailment is no more than a coryza, or cold in the head, febrile action not having appeared, he may take, upon going to bed, an active stimulating draught, consisting chiefly of ammonia, camphor, spirit, aether, ni- trici, &c, with or without a narcotic. Either of the following will be used with advantage as long as febrile action, or any acute affection of the bronchi, has not appeared: — No. 96. It Spirit, Miner. Nit. 3 j.— 3 iij.; Tinct. Cam- phoric Comp. 3; j.— 3 ij.; Mucilag. Acacia; 3 ij.; Spirit. Anisi 3 j-—3 ij i Liq. Ammon. Acet. 3 ij.; Mist. Cam- phors ", j.; Svrup. Tolutan. 3 j. M. Fiat Haustus, hora somni sumendus. No. 97. |{ Camphors rasas, gr. iij. — vj.; Ammon. Sub- carbon, gr. vj.—x.; Pulv. Ipecac, gr. j.; Extr. Hyoscyami gr. vj.; Conserv. Ros. q. s. ut fiat Bolus, h. s. s. 17. The above draught will often arrest the dis- ease, when given sufficiently early. In some cases I have directed the bolus to be taken with it, either the hyoscyamus or the tinct. camph. co. being omitted. On the following morning, a sto- machic aperient maybe taken; but nothing more is necessary, not even diluents, as, at this period, they will have little further effect than to increase the defluxion. When the pulse becomes acceler- ated, and somewhat fuller or harder than natural, with other signs of febrile action; or when the tliroat is more or less affected, and particularly if there be irritation about the glottis and trachea; a different practice is required. Diluents will now be of service, particularly in conjunction with emollients, diaphoretics, &c. Any of the medicines of this description in the Appendix (F. 238. 244.), or those denominated pectoral (F. 389.426.), will be of service; or the following may be used. Richter states, that the first of these has generally been employed by him early in catarrh. No. 98. R Calomel gr. j.; Extr. Hyoscyami gr. ij.; Gum Acaci* Pulv., Sacchari Albi, 5a gr. xv. Misce et fiat Pulvis. Dispens. tales quatuor. Sumat sger tertia quaque hora unuui. No. 99. R Mucilag. Acacias 3 j.; Mist. Camphors et Mist. Amygdal. Dulc. uu J is,) Liquor. Ammon, Acet, 3 iij.; Tinct. Camphors Co., Spir. .Ether. Nit., aa § ss.; Syrup. Tolutan. 3 ss. M. Fiat Haustus, quarta vel quinta, quaque hora capiendus, 18. Whenever we deem it requisite to act moderately on the bowels, either in the course or at the decline ofthe complaint, a full dose of the flour of sulphur, either with, or without cream of tartar, will be found to act most beneficially, both on the catarrh and on the abdominal functions. When febrile action becomes more fully developed, or if the disease assumes an inflammatory charac- ter, with headach, flushed countenance, or hard cough, a suitable quantity, either of the liquor antimon. tartariz., or, ofthe vinum ipecacuanha?, may be added to the above draught; and either of the following given at bed-time: — No. 100. R Pulv. Ipecacuanha; gr. ij.; Hydrarg. Sub- mur. gr. iij.; Pulv. Opii Puri gr. j.; Mucilag. Acaciae q. s. ut fiant Piluls ij. No. 101. K Pulv. Jacobi Veri gr. iij.— v.; Hydrarg. Subinur. gr. iij.; Opii Puri gr. j. (vel Extr. Hyoscyami gr. v.); Syrup q. s. M. Fiant Piluls ij. 19. When ailment begins to subside, or when it seems likely to degenerate into a chronic state, with more or less affection of the bronchi, the treatment recommended in Catarrhal bronchitis, or in the slighter chronic states of the disease, should be prescribed. (See Bronchitis, § 69.) Hufeland recommends a decoction of the un- toasted coffee-berries, or the carduus benedictus, in those cases. Jo e r d e n s advises the oleum cam- phoratum (F. 4-19.) on sugar; Lentin, the oleum terebinthinaj rubbed on the loins; and Kortum, camphor, with sal ammoniac. The decoction of Iceland moss, with ipecacuanha, or spiritus aether. nit. and syrup of poppies, may also be used, or either of the following : — No. 102. Zinci Oxydi gr. j. (vel Sulphatis gr. ss.); Pulv. Ipecacuan. gr. ss.; Extract Hyoscyami (vel Conii) gr. iij.; Extr. Glycyrrh. gr. ij. Fiant Piluls ij. ter quatervje in di* sumends. No. 103. R Extr. Papaveris Alhi gr. iij.; Mucilag. Aca- cis 3 j- i Tinct. Camphors Comp. 3 ss.; Spirit. Anisi 3 j. J Decocti Althaes et Aq. Sambuci aa ^ ss. ; Spirit. iEther. Nit. TT) xx.; Syrup. Tolutan. 3 j. M. Fiat Haustus, ter quaterve quotidie capiendus. 20. When catarrh is connected with biliary disorder, or with accumulated sordes in the prima via, an ipecacuanha or antimonial emetic at the commencement of the treatment will often be of much service ; especially when followed by a dose of calomel and an aperient draught, or sto- machic purgative, in order to evacuate whatever morbid secretions or fiscal matters may have been collected. If it be complicated with rheumatism, calomel, combined with antimony and opium, and subsequently with camphor, ipecacuanha, and opi- um, will be found of service ; biliary collections, &c. being carried off by the exhibition, every day or alternate days, of a stomachic purgative. If catarrh be accompanied with symptoms of debi- lity, or with those of a nervous character, forming what some German pathologists have termed nervous catarrh, the liquor ammonia? acetatis, with larger doses of camphor than under the pre- ceding circumstances, or with the spirit, ammon. arom. or succinati, or the spirit, artheris sulphur. comp., and any of the anodynes in common use, are appropriate medicines. When the disease be- comes chronic, change of air is most beneficial. During the treatment, the patient should avoid ex- posures to atmospheric vicissitudes, and partake on- ly of light bland diet, observing the injunctions laid down for the management of convalescence from bronchitis. (See Bronchitis and Influenza.) 298 CELLULAR TISSUE —Alterations or. Bibliog. and Refer. — Celsut, De Medicina, iv. 2. p. 375.— Botal, Comment, de Catarrho. Lugd. 1565, 160. — Schneider, De Catarrhis, libri vi. 4to. Witeb. 1660. — Rolfink, De Catarrho Narium. Jen. 1690. •, et De Catarrho ad Nares, ad Fauces, et Pulmones. Jens, 1672.—Juncker, De Congestionibus, vulgo Catarrhis et Rheumatismis. Hals, 17?8. — Chandler, Treatise on the Disease called a Cold, Svo. Lond. 1761. —Stoll, Rat. Medendi, t. iii. p. 39., t. iv. p. 223. — Wallich, De Frequenti Catarrhorum e Primis Viis Origine. Goet. 1777. — J. P. Frank, De Cu- rand. Morbis, lib. v. pars i. p. 108.—Kelson, On the Nature and Cure of Colds, 8vo. Lond. 1797. — Cullen, First Lines of the Pract. of Med. vol. ii. p. 83. 4th ed. — Haartmann, De jEtiolog. Catarrhi, Abo. 1802. — Kortum, in Hufeland und Himly, Journ. der Pract. Heilk. July, 1810, p. 48. — Hufeland, N. Annalen, b. i. p. 173. — Lentin, Beytrnge, ii. obser. 16.—Joerdens, Hufeland's Journal d. Pr. Arzn. b. vi. p. 429. — Parr, Med. Diet. vol. i. p. 369. — Richter, Therapie Specielle, b. ii. p. 84. — Hildenbrand, Institu- tions Practice-Medics, t. iii. p. 459. — Duges, Sur l'Etat Catarrhal. Rev. Med. t. iii. p. 210. 1825.— Macculloch, On the Production and Propagation of Malaria, and the Dis- eases occasioned by it. 8vo. Lond. 1827. CELLULAR TISSUE. Syn. Tela cellulosa, Corpus cribrosum, Tela mucosa, Auct. Var. Tissu Cellulaire, Fr. Tissu Muqueux, Bordeu. Corps Cribleux, Fouquet. Reticular Membrane, W. Hunter. Filamentous Tissue. Cellulo-fila- mentous Substance. Its Diseases. Alterations of the. Classif. Spe- cial Pathology.—Morbid Structures. 1. A. The quantity ofthe cellular tissue varies greatly in different constitutions, a large proportion of the soft solids consisting of this structure, par- ticularly in persons of a lax fibre and rounded fleshy form. It is relatively more abundant in the female than in the male; in the young than in the aged; in the sanguine, phlegmatic, or lym- phatic temperaments, than in the melancholic ; and in those who are fair, than in the dark com- plexed and swarthy. It may be diminished, in parts, from pressure; or throughout the body, from disease, or inanition. Long continued and laborious exertions will also apparently lessen it; or at least diminish its bulk, by causing the ab- sorption of the serous and fatty matters deposited in its areolae or interstices. It is remarkably in- creased by full and rich living, and by indolence; but its bulk is then evidently, in a great measure, owing to the general fulness of its minute vessels, and to the greater proportion of fluid contained in its interstices. Partial increase of this tissue is also observed, but chiefly in consequence of disease. It forms, in such cases, the basis of various morbid growths, particularly encysted, scrofulous, sarcomatous, and scirrhous tumours. 2. B. The consistence of the cellular tissue also varies greatly. In some persons it is unusually lax and extensible; in others, it is uncommonly dense and tenacious. The slighter changes of consistence are the result of original conformation, and of age. It is usually more lax in females than males, in the phlegmatic and lymphatic temper- aments, than in the melancholic and bilious ; and in very young persons, than in those of mature or advanced age. The state of vital energy also influences its consistence; for as the powers of life are reduced by disease, &c its cohe- eion is proportionately lessened, and it becomes more lax and inelastic. Changes of consistence occurring in parts are chiefly the consequences of inflammatory action. Continued pressure has the effect of condensing it, and changing it from a nearly semifluid state, into a fibrous, lamellated, and firm structure. 3. C. Inflammation of this tissue gives rise to the most varied and important changes, according to the vital energies of the frame, the state of constitution, and habit of body, the nature of the exciting causes, and the intensity of the disease. In a previously healthy state of the system, and when the exciting cause is not of a septic or poi- sonous nature, the inflammation is usually of the plilogistic or phlegmonous character, and its ex- tension is limited by the formation of coagulable lymph around the centre of the part inflamed; and which, becoming condensed with the cellular tissue exterior to it, forms a cyst for the enclosure of the purulent matter which is usually formed within the part, when the inflammation has pro- ceeded to a certain height. (See Abscess, § 5.) 4. When the inflammation arises from septic or poisonous animal secretions, or from the mora common causes of irritation, or of local injury acting on an unhealthy habit of body, or during unwholesome or epidemic states of the air, it as- sumes a spreading or diffusive character. The disease, however, may be spreading, without being primarily diffusive; for it sometimes commences in a point or circumscribed spot, as in phlegmonous inflammation; and from the influence of certain causes, hereafter to be noticed, coagulable lymph is not formed so as to limit its extent, as in that form of the disease, and it consequently spreads more or less rapidly; the part soon losing its vitality, and the secretion from the affected vessels infiltrating and contaminating the portions adjoining it, until ex- tensive destruction and sphacelation of this tissue takes place. The inflammation may, on the other hand, owing to nearly the same causes, attack, al- most coetaneously, a considerable extent of struc- ture, and terminate either in the same way, or in a manner nearly resembling it. Spreading inflam- mation of the cellular tissue is generally the con- sequence of external exciting causes, particularly punctures, abrasions, wounds, fractures, &c. acting upon a predisposed system, and more commonly gives rise to a foul serous or sanious secretion, and terminates in sphacelation or gangrene; whilst dif- fusive inflammation is more usually produced by internal causes, or such as affect the nervous or constitutional powers previously to the develope- ment ofthe disease in the cellular tissue; the secre- tion which is formed in the part approaching more nearly than that of the foregoing to a puriform matter, and extending in various directions in the course of this structure, under the integuments, &c which it but little affects. The former is often con- nected with hospital gangrene, or is nearly allied to it, as well as to various forms pf foul spreading ulceration; the latter is frequently an attendant upon erysipelas, without, however, constituting any of the states of that disease; and upon the in- oculation of animal poisons, as in the dissection of bodies recently dead of diseases in which the blood and soft solids are more or less vitiated. (See Ce llular Tissue—Diffusive Inflammation of.) 5. Cellular tissue is also often the seat of chronic inflammation, generally in circumscribed parts, giving rise to cold or chronic abscess (see Abscess, § 19.); or to certain manifestations of scrofulous disease. In this state of inflammatory action, gelatinous or albuminous fluids are com- monly effused into the interstices of a greater or less extent of this tissue; imparting to it a swollen or hardened appearance; as in rheumatism, gout, 1 imperfectly cured erysipelas, pelagra, elephanti- CELLULAR TISSUE—Diffuse Inflammation op. 299 asis, and probably that peculiar affection denomi- nated the induration of the cellular tissue of new- born infants. Otto comprises also phlegmasia dolens under the class of lesions of this tissue, which arises from chronic inflammation; but we have not sufficient evidence of this origin. In- deed, facts, as far as they have been ascertained regarding it, very conclusively show, that other structures besides this are affected at a very early period of the progress of this disease. 6. D. Infiltrations, or effusions of fluids from the circulating vessels, frequently take place in this tissue, and constitute the prominent phenomena of various diseases. Hamorrhage sometimes occurs in it, either from external injuries, or from internal causes affecting the vitality of the system and the states of the capillaries and circulating fluids. When it originates in the latter source, the effused blood is usually infiltrated into the interstices of the structure in circumscribed spots, forming ec- chyinoses, and sugillations, as in scurvy and pur- pura hemorrhagica, &c. When the haemorrhage is extensive, it is commonly owing to the rupture of an aneurismal vessel or varix. The infiltration of serous fluids is very Common, either in circum- scribed parts (oedema), or more or less generally, although in different degrees, in the greater part or the whole ofthe body (anasarca). This pre- ternatural increase of the serosity usually moisten- ing the cellular tissue is owing to various causes, explained in the article Dropsy ; and CTiiefly to increased exhalation, either from augmented determination of the circulation, or deficient tone ofthe exhalants, or both,—to impeded absorption, either from obstructed circulation h the veins or inactivity of the absorbents, — and to oppletion of the vascular system by the senus or watery Earts of the blood, from obstructed elimination y the kidneys or by the respiratory and digestive mucous surfaces, and by the slcn. A general state of very slight cedema, or an niusual fulness, softness, and flaccidity of the cellular tissue, — a condition obviously depending upon its laxity or deficient cohesion, conjoined with the presence of a greater proportion of watery fluid than in the healthy state, — not infrequently also is ob- served, particularly in phlegmatic and lymphatic constitutions. This has usually been termed leu- cophlegmasia; and although it nay not amount to actual disease, yet it undoubedly forms the first stage of several slowly formed maladies, and is usually attended with that stafe of the frame described in the article Cachext. It is of im- portance to attend to the chief prthological rela- tions of this state of the cellular tissue, as they furnish useful indications respectng the nature and treatment of various diseases with which it is often connected. It commonly proceeds from an originally weak conformation, subsequently heightened by diminished vital pover of the sys- tem in general, and defective cohesion of this tissue in particular. 7. The urinary secretion sometimes escapes into the cellular structure, which it violently in- flames ; the part thus infiltrated being usually affected by the spreading form ofthe disease, and the constitution thereby suffering most severely, as in other cases of this state of inflammation. This tissue is sometimes also infiltrated by aeriform fluids, constituting the emphysema or pneumatosis of authors. This species of infiltnition arises either from the escape of air into the cellular substance, owing to laceration of some part of the respiratory mucous membrane; or from a morbid secretion by the vessels in certain advanced stages of dis- ease, as in the last period of some forms of in- flammation. (See art. Emphysema.) 8. E. The cellular tissue is also very frequently the seat of a great variety of morbid growths, and formations of a specific and malignant kind. Amongst these, the most important are simple serous cysts, hydatids, tubercles, melanosis, earthy and bony concretions, the vascular sarcoma of Abernethy, &c. These adventitious produc- tions very often commence in some part or other of this tissue, even when they are found in other structures; the matrix, or medium of connection furnished by it to other textures and organs, being most frequently their point of origin. Certain parasitic animals, especially the larvae of the cestrus, filaria, and cysticerci, are also occasion- ally met with in the cellular membrane. Changes of colour are not unusual, most commonly in con- sequence of biliary obstruction, giving rise to jaun- dice ; and of certain malignant fevers, when it is either yellowish or yellowish green, and deficient in its vital cohesion. Cellular Tissue—Diffusive Inflam- mation of the. Classif. III. Class, I. Order (Author). 9. Defin.—Severe constitutional disturbance, either preceding or following intense pain and diffuse sioelling of some part of the cellular tissue, with rapid pulse and depressed vital power. 10. The parts of the cellular tissue chiefly affected, according to Mr. Hunter and Dr. Craigie, are those in which the adipose sub- stance is most abundant. In respect, however, of its seat and nature, this important malady has been much misunderstood, owing to the circum- stance of its most commonly occurring as a com- plication with diseases of those structures, whose anatomical connection with this tissue is extremely intimate. Dr. Duncan, to whom we are in- debted for the most comprehensive account of it which has hitherto appeared, has erred in consid- ering other maladies, thus contingently related to it, as forming varieties of it, rather than as being occasional complications with it. It is true, that, while diffusive inflammation of the cellular struc- ture arises primarily, constituting the only or prin- cipal complaint, it is also associated (generally in a secondary form, or in consequence ofthe exten- sion of inflammation from immediately adjoining tissues) with inflammations of absorbing vessels and glands, with phlebitis, with inflammation of the fasciae, and most commonly with erysipelas; these generally proceeding from the same causes, and from similar states of constitution and vital energy of the patient, as occasion it; and one or other of these diseases often appearing simultane- ously with it. But, when thus associated, it may constitute either the least, or the most remarkable part of the malady; and, therefore, in such cases at least, can only be viewed as a more or less important part of a complicated disease. 11.1. Causes.—A. The predisposing causes, as far as they are ascertained, are epidemic states of the atmosphere; impure conditions of the air originating in local sources, particularly the foul air of crowded or imperfectly ventilated hospitals and apartments; morbid accumulations of bile in 300 CELLULAR TISSUE —Inflammation of —Symptoms. the gall bladder and ducts, and of sordes, &c. in the prima via; lowered vital power, from what- ever cause; the use of unwholesome food, a ca- chectic habit of body, and deranged state of the digestive functions, or of the secretions. B. The exciting, causes are chiefly local injuries and sprains, especially punctures and abrasions ; vena'section and the ligature of veins; the inocu- lation of various animal poisons, generally of a septic tendency; acrid substances, or vegetable or animal matters in a state of disease or decomposi- tion, applied to the cellular tissue; and even the simple contact of morbid secretions and fluids with any part of the body. The numerous instances which occurred a few years since in Plymouth Dock, and described by Dr. Butter and Mr. Tripe, were chiefly referrible to epidemic or endemic states of the air; were generally excited by local injury; and were complicated with erysipelas. 12. II. Symptoms.—A. The local symptoms are variously modified, according to the causes by which the disease is produced, a. In some cases it proceeds with very severe lesion of the part to which the cause is applied, as when the fluids and secretions of a diseased animal come in contact with the skin, and give rise to the disease called "pustule maligne" by the French, or malignant anthrax. In this case the morbid matter produces a vesicle, from its effects on the rete mucosum, followed by a tubercle, arising from the extension of the inflammation to the true skin, whence it penetrates to the subjacent cellular tissue. Its progress then is very rapid and alarming. A considerable swelling now extends to some dis- tance, presenting a peculiar character. The sur- face of the skin is shining, and the swelling is elastic, diffused, and resisting, with a throbbing pain and sense of heat, followed by a feeling of torpor, tightness, and weight of the part. This morbid state extends in all directions; and, upon examination, excites a sensation between the soft- ness of oedema and the elasticity of emphysema, to which the terms boggy, or doughy, have been applied. The central parts generally soon be- come entirely deprived of life, and the mortifica- tion glides below the skin, and destroys the cellu- lar tissue all around; the constitution being most seriously affected. A nearly similar state of the part primarily injured not infrequently follows the application of various acrid matters, animal or vegetable, directly to the cellular tissue itself. Punctures, also, which penetrate as far as this tissue, or mere abrasions of the cuticle, may also occasion it; the chief difference being in respect of the extent to which the skin is affected. In some of such cases, particularly when punctures are the cause, either with or without the applica- tion of morbid matter, the skin is very slightly diseased, although the cellular tissue is very ex- tensively destroyed; whereas, in other instances, especially when the cuticle is abraded, or when acrid matter is applied externally to the skin, this structure is very manifestly inflamed at the same time, and the malady presents the characters of erysipelas, complicated with this affection of the cellular membrane. 13. 6. When the disease arises from punctures, mechanical injuries, chemical irritants, and some- times from wounds received in dissection, the constitutional disease is, as in the foregoing in- stances (§12.), preceded by the local affection. The mischief commences in the seat of injury, and extends from thence to the trunk ofthe body, and sometimes also in an opposite direction, with- out leaving any interval apparently sound. The progress of this variety differs greatly in different cases; being in some confined to the limb, or part of the limb, to which the cause is applied, and in others proceeding rapidly to the trunk, and terminating fatally. In a few of the in- stances following venaesection, the puncture heals as usual, and either remains permanently united, or opens again, and gives vent to some purulent matter; but more commonly union does not take place; the lips of the incision remaining slightly swollen, red, and everted. Some ichorous or puriform discharge appears, and disease extends continuously from the wound to the shoulder or breast. 14. c. In the most dangerous form of the ma- lady, as that consequent upon the inoculation of a virus or morbid matter, a vesicle or pustule forms in the part to which the poison is applied, with very remarkable constitutional disturbance, followed by severe diffusive inflammation of some part of the cellular texture, generally on the same side with that on which inoculation of the disease took place, but at a distance from it, and not continuously with the primary pustule. In such cases, the manner in which the malady is propagated from the local injury,—which is most commonly in the fingers, — to the seat of the diffusive inflammation, which is usually in some part of the trunk, has not been satisfactorily shown. It has been supposed to pass along the absorbents, aid, arriving at the axillary glands, to excite inflammation in them, extending to the surroundng cellular tissue ; others have thought that the process takes place along the veins; but the accuracy of either of those views has not been demonstrated by dissection, both these sets of vessels having been found free from disease in cases of this description. The history of this most dangerous malady, and the nature of the cause whic.i excites it, render it more proba- ble that the morbid impression is made upon the organic nerves af the part, and that the frame is soon generally affected, owing to the anatomical and functional relations of this system of nerves; the intimate co.inection of which with the blood- vessels disposhg the consecutive diffusive in- flammation to tppear on the same side with that on which the norbid impression was first made. The primary pustule is usually of very little ex- tent or severiiy, often heals before the consecu- tive inflaminaaon takes place, and is evidently the local effert of the virus upon the capillaries of the part to which it was applied. But it is quite insufficient to account for the rapid and violent constitutional disturbance which follows, and which cat only be explained by referring it to the change produced by the morbid matter in the organic system of nerves primarily, and con- secutively in the vascular system, and in the blood itself. 15. The chief and not infrequent illustration of this form of the disease is furnished us in the cases which follow punctures received on open- ing recent subjects. In the course of ten or twelve hours from the time of sustaining the in- jury in the fingisr, or not until after five or seven CELLULAR TISSUE—Inflammation of—Terminations. 301 days, the patient complains of rigors, remarkable debility and frequency of pulse, with sickness at stomach, retchings, Sec. A pustule appears in the part, but not always ; and generally no con- nection can be traced between it, even when it is formed, and the diffusive inflammation which fakes place during the progress of the constitu- tional affection. In some cases, a few red lines may be traced, or swelling of the surrounding .part is observed ; but neither advances any dis- tance, the parts above being perfectly sound. In the course of the violent fever induced by the inoculation in the hand, the consecutive inflam- mation usually appears in the axilla, and extends towards the sternum, along the neck, down to the loins or haunch, or even to the thigh of the same side. In some instances, it terminates at the mesial line ; in others, it passes continuously to the other side. It occasionally is translated from one side or part to the other, by a kind of metastasis, as in gout or erysipelas. 16. The inflammation of the cellular tissue of the trunk, whether arising from a continuous extension of the disease from the arm, or part originally affected, as in certain states of the dis- ease (§ 12, 13.), or in the course of the constitu- tional commotion (§ 14.) excited by the inocula- tion of a morbid virus, always possesses peculiar characteristics : it is diffuse or extensive, without the smallest tendency to point; being flatly ele- vated above the sound parts, usually by a raised or defined margin. It is smooth and equal, with- out central hardness, and with all the characters already noticed (§ 12.). In general, no cords, which can be supposed to be diseased lymphatics, veins, or arteries, can be traced under the surface, and the glands are either very slightly or not at all enlarged. The diffused swelling commonly furnishes an obscure sense of fluctuation; but, fre- quently, when punctures have been made into it, little or no discharge has been procured. 17. The pain ofthe swollen part is most acute in every instance, whether the swelling be in an extremity, or extend along it to the trunk, or commence in the trunk itself; and it is quite in- dependent of whatever affection of the skin may accompany the malady. In some cases, the in- teguments present not the least redness, although the cellular tissue has extensively suppurated, or even sphacelated; but the skin is commonly more or less affected, although in a secondary manner, in consequence of the extension of disease from the cellular tissue to it, and generally subsequent- ly to the manifestation of acute pain. In the ad- vanced stages, the skin has often a reddish or pink coloured blush, and occasionally a mottled or livid hue. In some cases, at a still further advanced period, solitary vesicles form over the diseased cellular tissue, and contain a serous, or sero-sanguineous, or ichorous fluid. The tem- perature of the part is sometimes much below natural. 18. B. The febrile commotion, whether ap- pearing consecutively ofthe diffuse inflammation, directly produced in the part primarily injured, or previously to the affection of the trunk, is of a typhoid or adynamic type, and is accompanied with the most marked disorder of the nervous system, with anxious collapsed countenance, and frequency of pulse ; more particularly when ex- cited by the inoculation of a morbid matter, as 26 by wounds from dissecting recent subjects, and when preceding the disease of the cellular tissue of the trunk. The fever sometimes commences insidiously, but more frequently in a very evident or tumultuous manner. The pulse soon becomes very quick, sharp, broad, soft, or compressible. The patient lies in the supine posture, with de- pressed shoulders, and without turning to either side. Delirium is common, but it is generally intermittent; and profound coma is rare. The respiration always is quick, laborious, and pain- ful, partly owing to the inflammation of the cel- lular tissue of the side of the thorax, and its ex- tension to the costal pleura. As the disease ad- vances, the peculiar cadaverous foetor emitted by the patient, the yellowish or lurid hue of the sur- face, the offensive and sometimes coloured sweat, which, ia rare instances, proves critical, and the tendency to ulceration in the parts pressed by the weight of the body, show that the blood, the se- cretions, and the soft solids, are more or less con- taminated. Towards a fatal close, the raving delirium is often accompanied with muttering, and starting of the tendons ; and alternated with stupor; the breathing becoming panting, labo- rious, or interrupted. 19. The Terminations of the disease vary with tke exciting cause, the state of the patient's constitution, and the part primarily affected. When it arises from mechanical causes, as after venaesection, simple puncture, &c, it may termi- nate with spreading suppuration, which may or may not be attended by sloughing of the cellular structure : and this result may occur both in cases which end fatally and in those that recover; a partial regeneration of this tissue taking place in some of the latter. In the milder cases, the in- flammatory action changes its character, and shows a tendency to stop ; the disease terminat- ing in phlegmonic suppuration and granulation. If the cellular substance adjoining a serous mem- brane become affected, this latter participates, and the inflammation spreads rapidly over it, generally producing an effusion of sanguineous serum ; but sometimes, also, adhesion of the op- posite surfaces. Occasionally the adjoining peri- osteum becomes diseased, and even the cartilages and bones denuded. A fatal termination occurs either rapidly from the intensity of the disease, or more slowly from some one of its sequelae: and usually takes place, in the first instance, in from four to fourteen days ; in the second, not till after two or more weeks, or even longer; but the common period is from the sixth to the tenth day. 20. III. Appearances on Dissection.— Dr. Duncan has given a very minute and ac- curate account of the successive changes that take place in the diseased structure. As the malady often attacks progressively various parts, it is sometimes found after death, in all its stages, in the same subject. In the part last affected, which is frequently the space between the last ribs and the os ilium, the cellular substance is merely oedematous, with increased vascularity ; the infiltrated fluid being either limpid or tinged with red, and readily flowing from the divided tissue. In a more advanced stage, the effused matter is less fluid, often higher coloured, but not yet puriform. The diseased structure is next found gorged with a white semifluid matter. 302 CELLULAR TISSUE — Inflammation of — Diagnosis. which greatly augments its thickness, separating the particles of fat at a distance from each other, but does not flow from the incision. In a subse- quent stage, this matter is opaque, whitish, or reddish, or greenish, but is now so fluid that it flows from the incision. It is still, however, con- tained in the cells of the tissue ; and it is only in the last stage, and after the texture of the part is entirely broken down, that this puriform mutter is met with in collections, mixed with portions of the sloughy tissue. At this last stage the matter is not circumscribed by any cyst, or defined cavi- ty, but is gradually lost in the adjoining cellular substance, without any line of demarcation. (See art Abscess, § 15.) 21. The cellular tissue itself is usually gray or ash coloured. It is detached extensively from the textures it connects, or adheres to them and the skin in sloughy shreds ; and long sinuous cavities are found between the tendons or muscles. The muscular structures adjoining are generally more or less diseased, the inflammation extending to their interfibrous cellular tissue ; which, how- ever, does not appear to be alone affected, the muscular fibres having their colour altered, and being more easily torn than in health. As respects the blood-vessels, the number of visible red ar- teries is increased, and the veins are enlarged, and turgid with black blood. Mr. J. Hunter states that he found, " in all violent inflammations of the cellular membrane, whether spontaneous or the consequence of accident, that the coats of the larger veins passing through the inflamed parts became also considerably inflamed; and that their inner surfaces take on the adhesive, suppurative, and ulcerative inflammations ; for in such inflam- mations, I have found in many places of the veins adhesion, in others matter, and in others ulcera- tion." (Trans, of Soc. for Improvement of Med. Knowledge, 8vo. Lond. 1793. p. 18.) 22. The lymphatic vessels have not been suf- ficiently examined. The axillary glands have, however, been observed somewhat enlarged, and embedded in the diseased cellular tissue. Dr. Duncan states, that, although a tender and swelled axillary gland has been frequently men- tioned as one of the first symptoms observed, he has never found them so much changed as at all to support the idea that their affection was the primary cause of the alteration of the surround- ing parts. The state of the fascia has been very generally overlooked in dissections of fatal cases of this malady, as well, indeed, as that of the blood-vessels and lymphatics ; but the fasciae, tendinous expansions, sheaths of tendons, &c. are not always unchanged, although they appear not to have suffered in some mstances. The skin is often severely affected, but not essentially or primarily, in the idiopathic form of diffused in- flammation ofthe cellular texture. 23. IV. Diagnosis and Complications.— a. Diffuse inflammation is readily distinguished from phlegmonous inflammation of the cellular tissue, by the circumscribed hardness of the latter, by the elevation of the tumour, and its pointing and becoming soft in the centre ; and especially by the phlogistic character of the attendant fever, which will also indicate die nature ofthe disease, when phlegmonous inflammation is seated be- neath fasciae. In the less severe cases of the dif- fuse disease, particularly when it is principally seated in those parts to which the exciting cause has been directly applied, and when it has been judiciously treated in the early stages, a disposi- tion to pass into the phlegmonous state, by the formation of coagulable lymph, and the limitation thereby put to its extension, are very generally observed. Indeed, this change of character con- stitutes the favourable termination of the disease ; although it may also occur as a complication in unfavourable or even fatal cases, especially when veins or fascia? are also affected. 24. 6. Diffuse inflammation of the cellular tissue is often consequent upon erysipelas, or complicated with it, particularly the erysipelas phlegmonodes; the difference between them con- sisting in the circumstance of this tissue being primarily and mainly affected in the former ; and consecutively of the inflammation of the skin, in the latter. 25. c. Inflamed veins may be distinguished from this disease, when they can be felt stretch- ing like cords in the direction of the swelling, and when the pain and tenderness on pressure are chiefly limited to the same line. There is usually, also, little or no affection of the skin, even secondarily, and the disease is generally more confined to a limb ; fulness of the pectoral, cervical, and lateral muscles and surface being commonly wanting. (See Veins—Inflamma- tion of.) When the tumefaction is very great, it is extremely difficult to determine respecting the affection or non-affection of the veins : the con- secutive inflammation of these vessels, however, and its complication with this disease, is very common, as Mr. Hunter has so accurately stat- ed, and more recent researches have confirmed. 26. d. The diagnosis between this malady and inflamed lymphatics is also extremely difficult, owing chiefly to the same cause, namely, to the cedema and congestion of the surrounding and distal cellular tissue consequent upon the obstruc- tion of these vessels in the inflamed state. The existence of superficial red streaks, not connected with veins, running along an extremity from the part where the exciting cause is supposed to have been applied, and swelling ofthe lymphatic glands to which they lead, are the only proofs we usually possess of the lymphatics being dis- eased ; and the absence of their appearance is the chief evidence of their being unaffected. But, as in cases of inflamed veins, diffuse in- flammation of the cellular substance very gen- erally follows inflammation of the absorbents, as satisfactorily shown by Abernethy, James, Duncan, and Breschet. The difficulty of diagnosis, however, in a great proportion of cases, excepting at their commencement, must be evidently owing to the very sufficient reason of their co-existence. 27. e. The same circumstance also explains the difficulty sometimes found of distinguishing the disease from inflammation of the fascia; for in the majority of instances, the affection commences in the cellular tissue, and extends to the fascia, this latter structure being very rarely inflamed primarily, unless after it has experienced some ex- ternal injury. Even when the fascia is primarily inflamed, it will not be possible, on some occa- sions, to form an accurate diagnosis, as disease commonly extends thence to the cellular tissue 1 on each side of it. When the fascia is affected, CELLULAR TISSUE — Inflammation of—Pathological Inferences. 3Q3 either primarily or consecutively, contraction of the limb is generally occasioned: but this is in- sufficient evidence of inflammation of the fascia, as inflammation and distension of the parts in- closed by it will produce this effect. When the disease commences in the cellular tissue, and ex- tends to that portion enclosed by fascia, or to this structure itself, the skin is often unaltered even in colour. In a most severe case, attended by Mr. Parker and myself, the whole leg and thigh, to far above the hip, were affected, and the limb contracted, and yet the skin was natural. The inflammation may, however, originate in the skin, extend to the subjacent cellular tissue, thence to the fascia, and, ultimately, to the cellular tis- sue beneath it; forming an important variety of erysipelas, well described by Mr. Copland Hutchison, and constituting the triple compli- cation of diffuse inflammation of the cellular sub- stance with that of the skin on the one side, and with that of the fascia on the other, the first being most extensively and destructively diseased. The local and constitutional suffering in such cases chiefly arise from the pressure made by the fascia upon the inflamed and tumid cellular tissue under- neath it. 28. /. Whilst it is important to distinguish be- tween injury or inflammation of a nerve, and this malady, it must not be overlooked that the one is often associated with the other; priority of affec- tion in respect of either being the chief object of diagnosis. When, after a puncture or other local cause, very acute pain is complained of, particu- larly in the situation and the course of a nerve, with severe or obstinate symptoms of great ner- vous irritation, convulsions, &c. accompanying it, we may conclude that the disorder has originated in a nerve; and, if to those symptoms are added the diffuse, boggy swelling, &c. already described (§12.), we may likewise infer that diffuse in- flammation has subsequently attacked the cellular tissue. 29. g. I have met with some instances of dif- fuse inflammation of the cellular tissue as a com- plication and termination of several severe or fatal states of disease in the puerperal state, both with and without affection of the skin; but only in the wards of a lying-in hospital. They have appear- ed in two forms: 1st, In the advanced progress of asthenic inflammation of the uterus, attended with an excoriating and foetid discharge, which has first irritated the skin about the nates, — the cellular tissue underneath becoming diffusely in- flamed to a great extent, and destroyed; and, 2d, After cases of inflammation of the uterine veins, evidently iii consequence of the vitiation of the circulating fluid. Dr. Otto, Dr. Duncan, and Dr. Craigie, refer phlegmasia dolens to diffuse inflammation of the cellular substance. But, I think, on insufficient evidence. If this tissue be really inflamed in that disease, other structures participate; and it certainly is not the part first affected. In the cases which I have seen exam- ined after death,—only three in all,—the nerves and veins were the parts to which the symptoms of disorder were first referred; the veins being obstructed in all the cases. (See Phlegmasia Dolens.) 30. h. The cellular tissue of the side of the neck and throat is sometimes diffusely inflamed, apparently from an extension of disease, in an- ' gina maligna, and worst form of scarlet fever, the patient sinking from it rapidly. I have, however, met with one case of this description, where re- covery ultimately took place. This disease also rarely occurs near the anus, or about the buttock and perinaeum, in the course of fevers, dysentery, &c. But it is more disposed, on these occasions, to limit itself, and to terminate in suppurating ab- scesses. When it occurs in aged persons, from the escape of urine into this tissue, it generally extends rapidly and terminates fatally; and a nearly similar result follows its appearance after important surgical operations, as after lithotomy, amputations, and the ligatures of veins and arte- ries for aneurismal dilatations of them. 31. V. Pathological Inferences.— a. Conformably with recently accumulated facts connected with diffusive inflammation of the cel- lular tissue, it may be concluded that it presents various morbid associations and grades of intensity, as well as distinct relations to the attendant con- stitutional disturbance, according to the diversified causes which occasion it:—1st, That depressed vital power, or a previously disordered state of the chylopoietic viscera, or general cachexy, is often requisite to its occurrence: 2d, That abra- sions, the irritation of acrid secretions or decom- posed animal or vegetable matter, simple punc- tures, injuries received during the dissection of subjects in a state of incipient decay, and the con- tact of morbid fluids, most commonly produce the disease primarily in the part in which the injury is sustained, the mischief spreading continuously from thence; although occasionally appearing af- terwards in other parts, without any continuous connection, when the circulation has become con- taminated by the primary affection: 3d, That, when originating and spreading as now stated, sometimes the skin, at other times the veins, occa- sionally the lymphatics, on some occasions the thecae or fasciae, and more rarely the voluntary nerves, or any two or more of these, participate more or less in the disease: 4th, There appear to be other causes, which, acting in the manner of specific poisons, produce comparatively but little effect on the part to which they are directly ap- plied; but which affect the system universally, chiefly by depressing and otherwise changing the organic, nervous, and circulating functions, the alteration of the cellular tissue appearing subse- quently: 5th, That the local affection in this form of disease, which may be denominated consecu- tive diffusive inflammation of the cellular tissue, is often of very small extent compared with the severity of the constitutional disturbance; and, very frequently, appearances of contamination of the frame present themselves before the cellular tissue is affected, and even then the affection may be trifling, or even not recognisable (see Poisons —Animal.): 6th, That the malady originating in the inoculation of a poison or virus, particularly during the examination of recently dead bodies, cannot be ascribed to inflammation of veins, or of lymphatics, or of nerves, or of fasciae, or even ofthe cellular tissue itself; and that, although this last most frequently exhibits morbid appearances, yet are these appearances obviously contingent upon general disease ofthe frame, interesting in a special manner its various vital manifestations. (See Author, in Lond. Med. Repos. vol. xx. p. 24. 1823.) 304 CELLULAR TISSUE —Infl 32. b. As respects the association of the local and constitutional affection, all the cases of this disease may be divided into two classes: — 1st, Those in which the constitutional disturbance is mainly owing to the primary local lesion, or its extension, whether it be inflammation of the cel- lular tissue alone, or of this tissue associated with inflammation either of veins, lymphatics, thecae, aponeuroses, or of the skin; the relation subsist- ing between the intensity of the primary local af- fection, and the constitutional disorder, being more or less apparent and co-ordinate (§ 12, 13.): 2d, Those in which the local lesion is obviously the least important change that has been induced, either directly by the exciting cause, or consecu- tively by the constitutional affection; and, even when it becomes the most serious, is manifestly the result of the constitutional affection (§14.), and disproportioned to it. Thus the local and the general symptoms are presented to us in a different order in these two forms of the disease. In the first, also, the febrile action is more in- flammatory than in the second, but still partaking df the irritative character, as has been very justly insisted upon by Mr. Travers. In the second, it is more asthenic; the nervous system is much more disordered; the anxiety, distress, and men- tal and physical depression, are greater than in the first; and all the organic functions more gravely affected; the blood, the secretions, and soft solids, becoming at last very evidently alter- ed.* (See Blood, § 139. et seq.) 33. VI. Prognosis.—The danger of this dis- ease is much less when it is accompanied with inflammatory, than with adynamic or highly irri- tative fever, and morbidly excited sensibility. In general, the rapid extension of the disease from the arm to the trunk; great tumefaction of the region of the pectoral muscles; the first appear- ance of the inflammation in this situation, or in any part of the trunk, from causes which first occasioned serious constitutional disturbance; re- markable frequency of pulse following rigors, with anxious collapsed countenance, ferrety eyes, delirium, difficult respiration, depression of mind, the accession of fresh rigors, extreme debility, and stupor; are all indications of great danger. The nature of the cause, also, should influence the prognosis. When it proceeds from the liga- ture of a vein, venaesection, and particularly from wounds in dissecting recent subjects, the danger is great. There is, however, less risk when the disease arises in the part to which the cause has been applied, and when the skin becomes much affected with a disposition of the inflammation to * It may be stated at this place, that the disease which has been observed to follow inoculation of an animal poison during the examination of recent subjects is obviously dis- tinct from diffuse inflammation of the cellular tissue, al- though this local affection, or some modification of it, oAen takes place in the advanced stage of that disease, which has accordingly been referred to in this article as one of the chief causes of the lesion now under consideration. The subject is, however, considered more fullv in the article on Poisons. In justice to myself, I should'state, that I pub- lished, in the London Medical Repository for July, 1823, p. 24—27., some remarks on the nature of the maladv infected by inoculation from recent subjects, and the operation of ani- mal poisons on the economy; and I request the favour ofthe reader who is interested in these important subjects to refer to these remarks, and to the conclusions, to which Mr. Travers has come, in his work on Constitutional Irritation, p. 413. Lond. 1826. .mmation of — Treatment. limit itself, and form healthy pus, than when it appears consecutively of a pustule merely in the part inoculated, and of fever with extreme de- pression. 32. VII. Treatment.—A. Prophylaxis. Pre- cautions are absolutely requisite when punctures are received in post mortem examinations, or when the cuticle about the nails and hands of the examiner is abraded. Some constitutions are more liable to be inoculated in this way than others, particularly persons who are out of health at the time, or whose vital energies are depressed. Wearing gloves during a morbid dissection may be of use in such circumstances. Dr. Duncan suggests the anointing of the hands with cam- phorated oil, or with simple axunge, before handling the viscera. Abrasions about the fin- gers should be protected by adhesive plaster. If, notwithstanding, punctures are received, or if an abraded or punctured part come in contact with any of the fluids or soft solids of a recently dead body, with animal or vegetable matter in a state of decomposition, with acrid or morbid secretions, suction or perfect ablution of the part ought in- stantly to be performed; a pledget of lint, wet with either a strong solution, or the oil, of cam- phor (F. 449.), or with turpentine, applied to it, and the application covered so as to prevent its quick evaporation. On the several occasions of the employment of these means, in the persons both of myself and of my medical friends, no dis- turbance has accrued from these accidents. Two partial exceptions, however, have occurred, but in such a way as to confirm the propriety of this practice, and illustrate the nature of one form of the disease. 1 he punctures, in these two cases, were received when examining the bodies of fe- males who had, but a few hours previously, died of malignant puerperal fever; and the application was not resorted to until after leaving the apart- ment where the inspection was made. In one of those cases, — that of a pupil, — camphor was used; in the other, — that of my friend, Mr. Churchill,—ammonia was employed. Both these gentlemen experienced, within twenty-four hours afterwards, considerable general disturb- ance, with sickness at the stomach, and nervous depression and debility. All disorder, however, disappeared in a day or two after the exhibition oil warm diaphoretics and stimulants; but in neither case was the least irritation observed in the part punctured. The morbid impression was evidently made upon the organic nervous sys- tem, as evinced by disorder ofthe functions more immediately dependent on it; but was not so in- tense, relatively to the state of predisposition, as to occasion further disease. As to the use of ligatures, &c, I must refer the reader to what I have stated respecting them in the article on Ani- mal Poisons. 35. B. Curative treatment.—a. It will be evi- dent, from the history of diffusive inflammation of the cellular tissue, that local means are chiefly applicable to certain of its states and complica- tions. When the primary local affection is at- tended by much pain, both cold and warm ap- plications have been recommended by different writers. The choice, however, between them, may be determined by the sensations of the patient: but warm fomentations, unremittingly employed, appear to me the safest, particularly when inflam- CELLULAR TISSUE —Inflammation of—Treatment. 3Q5 mation is externally apparent. When the local affection is limited chiefly to the part to which the cause was applied, or its vicinity, the detrac- tion of blood from it by leeches or scarifications, and incisions through the integuments, ought not to be neglected. The latter of these two modes of local evacuation, as first recommended by Mr. Copland Hutchison, is evidently the most beneficial, not merely by procuring a more decid- ed and rapid discharge, but also by giving an ex- ternal outlet to the matter which otherwise would infiltrate the cellular tissue, and extend the mis- chief. Even in cases of great vital depression, and when the cellular tissue is consecutively dis- eased, incisions should not be neglected ; they being compatible equally with an energetic, tonic, or stimulating treatment, as with its opposite: and they are not the less necessary in the early stages than at later periods, and when fluid is diffused through the cellular structure. When the part affected is deeply seated, they should be deep and large, so as fully to reach it; their number being proportionately diminished. But the great object is to make a free passage for whatever fluid mat- ter may have formed, or that will form subse- quently. This practice has received the appro- bation of Dr. Duncan, and the best recent wri- ters on this disease; and its propriety has satisfac- torily been shown in those cases which have fallen under my own observation. 34. b. The general means of cure are usually directed with the intention of subduing the local affection, and more especially the state of high nervous sensibility and vascular irritability which exists, whether this state be consequent upon the primary lesion produced by the exciting cause, or whether it be the immediate effect of that cause, and the antecedent of any affection of the cellular tissue, as in cases of inoculation by mor- bid matters or animal poisons. But, although this intention is generally kept in view, very dif- ferent, and even opposite, measures have been recommended for fulfilling it. It is evident that the same measures are not suitable to all states and periods of the disease ; and possibly to this cause may be imputed the great diversity of means which have been advised, and the partial success attributed to very opposite methods. Much also is owing, more generally than has been admitted, to the constitutional powers of the patient. A number of practitioners and wri- ters advocate general blood-letting, and trust chiefly to it for the fulfilment of the above inten- tions, without adv erting to the fact, that the mor- bid states forming the essential characters of the disease are, in their severest and most deadly forms, independent of sthenic action, and cannot be either limited or subdued by venaesection, al- though it may be required to'a moderate extent; particularly when the local affection arises prima- rily and directly from the exciting cause, impli- cates any of the parts which I have noticed as being involved in its complicated forms, and is chiefly antecedent of the grave constitutional dis- turbance characterising the advanced stages of disease. But even in such cases, the depletion should be practised early, and confined chiefly to young, plethoric, or robust persons ; the local evacuation consequent upon free incisions being Bufficient in most cases. In other respects, the treatment in this form of the disease may be sim- 26* ilar to that recommended in inflammation of the veins ; for the principle acted upon by Mr. John- Hunter in respect of that malady, and which is founded in accurate observation, is equally appli- cable to this — namely, to impart energy to the system, so as to enable the vessels to form coagu- lable lymph, by which the extension of the mor- bid action may be limited, and a diffusive or spreading inflammation may be converted into the phlegmonous state. This practice is still more imperatively required in the other form of the disease, or that in which the affection of the cellular tissue is consecutive of a constitutional disturbance, excited by a morbid virus or animal poison. 35. The frequent inefficacy of depletions and the antiphlogistic treatment, and even their in- jurious effects, as shown by the rapid sinking consequent upon them, are fully demonstrated by the history, given by Dr. Butter, ofthe disease which occurred in Plymouth Dock, and by the cases after wounds in dissection recorded by va- rious writers. The instances of recovery after this practice cannot be brought as evidence of its efficacy ; inasmuch as the smallness of their num- ber ; the tonic treatment, which, in several of them, followed vascular depletions; and constitu- tional energy ; may be adduced to disprove it. After studying the cases which have been pub- lished by Dr. Duncan, Dr. Colles, Mr. Tra- vers, Dr. Dease, Dr. Butter, &c, and re- flecting on my own limited experience, I would strenuously recommend the following measures, in addition to those already advised : — As to the question of blood-letting, that is already disposed of; but I may further add respecting it, that, however great the severity of the pain, or the sensorial excitement; or however frequent, open, sharp, or bounding the pulse; these symptoms should be arguments against, rather than in fa- vour of venaesection. But if the pulse be not re- markably frequent, or if it be firm and constricted, then this operation ought to be performed. Yet I should expect little or no advantage from this practice, in those cases of the disease which pro- ceed from the inoculation of putrid or morbid animal matters or poisons, whatever the charac- ter of the pulse may be. It is, however, seldom such as can warrant depletion in these cases ; being generally of the former description, and rarely ofthe latter. The object which we should propose to accomplish, next to that already stated, is to rouse and support the energies of life, and thus to oppose to- the extension of the disease an augmented vital resistance. This can be done only by a stimulating and tonic treatment, and by the expulsion from the frame of such impurities and morbid matters as may tend to impede the natural functions, and depress their energies. The means which we should employ with these views, if judiciously selected, will be more efficacious than any other for the fulfilment of the intention proposed above (§ 34.). The agents which I have found most successful in attaining them, are large doses of camphor, with opium, sometimes also with calomel, and the occasional exhibition of spirits of turpentine, either alone or with castor oil, and of one of the enemata (F. 148, 149.) contained in the Appendix. The plan I have fol- lowed in several cases of this disease, mostly of a more or less complicated nature, which I have 306 CELLULAR TISSU. — Induration of. treated, has been to give the following bolus, or the pills first prescribed; and a few hours after- wards the draught, which, in three or four hours, should be followed by an enema (F. 151.): — No. 104. R Camphors rasae gr. x. — xv. ; Hvdrarg. Suh- mur. gr. x. — xx.; Opii Puri gr. jss. — ij.; Pulv. Capsici gr. iv.; Conserv. Rosar. q. s. ut fiat Bolus, statim sumendus, et horas post tres vel quatuor repetendus. No. 105. R Camphors rasa; gr. vij. — xij.; Ammon. Carbon, gr. xv.; Hydrarg. Submur. gr. xx.; Pulv. Capsici Annui gr. viij.; Opii Puri gr. iij.; Mucilag. Acacia? q. s. ut fiant Pilula; xij., quarum capiat binas oinni hora vel bihorio. No. 106. R Olei Terebinthime ^ss.— ^j. (vel etiam Olei Ricini ^ss.); Olei Ca^eputx TT| vj.; Lactis Recentis 3>j- Fiat Haustus. 36. If a free evacuation of the bowels be pro- cured, the bolus and draught should not be re- peated more than once; if the evacuation be scan- ty, they may be given a third time, having pro- longed the period between the second and third doses; in the intervals between which, as well as subsequently, the following pills and draughts may be taken : — No. 107. R Camphors rasa- gr. iij. — v.; Ammon. Car- bon, gr. iv. ; Pulv. Capsici gr. j. ; Mucilag. Acaciae q. s. M. rinnt Pilula; ij., secunda, tenia, vel quarta quaque hora sumcuda;, cum Haustu sequente. Nn. 108. [{ Mist. Camphorae ^ j.; Liq. Ammon. Acet. Vss. ; Spirit. jEther. Sulphurici Comp. ^j. ; Tinct. Cap- sici Annui TT) x.; Syrup. Aurantii ", ss. M. Fiat Haustus, cum PH. supra prescriptae capiendus : vel. No. 109. |{ Infus. Cinchona; %'].: Liq. Ammon. Acet. ^ii. Spirit. Amnion. Arom. 'ss.; Tinct. Capsici IT) xi .; Olei Ca eputae TT) vj. M. Fiat Haustus, ut supra sumendus. 37. In the slighter cases, less active means will be found sufficient; but when the disease assumes a serious form, and particularly if the constitu- tional symptoms manifest themselves before the affection of the cellular tissue has commenced or made any sensible progress, the above or similarly active remedies must be energetically prescribed. 33. During the course of the more adynamic states of the malady, after alvine evacuations have been procured, I have seen the best effects follow the liberal use of wine, and large doses of bark with the aromatic spices. If the tongue and mouth be parched, the pills or bolus, and the tur- pentine draught, prescribed above, should precede the exhibition of the wine, bark, or sulphate of quinine. The irritability of the stomach and de- lirium, often accompanying the advanced stage of the worst states ofthe disease, being more readily allayed by powerful stimuli, as camphor, capsi- cum, ammonia, ether, spirits of turpentine, caje- put and other essential oils, wine, bark, sulphate of quinine, brisk bottled ale and stout, very small doses of opium, brandy, &c, than by medicines of any other description, it will be necessary to administer these, in forms of combination suited to the circumstances of the case ; chiefly with the view of rousing and supporting the energies of life, changing the state of morbid action, and thereby preventing the extension of the local mischief, and the tendency to contamination of the fluids and solids of the frame. The reo-imen during the treatment should be in accordance with these intentions, and the patient should be allowed what he may crave for ; as desire in such cases for articles of food, or for particular beverages, is the instinctive expression of the wants of the economy. BinLIOO. and Refer.— Morand, Hist, de I'Academie Roy. des Sciences, An. 1766.— J. Hunter, Med. and Philos. Comment, vol. ii. p 430. 8vo ed. 1775.; and Trani. of Soc' for Improvement of Med. Knowledge. Lond. 1793. Wil- I son and Wells, Ibid. vol. iii. pp.360. 3G7. — C. Smyth, Med. Communications, kc vol. ii. p. 190. Lond. 1790.— | Colles, On Wounds received in Dissection, Dub. Hosp. Re- [ ports, vol. iii. p. 200.; el Ibid. vol. iv. p. 240. — Dease, in Edin. Med. and Sure. Journ. Julv, 1826.— Wiseman, in Ibid. July, 1825. —Duncan, Trans', of Med. and Chirurg. Soc. of Edin. vol. i. p. 470. — Hti-isst, in Journ. de Med. kc. t. xii. p. 417. Paris, 1806. — Home, Philo«. Trans, for 1810, p. 75. —James, On the Nature and Treatment of In- flam. &c. 8vo. Lond. 1821. — A. C. Hutchison, Trans, of Med. and Chirurg. Soc. vol. v. p. 280. — Travers, On Con- stitutional Irritation, 2d ed. Svo. Lond. 1827.; in Lond. Med. and Phvs. Journ. Feb. 1823, p. 176. — Barlow, in Ibid. Aug. 182*3, p. 177. — Rust's Magazin fur die (jctim- mte Heilk. b. xiv. p. 100. — Wansborough, in Lond. Med. Repos. Mav, 1823, p. 353. — Author, Ibid. vol. xx. p. 24. — Shaw, In Med. and Phvs. Journ. Ap. 1825, and Feb. 1827. — Nelson, in Ibid. Aug. 1823.— Thomson, in Ibid. Ap. 1825. — Forbes, in Ibid. Julv, 1826. — Earle, in Ibid. Jan. 1827. — Butter, On Irritative Fever, kc 8vo. 1825. — Craigie, Gen. and Path. Anatomy, Svo. p. 34. Cellular Tissue — Induration of. Syn. OZdematie concrete, Billard. Sclereme, Chaussier. Squirrho-Sarque, Beaumes. Skin- bound. Classif. III. Class, I. Order (Author). J. Defin. A wax-like consistence of the skin and sub-cutaneous cellular tissue, commenc- ing in the hands, face, and lower extremities — the parts most remote from the centre of the cir- culation; often extending to the trunk, the parts being cold, often pale, yellowish, or rose-colour- ed, frequently mottled, or livid, with weak pulse and respiration, terminating in congestion of the lungs and asphyxy. 2. This affection was first described, in 1718, by J. A. Uzembezius, physician to the hospital at Ulm, and afterwards more fully investigated by Doublet, Aniiry, Auvity, Hulme, Den- man, and Underwood, as well as by several contemporary writers. It is very prevalent and fatal in some of the lying-in and foundling hospit- als on the Continent, but is comparatively rare in this country, especially during recent times. Its nature and seat have been 'much discussed by foreign medical writers; and even at present, va- rious points connected with its pathology are not fully established. It is, however, evident that the disease assumes various forms, and exhibits different morbid relations, which may be referred to the two following varieties. Var. i. Oedematous Hardening of the Cellular Tissue; Sclereme cedemateux, Chaussier and Duges. 3. In this form of the disease, the sub-cuta- neous cellular tissue is infiltrated with a yellowish coagulable albuminous serum; the limbs of the infant are more or less tumefied as well as hard, are somewhat rigid, and the skin assumes a vio- let tint, owing to the pulmonary congestion ac- companying it; with weak oppressed respiration, and feeble irregular pulse. In some cases, it commences with simple oedema, particularly when it arises from exposure to cold. If the cold have acted upon the greater part or whole of the sur- face of the body, the affection is sometimes more or less universal, but usually most remarkable in the limbs. It rarely attacks the abdomen, chest, and neck. The parts diseased are cold, tumid, discoloured, insensible, hard, and receiving and preserving the impression ofthe finger when very firmly applied. During the progress ofthe affec- tion, the cry becomes very weak and peculiar dyspnea increases ; the thorax is dull on per- cussion ; and the impulse of the heart, and the respiratory murmur, are found weak on ausculta- CELLULAR TISSUE —Induration of—Causes. 307 tion. Death often follows in from four to eight days, without any convulsion, but generally pre- ceded by a lethargic somnolency; and spasmodic attacks resembling slight trismus, and opisthotonos sometimes occur in the advanced stage. The in- durated parts occasionally assume an erysipelatous appearance, and, in rare instances, pass into spha- celation. In favourable cases, or after an early and judicious treatment, the affection subsides; the hardness, and afterwards the oedema, disappearing in the course of two or three weeks. M. Gar- dien states, that he observed suppuration of the affected part to occur in one case only. Var. ii. Induration affecting chiefly the Adipose Tissue; Sclereme concret, Chaussier, Duges; Skin-bound, of English authors. 4. This variety generally depends upon the sudden impression of severe cold; is compara- tively rare, and is chiefly met with in lying-in and foundling hospitals. The cheeks, limbs, fore- arms, thighs, back, abdomen, chest, and neck, successively, or two or more of them simultane- ously, assume a remarkable hardness, which yields not to the pressure of the finger. The temperature and sensibility of the surface are much depressed; and with difficulty raised. The skin is pale or yellowish, and wax-like; some- times livid or mottled. Trismus and opisthotonos are more common in this, than in the preceding variety. There is little or no tumefaction or oedema; the skin being fixed and immoveable upon the subjacent parts. In some instances, the extremities and back are somewhat emaciated, dry, and even rigid, particularly in the advanced stage; and the cheeks and temples are collapsed. At the commencement, the appetite and digestion are often not much affected; but during the pro- gress, and towards the close of the disease, the bowels become more or less disordered. Dr. Denman and Dr. Underwood seldom met with it but accompanied with some bowel com- plaint. The infant soon becomes too feeble to draw the breast; it utters a peculiar moaning noise, or feeble whining cry; and has the ap- pearance, even early in the complaint, of dying; and, at last, sinks apparently asphyxied. In favourable cases, the skin and extremities lose their hardness and rigidity, and the infant re- covers gradually, if pulmonic inflammation does not come on, and carry it off. Inflammation of the indurated parts seldom or never appears in the course of this variety. 5. Pathology.—M. Gardifn states, that he has sometimes remarked a slight increase of heat precede the insensibility, coldness, and hardness of the parts affected; but without any general febrile symptoms. The only indications of dis- order he has observed to usher in either variety, are difficulty of respiration, and a peculiar feeble- ness of the pulse and of the voice. Somnolency or lethargy is very usual during the course of the disease, and, as M. Doublet observes, increases towards a fatal termination. The affection, par- ticularly the latter variety, is rarely congenital. M. Duparcque has detailed two cases in which the infant upon delivery was so hard and rigid as to resemble a mummy, the vessels of the umbili- cal cord being diseased. (5. A. Causes. — The different states of this disease have been attributed to a syphilitic taint. It is, however, most commonly owing to the in- fluence of cold upon new-born infants, and gen- erally occurs from the second to the fourteenth day from birth. Imperfect or unwholesome nourishment, and the influence of a vitiated at- mosphere, particularly the air of crowded hospit- als, upon the imperfectly developed respiratory functions, are, in my opinion, amongst its most energetic causes. It is very apt to occur in pre- maturely born infants, in those of a feeble con- stitution, and who are deprived of the mother's or nurse's milk. M. Palletta remarks, that out of sixty-five cases, forty were prematurely born. M. Ratier states, that its dependence upon atmospheric cold is shown by the greater number of cases at the Hospice des Enfans Trouves, when winter sets in. But as a free ventilation, and dissipation of the foul air of an hospital ward, are in some measure prevented during cold weather, the prevalence of the dis- ease at this season may be equally owing to this circumstance. M. Billard has shown that the number of cases in the warm months is usually not much less than in the cold, in the above- named hospital. Dr. Bigeschi, however, states a fact, in his report of the Lying-in Hospital at Florence, which shows the great influence of cold in causing this affection. He observed the disease very prevalent during the winter season, especially if rigorous; and he consequently ordered the in- fant to be kept in the mother's bed, as warm as possible; and from that time no case of it occurred. M. Souville has met with the disease frequently in the northern departments of France, and also attributes it chiefly to cold, the influence of which is likewise admitted by Palletta. It some- times, also, occurs in the course of the bowel complaints incidental to infants, particularly when improperly nourished; and it is frequently com- plicated with the jaundice of this epoch. M. Bil- lard states that, in seventy-seven cases with oedematous induration, thirty were jaundiced. 7. B. Appearances in fatal cases.—In the first or most common variety, the cellular tissue is found loaded by a thick albuminous serum, which coagulates by heat, and which, according to M. Leger and Mi Billard, partly escapes upon dividing it. Dr. Palletta, however, states that, upon division, it remains firm and concrete, the infiltrated matter not escaping. In the second or more rare form of the affection, the cellular and adipose tissues are hard, concrete, and frequently of a deep yellow colour. The adipose tissue often presents a number of small dark yellow grains dispersed through it. The lymphatic glands, as well as the mesenteric glands, are enlarged; and slight serous or sero-albuminous deposition into the cellular tissue is observed throughout the body, with sanguineous or sero-sanguineous infil- tration of parts of it; and effusion into the shut cavities. The vessels of the brain are usually congested. The cavities of the heart are loaded with blood; the foramen ovale is sometimes more open than it should be; the pericardium contains some sanguineous serum ; the lungs are often congested or hepatised; and the larynx and epiglottis oedematous. The liver is frequently large and congested ; the gall-bladder and he- patic ducts full of bile; and the gastro intestinal mucous surface more or less inflamed. The most constant morbid appearances are the engorgement of the venous system; the dark or black state of 308 CELLULAR TISSUE —Induration of— Treatment. the blood; the accumulation of a thick, deep- slowness of the circulation and the depression of coloured, viscid, or coagulated fluid in the adi- the vital powers. pose and cellular tissues, imparting to them a 9. Diagnosis and Prognosis. — A. This condensed or firm appearance; and the conges- : affection is obviously more or less intimately tion of the thoracic viscera: but these latter are related to oedema on the one hand; and, in some commonly not otherwise diseased. instances, to erysipelas on the other: —to the 8. C. Proximate Cause.—The first variety of former, by the effusion of fluid in the cellular this affection may be considered as a form of , tissue; but differing from it chiefly in the persist- cedema; the peculiarity resulting chiefly from the ent, firm, wax-like, and coagulated state of the thick, coagulable nature of the effused fluid, and infiltrated part, and in the reddish yellow, livid, the deficient developement of animal heat in parts or mottled appearance of the skin;—to the lat- far removed from the centre ofthe circulation; in ter, by its frequently dark red, or livid colour; consequence of which the adipose matter either but differing still more widely from it, in the prin- is secreted in a morbid state, or cannot be pre- cipal affection of the cellular tissue, in the re- served in its natural semifluidity. The second or markable coldness ofthe part, languor of the cir- more rare form of the affection is chiefly to be culation, and general absence of any change in attributed to this change ofthe adipose substance, the skin itself. And it is distinguishable from both, which, owing to defective vital manifestation in by the peculiar cry of the infant ; the weak, the part, and the depressed grade of animal moaning, and sibilant respiration, the dyspncea, warmth, assumes the condition which it usually the feeble irregular action ofthe heart; the leipo- presents soon after death. M. Denis supposes thymia and lethargy, and the frequent complication that the disease is connected with the gastro- with trismus and tetanic spasm; as well as with intestinal irritation so frequently found upon dis- the peculiar jaundice of infants. It may be also section. Dr. Hulme and, more recently, Dr. mistaken for erythema nodosum; but the knotted Palletta viewed it as consecutive of, and oc- sensation, upon passing the fingers over the skin, casioned by, the congestion of the lungs and the furnished by this affection, is sufficient, of itself, to ditficulty of the pulmonary circulation ; whilst distinguish it from the smooth, cold, and diffused M. Baron, physician to the Parisian Hospital, hardness of the present disease. in which from two to three hundred cases occur 10. B. The Prognosis should be always re- every year, considers that the internal congestion served or cautious. A large proportion of those takes place subsequently to the appearance of attacked die, particularly in hospitals, even under the disease. I believe that this is the more cor- the most judicious management; sometimes, in rect view; for M. Billard found unusual con- two, three, or four days, in the most severe cases, gestion or hepatisation of the lungs in less than and in prematurely born children that have been one half the cases he examined. There can be exposed, soon after birth, to cold. But, generally, no doubt, however, that as the affection of the the disease does not terminate either way hi less cellular tissue proceeds, and as the circulation in than from six or eight days to twenty or thirty. this tissue and in the extremities is more and It may even be more prolonged; and when re- more retarded, congestion of the internal viscera covery is advancing, inflammation of the lungs comes on; but not always in the same organ; or digestive canal, or effusion on the brain, may the encephalon, cavities of the heart, liver, and occur, and either cut off the patient, or put his life spleen, also experiencing this change; sometimes in the utmost jeopardy. with serous or sero-sanguineous efiusion into the j 11. Treatment. — The intentions of cure adjoining shut cavities. The frequent complica- will vary with the particular form of the disease. tion of the disease with jaundice would seem to In the first, or oedematous variety, in which vas- indicate that the biliary organs are more or less cular plethora is generally present, depletion is affected; and such may be the case in respect often of service; particularly if the circulation in of their functions: but M. Billard found, in the extremities and affected part be at the same ninety cases, twenty only of organic lesion of time excited by means of frictions with warm stiin- the liver, the icteric appearance being evidently ulating liniments. MM. Baron and Billard dependent upon the morbid state of the serum prefer frictions to the use of the vapour bath, re- of the blood, and the deficient vital endowment commended by MM. Duges, Peligot, and ofthe cutaneous capillaries. M. Breschet had others. In the second variety, in which there is found the foramen ovale more than commonly less oedema, and greater induration, and, according open in many cases, and inferred that the atfec- to several recent writers, a coagulated state of both tion was caused by this circumstance. M. Bil- the adipose substance and the fluid effused into the lard states, that his numerous examinations do cellular tissue, blood-letting may not be admissible. not countenance this inference, but admits that MM. Chambon, Palletta, and Gardien, they are often coincident changes. This writer, however, consider that, in this variety also, de- who has paid much attention to the subject, con- pletion should be practised, in order to relieve the eludes, that general debility, congenital plethora cerebral congestion attending it; and therefore re- of the vascular system, congestion of venous blood commend two small leeches to be applied behind in the tissues, and unusual dryness of the skin the ears. In this practice 1 have generally con- previous to the exfoliation of the epidermis, are curred, but have adopted it with much caution in its chief predisposing causes; and that vascular prematurely born or weakly infants; directing, plenitude, an engorged state of the cellular and also, for all the states of the disease, calomel or adipose tissues, and the influence of external hydrarg. cum creta, with soda, and small doses of agents interrupting cutaneous transpiration, are ammonia; the compound decoction of sarsaparilla its more immediate causes; the coldness of the with liquor potassae; the warm bath, followed by extremities and affected parts resulting from the repeated frictions of the surface with stimulating CHEST — External Examination of, in Disease. 309 liniments; and the nourishment Nature intended for the infant. Although a very common and fatal disease in France, it is seldom observed in this country; and even at the Infirmary for Children, cases of it have very rarely presented themselves. I have not met with an instance of it in the Queen's Lying-in Hospital. 12. After the above means have been perse- vered in for a time, a few drops of spirits of tur- pentine and sweet spirits of nitre may be given occasionally in sugared dill-water; and the infant enveloped in very soft flannel or wash-leather, which ought to be covered over with oiled silk, in order to prevent the dissipation of the animal heat Dr. Palletta states that he treated, with uncommon success, the very numerous cases that occurred in the Lying-in Hospital at Milan, with half a grain of the kermes mineral (F. 637.) giv- en three or four times a day, and warm bran or warm flour applied to the parts affected. Andry and Gardien advise the use of blisters;—the former to the affected parts; the latter to the nape of the neck, with the view of preventing the oc- currence of cerebral congestion;—but I have had no experience of their use ill this disease; and consider them less efficacious than frictions with stimulating liniments, several formulae for which are given in the Appendix. During treatment, a pure warm air, and the natural food ofthe infant, furnished by a healthy nurse, will be found ex- tremely conducive to recovery. Bibliog. and Kefer.—Uzembezius, in Ephem. Nat. Curio*, cap. ix. oh. 30. p. 62. 1718.—Doublet, in Journ. de Mfcd. Avr. 1785, p. 447.—Beaumes, Fondemens de la Sci- ence Method, des Maladies, t. i. p. 314.—Underwood, On the Diseases of Children, 8'h edit. 8vo. p. 256.—Gardien, Traite Comp. d'Accoucheinens et des Malad. des Filles, des Fern, et des Enfans, t. iv. p. 91. Paris, 1826.—Palletta, in Archives 0ji n. de Medecine, t. v. p. 105., et Ibid. t. ix. p. 276. —Leger, in Ibid. t. vii. p. 16.—Duparcqm; Nouv. Bihlio- theq. Med. Sept. 1828, p. 333.—Ratier, Archives Gener. de M.'decine, I. xvii. p. 42.—Billard, in Ibid. t. xiii. p. 204., el Traite des Maladies des Enfans, kc 8vo. Paris, 1828, p. 169.—Dugis, Manuel d'Obstetrique, kc. Paris, 1830, p. 437. CEPHALITIS. See Brain, Inflammation of. CHEST. Syn. Thorax, Fr. Der Brustkasten, Ger. Tor ace, Ital. The Thorax. External Examination of, in the course of Disease.—Classif. Gen- eral Pathology—Semeiology. 1. Regions of the Chest.—It is necessary to divide the chest into different regions, in order to give precision to our diagnostic researches. This is done by drawing horizontal and vertical lines from certain conspicuous parts of the body. The first horizontal or transverse line extends anterior- ly from the humoral extremities of each clavicle, across the junction of the clavicles with the upper fiart of the sternum, posteriorly passing over the ast cervical vertebrae; the second, around the middle of the chest, anteriorly passing over the nipples, and posteriorly passing between the spine of the scapulas and their inferior margins; the third passes around the lowest part of the chest, from the zyphoid cartilage, and over the hypo- chondria. The first vertical line extends from the upper to the lower extremity of the sternum; the second and third, from each acromial ex- tremity of the clavicles to the external rami of the pubes; the fourth and fifth, from each poste- | rior margin of the axillae to the cre.sts of the ilia; | the sixth and seventh, from the clavicular trans- verse line along the posterior border of each scapula, or a little exterior to it, to the middle horizontal line; and the eighth, along the spinous processes of the dorsal and cervical processes. To these lines may be added one drawn on each side, from the last cervical vertebra, around the lower part of the neck, and sloping downwards to the upper part of the sternum. Thus the chest will be divided into sixteen regions, viz. two su- perior, or humoral regions; four anterior,—the subclavian and submammary; four lateral'—the axillary and subaxillary; and six posterior,—the scapular, subscapular, and interscapular. 2. The viscera lodged beneath each of the different regions of the chest, and the nature of its parietes, are too well known to require any notice. I therefore proceed to point out the va- rious methods which are employed to investigate the diseases of the thoracic organs. These con- sist of inspection, mensuration and manual exam- ination, percussion, succussion, and auscultation. 3. A. Inspection.— It is important for the physician to take into consideration the form and size of the chest, in estimating the causes, nature, and tendencies of disease. Vigour of constitution is generally incompatible with a small or ill form- ed thorax; this conformation not only disposing to various affections of the viscera contained in this cavity, but also aggravating their severity. Every change from the due proportions of the chest ought to be considered of importance. This cavity is generally artificially modified in its form in females. Its capacity is reduced in a trans- verse direction, by the lateral compression to which it is subjected; and, owing to the same cause, the superior abdominal viscera are pushed upwards, and it is thereby further diminished in a vertical direction. But the compression thus ex- ercised not only reduces the absolute capacity of the chest, but it also prevents the elevation of the ribs, and the descent of the diaphragm during respiration, rendering each inspiration of small amount, and insufficient for the developement and wants of the frame. It moreover presses the lower ribs downwards and inwards upon the more important viscera contained in the abdomen; pre- vents the ascent of the contents of the caecum; and favours lateral curvature of the spine, which, in its turn, tends remarkably to diminish the ca- pacity ofthe chest. 4. During inspection of the thorax, there are other circumstances, besides its form and size, which should fix attention. The actions of its parietes, the equality ofthe motions of each side, and their connection with the movements of the abdomen, are of the utmost importance. In pleuritis, the motions of the ribs of the affected side are greatly impeded; and if both sides be affected, the costal parietes are but little moved during respiration, this function being chiefly per- formed by the diaphragm and abdominal muscles. On the other hand, when the diaphragm, or either of its serous surfaces, are inflamed, or when intense inflammation affects any of the su- perior abdominal viscera, respiration is chiefly performed by the costal parietes. In the first case the respiration is said to be abdominal, in the second thoracic. 5. It is chiefly by actual inspection of the chest that we can ascertain the existence of a:dema of its surface : the distance between the ribs, the prominence of the spaces between each, 310 CHEST — Deformities of t&e. the existence or non-existence of partial contrac- tions, and bulgings or prominences of its walls,— are all important facts in our diagnosis of diseases seated in this cavity. Thus, in phthisis, when the pulmonary tissue is tuberculated, shrunk, or contracted, &c, a falling in of the ribs, particu- larly of the subclavian region of one or both sides, is observed; whilst in asthma and emphysema of the lungs, the ribs are full and expanded. This state, however, of the ribs may exist only on one side; as in cases of pleurisy of one side, termi- nating in effusion, in empyema, and in pneumo- thorax, we often observe the affected side ex- panded, and the intercostal spaces prominent, whilst the other is natural. In other instances of organic disease, one side may be uncommonly contracted; as after cures of old, or chronic, or circumscribed pleurisy, in partial or general de- struction of one lung, and in lateral curvature of the spine. In many of these, the opposite or sound side is fully developed, owing to a slight hypertrophy ofthe sound lung; in cases of curva- ture, one side is always prominent in proportion to the depression of the other. The prominence ofthe sternum, and lateral depression of the ribs, which is so common in children; and the falling in of the sternum, and prominence of the ribs; are ascertained by inspection. 6. B. Manual examination and mensuration.— It is of importance to ascertain the existence of tenderness on pressure in various parts of the chest, particularly when the patient complains of pain, or difficult respiration. This can only be done by manual examination. Extreme sensi- bility of the external surface indicates either irri- tation ofthe membranes ofthe spine, or rheuma- tism affecting the parietes of the chest. When pressure in the intercostal spaces is required to develope the pain, disease is usually seated in the pleura, or parts beneath it, or in the pericardium. It is seldom, however, that we can occasion pain by pressing between the ribs in cases of organic disease of the substance of the lungs, or even of the pulmonic pleura, unless this latter has formed adhesions to the costal pleura. During manual examination, attention should be paid to the ex- istence, the kind, and the extent of moisture on the surface of the chest; to its temperature, which is generally more or less increased in in- flammations; and to the palpitations or impulse of the heart. It is evident that the existence of oedema or emphysema of the surface of the chest is chiefly to be ascertained by manual examination of it. 7. Mensuration of the chest may be sometimes required, in order to ascertain either the degree of prominence of one side, or of the contraction of the other. In both cases a piece of tape is used; the measurement being made from the spinous processes of the vertebra; to the central line of the sternum, and from the top of the shoulder to the lowest rib. The admeasurement should be taken during a full inspiration and ex- piration, and the progressive increase or decrease noted. It will often happen that no difference between either side exists during a state of tran- quil respiration; and yet, upon forced respiration, the difference is very manifest. 8. Mr. Abe rxf.th y proposed, many years ago, —and the proposition has been recently revived on the Continent,—to ascertain the capacity of the lungs, by measuring the quantity of air they are capable of containing, as an indication of the ex- tent of disease by which they are affected. The recommendation was rational, and deserving of greater attention in several affections of this organ than it has received, particularly when the evi- dence furnished by the measure is duly estimated in conjunction with other signs. The method simply consists of the patient taking as deep an inspiration as he is able, and then expiring through a tube, one end of which is passed under a glass jar, containing, and inverted over, water. The quantity of water displaced is the measure of the capacity of the lungs. A person, full grown and in health, usually displaces from six to eight pints. If the amount be much less than this, it may be inferred that the lungs are obstructed by disease of their substance, or by tumours, effusions of fluid in the pleura, or other causes pressing upon them externally. Although muscular debility, or spasm, may diminish the quantity of air inspired, yet there can be no doubt that the method is cal- culated to furnish very useful information. 9. Some years since, it was proposed by a physician on the Continent, to test the capacity and soundness of the lungs by causing the patient to take as full an inspiration as possible, and to count from one upwards, in a deliberate manner, during the following expiration, and whilst ex- piring as slowly as he can. The number that will be reached, either during the expiration or whilst the breath is retained, or before a new in- spiration is entered upon, will be an index of the soundness of this organ. Dr. Lyons, who has more recently recommended a modification of this method, advises that the period should be noted by the seconds hand of a watch. He states that a healthy individual will not continue counting above thirty-five seconds; and that, in confirmed phthisis, the period never exceeds eight, and sel- dom six seconds. I have practised this method during the last five years, and have seldom found a healthy person who could proceed beyond thir- ty-five seconds, and scarcely one who could go beyond forty; but I have met several cases of pulmonary consumption, where, up to a very ad- vanced stage of the disease, twelve, fifteen, and, in one case, twenty seconds were reached; and even in the last stage, eight or ten seconds are not uncommon; although the number mentioned by Dr. Lyons is much more frequent. Percussion, succussion, and auscultation of the chest are comprised in the articles Auscultation and Percussion. Bibliog. and Refer. — Auenbrugger, in Journ. de Medecine, t. xxxii. p. 84.—Double, in Journ. Gtner. de Med. t. xxix. p. 241—Laennec, De 1'Auscultation Mediate, kc. 2d edit. 8vo. t. i. Par, 1826.—Abernethy, Phvsiological E>says, part ii. p. 157.—Lyons, Edin. Med. Journ. vol. xxviii. p. 453.—Dupuytren, Archives Gen. de Mid. t. xvi. p. 556.—Piorry, Procede Operatoire, kc. dans l'Exploratioo des Organes, Svo. Paris, 1831. Deformities of the Chest. — Classif, I. Class, III. Order (Author). 1.1. Lateral Depression of the Chest, Depression ofthe lateral parietes of the chest had escaped the attention of authors, although of very frequent occurrence, until M. Dupuytren wrote a memoir on the subject (Repertoire Gen. d'An- atomie, fyc. t. v. p. 110.) A few scattered remarks on the subject may be found in the writings of Van Swieten, J. L. Petit, Levacher, and CHEST—Deformities of the. 311 others, who have attributed it to rickets and other affections, and have evidently been unacquainted with its nature, causes, effects, and method of treatment. Not a week passes without cases of this contraction being presented at the Infirmary for Children ; and although sometimes a con- genital deformity, it has appeared to me very fre- quently to be greatly increased, if not altogether occasioned, subsequently to birth, by the very common practice among nurses of lifting the child Iby pressing the palms ofthe hand on the sides of tl»e chest, immediately under the arm-pits. This deformity consists of a greater or less depression of both sides of the thorax, with a proportionate protuberance of the sternum and abdomen for- wards, and of the vertebral column backwards. 2. It is most commonly found in infants born of debilitated, lymphatic, scrofulous, and rickety parents,—particularly those inhabiting low, cold, and moist situations, or who live in small ill-ven- tilated apartments,—and amongst children who are badly clothed and nourished. In many cases the deformity does not consist of merely a level depression of the lateral parietes ; but the ribs are actually bent inwards, the sternum and spine forming a curve outwards. In some, the lower or upper parts of the sternum are the most promi- nent. This extreme grade of depression is sel- dom or ever met with at the moment of birth ; M. Dupuytren thinks differently. My expe- rience leads me to state that it generally comes on gradually after birth, owing to deficient infla- tion and developement of the lungs, arising from the weakness of the muscles of inspiration, and flexibility of the ribs at the time of birth. In cases of this description, the vital energy of the lungs is insufficient for their healthy actions, and the respiratory mechanism is unable to accom- plish their full expansion, or to sustain the con- tinued pressure of the atmosphere, before which the soft and imperfectly formed thoracic parietes gradually yield. The manner in which nurses frequently lift infants, as already stated, tends fur- ther to increase the mischief, particularly in those who are originally weak and ill-nourished. The effects of this coarctation of the thorax upon the functions, and ultimately on the structure, of the lungs and heart, soon become very evident. We usually find the pulse quick, and the breathing op- | pressed ; with a weak voice, occasional anxiety, I and incapability of speaking or reading for any time, or of uttering many words without frequent pauses. In the newly-born infant, there is great difficulty of suckling, from its inability to raise the ribs with sufficient power to perform this process. It is seized with suffocation when at the mother's breast, which it often quits with fits of crying. 1 As it advances in age, the disorder of respiration j and circulation is still more remarkable, particu- larly upon ascending acclivities. The pulse be- I conies quick, irregular, or intermittent ; and is accelerated upon the slightest cause, whether physical or mental. 3. In children whose chest is thus compressed, the tonsils generally, or rather constantly, be- come tumid,—so much so, as frequently to in- crease the disorder of the respiratory actions ; and all the structures and organs of the body are impaired both in function and in develope- ment, owing to the derangement which the de- pression occasions to respiration and circulation. I In many cases which have come before me, rapid emaciation, great debility, defective assimi- lation and sanguifaction, an atrophied and flaccid state of the muscles, softening of the bones, fre- quently asthenic or chronic bronchitis, and swell- ing of the glands, have followed the deformity, and terminated the life of the patient. 4. Organic lesions.—In these cases the ap- pearances observed on dissection are such as the original and consecutive ailments lead us to ex- pect. These consist in retarded developement of the skeleton ; want of union between the bones composing the cranium; enlargement of the heads ofthe long bones, sometimes with softening and flexures of their bodies. Dentition is also retard- ed ; and, if it have proceeded, the crowns of the teeth are eroded. The voluntary muscles are atrophied, soft, pale, and exhibiting a fish-like structure. The lungs are compressed towards the vertebral column, and present a correspond- ing depression to that ofthe lateral parietes ofthe chest, with the marks of the ribs indented in their posterior and lateral surfaces. This organ is often studded with tubercles of various sizes ; portions of it are frequently often inflamed or hepatised ; and, in some cases, attended with bronchitis, the bronchi are more or less loaded with mucus, or muco-purulent matter. The substance of the heart is commonly pale and flaccid ; and, in young infants, the foramen ovale is sometimes widely open; and in older children, but imperfect- ly closed. The mucous follicles of the intestinal canal are often tumefied, but rarely ulcerated, ex- cepting when a chronic diarrhoea has attended the latter stages of the thoracic compression. The mesenteric glands are also occasionally much en- larged. 5. II. Depression of the Sternum, with lateral prominence of the ribs.—This deformity is the reverse ofthe former : the sternum is press- ed inwards, either at its middle or lower part, or along its whole extent ; the ribs are very much bent, and prominent laterally ; the chest being broad, but compressed anteriorly, the shoulders high, and the spine either straight or but little al- tered from its natural form. This change has also been much overlooked by authors. Mr. Coul- son, however, has lately noticed it in an instruc- tive article on deformities of the chest. It is by no means uncommon both in young and grown up subjects, although not so frequent as the lateral depression. In cases of depression of the sternum, the lungs and heart are compressed anteriorly; their functions much altered, and ultimately their structures. This deformity is very seldom con- genital, being the consequence of weakness, or of a scrofulous or tubercular diathesis. I have met with two instances of it out of six members of one family who died of consumption soon after puber- ty. It is in some cases antecedent of any appar- ent disease of the lungs ; in other instances, it is consecutive of pulmonary disease ; and in others, of external pressure and stooping occupations. 6. It is not uncommon to find females with the chest of a cylindrical or oval form, instead of being a truncated cone ; entirely in consequence of the inordinate pressure to which its lower part has been long subjected from tight lacing of the stays. fn some of these cases, the sternum, particularly its lower part, is pressed inwards. The effects, however, of this habit, and of the deformities 312 CHICKEN-POX. which it occasions, have been alluded to in anoth- er part. (See Che st—Examination ofthe, § 3.) 7. Treatment.—A. The cure ofthe lateral depression of the chest is by no means so hopeless as it may appear, particularly if it be attempted at an early period, and before serious organic mischief has been produced. Invigorating medi- cines and nourishing diet are requisite, particularly in conjunction with various external and mechan- ical means. 8. a. The external treatment which I have found the most successful, consists of warm or tepid salt water bathing in infants ; and in direct- ing the mother to make pressure very frequently through the day upon the protuberant spine and sternum, by placing one hand on the former and the other on the latter. But this pressure must be so managed as to be made only at the mo- ment of expiration, and entirely suspended during the moment of inspiration, so that no impediment may be in the way of the free dilatation of the parietes of the chest. The practitioner should take care to instruct the mother in the manner of employing the pressure upon the sternum and spine, with the view of throwing outwards the depressed lateral walls of the chest. The more frequently this pressure can be employed, the better ; and its benefits will be considerably pro- moted by applying the following liniment, night and morning, along the spine, or even upon both the sternum and spine. I have employed this and similar liniments, in these situations, with the greatest advantage, in this and several other diseases connected with debility, particularly in young subjects. No. 110. rt Linimenti Comphorae Comp., Linim. Sapo- nis Comp., aa % j. : Olei. Terebinthinae ; vj. : Iicnzioni 5 ij.: Styracis Balsami 7, jss.; Olei Cajeputw, Olei Liuionis, aa 3 ss. M. et fiat Linimentum. 9. In public practice, I have usually substituted for the above, either equal parts of the compound camphor and turpentine liniments ; or these, with the addition of the soap liniment, or their equal quantities of olive oil and turpentine, with a little soft soap. In conjunction with these means, the artificial salt water bath, with a very large pro- portion of salt, at a temperature suited to the peculiarities of the case, will be found extremely serviceable. As soon as children affected by this depression of the walls of the chest can be brought to employ the muscles of the upper part of the body in a determinate manner, this mode of treatment should also be employed. Perhaps the best mode of overcoming the depression, by developing muscular action and power, is to cause the child to raise weights, by means of ropes and pulleys placed at a considerable height over its head ; so that, by taking hold of the rope with both hands raised above the head, and pull- ing it downwards, the muscles may be brought into action, and the parietes of the chest thereby dilated. But moderate and duly regulated exercise, particularly of the muscles of the arm and trunk of the body, accompanied with invigorating medi- cines and regimen, will be productive of benefit. 10. b. Internal treatment should always be conjoined with the means stated above. The digestive functions generally require regulation, and tonic or permanent excitement. After hav- ing evacuated morbid secretions and faecal ac- cumulations from the bowels, by means of the usual purgatives, of which rhubarb, or senna com- bined with a tonic bitter, is among the most suit- able, Brandish's alkaline solution, or the solution of potash, or other preparations of this substance, may be given, either in some gruel or mutton broth, or in a tonic infusion, or combined with the preparations of iron. The following powders may also be taken once, twice, or thrice daily:— No. 111. R.Ferri Sulphatis exsic. gr. ij.—vj.; Polas»s Sulphatis gr. xij.—xx.; Pulv. Oascarillae 3j — ,jss. Misce bene, et divide in Cartulas xij. wquales, quarum espial unam bis terve quolidie. No 112. R Potass Sub-carbon, gr.j.—iv.; Fern Sub- carhon. gr. iij.; Pulv. Ilhei s;r. iv—ix. ; Pulv. Cascanlla (velCalumbaji gr. v.—xij. Misce. Fiat Pulvis. No. 113. K Kerri Tartarizati gr. iij.—xvj. ; Pulv. Ca- lumba; gr. vj.—xij. ; Pulv. Zingib. gr. ij. M. Fiat Pulvis. 11. Instead of these, the tincture of ammo- niated iron ; mixtures containing sulphate of quinine ; or the tincture of iodine, in doses of one to three drops, twice or thrice daily, may be employed advantageously. In every other re- spect the treatment is the same as that recom- mended for Rickets. But whatever mode of cure be adopted, change of air, or at least a wholesome pure air, with regular exercise, is requisite to its success. In this deformity, the various exercises resorted to with the view of imparting strength and agility to the frame, will be useful, if judiciously directed. 12. B. The treatment of the other deformities of the chest must be conducted very nearly on the same principles ; the pressure, in cases where it may be proper to have recourse to it, being made in an opposite direction to that recommended above, when the anterior parietes are depressed. But this deformity is very seldom met with so early in life as to admit of any expectation of advantage from the use of pressure. The other means, as long as the pathological states of the thoracic viscera do not contra-indicate them, are the most applicable. Bibliog. and Refer.—Dupuytren, in Repertoire Ge- nerate d'Analomie et Pathologie, &c. t. v. p. 128.—Coul- son, in London Medical Gazette, vol. iv. p. 69. CHICKEN-POX. Syn. Varicella, Crystalli, Va- riola Spuria, Variola Lymphatica, Variola Volatica, Auct. Var. Variola Pusilla, He- berden. Exanthema Varicella, Parr. Syno- chus Varicella, Young. Emphlysis Varicella, Good. Verole Volante, Fr. Die Undchten Kindspocken, Ger. Ravaglione, Ital. IVater- jags, IVater-pox. Classif. 1. Class, 3. Order (Cullen). 3. Class, 3. Order (Good). III. Class, III. Order (Author). 1. Defin. An eruption over the body, of semi- transparent glabrous vesicles, with red margins, accompanying a slight attack of fever, seldom passing into suppuration ; but, on the third day, bursting at their tips, concreting into small puck- ered scabs, and leaving no cicatrices. 2. Under the name chicken-pox, or varicella, have generally been comprised certain eruptions, which closely agree in many features with each other, and which in some respects resemble small- pox. It is from tliis latter circumstance that they claim a very particular notice, as they are gene- rally of so slight a nature as to require but little medical treatment. They were formerly very generally confounded with small-pox ; but the difference between them was remarked as early as the beginning of the sixteenth century by Vi- dus Vidius and Ingrassias. Sennert and CHICKEN-POX — Description of. 313 Riveri, professors at Wirtemberg and Montpel- Iier at the commencement of the seventeenth century, and Diejierbroeck, state that the distinction was well known in Germany, France, and Italy, to the vulgar, who had a separate ap- pellation for this eruption. Morton was the first in this country to mark the difference, and to describe this disease under the name " chicken- pox," by which it appears to have been common- ly known before he wrote. Since then it has been noticed by Fuller, and accurately defined as a distinct disease by Heberden. He, how- ever, contiuued to designate it by the term vari- ola pusilla; whilst his contemporaries, Vogel, Burserius, and Sauvages. also applied to it the generic term variola, with the specific desig- nation of volatica, spuria, and lymphatica. But, as Dr. Bateman has remarked, this circumstance cannot be considered evidence of their consider- ing it as genetically the same with small-pox. The entirely distinct nature of chicken-pox was very generally believed in, since Dr. Heberden pointed out the difference between it and the small-pox, until recently questioned by Dr. John Thomson, by whom the opinion of the earlier physicians, that they are merely varieties of the same disease, has been revived. This learned physician, and M. Berard, urge in favour of this opinion the circumstance of variola and vari- cella appearing from the same exciting causes, whether those affected have been vaccinated or not ; and affirm, that persons exposed to the in- fection of chicken-pox have caught small-pox, and that the former appears only in those whose constitutions have been modified by the influence of either small-pox or cow-pox. On this subject MM. Schedel and Cazenave remark, that in those epidemics which they have had opportuni- ties of noticing in Paris, the several eruptions might be classed under three heads: 1st, Variola properly so called; 2d!y, The malady termed va- riloide, or variola modified ; 3dly, An eruption purely vesicular, offering every appearance of varicella. The same cause, namely, variolous infection, seemed to develope these several erup- tions, which were observed in the same quarters, in the same streets, in the same houses. When the disease made its appearance among a numer- ous family, some had small-pox, some modified small-pox, and others chicken-pox. One circum- stance was striking to every one, namely, the mildness of the disease in those persons who had been vaccinated, and in the majority of those who had already had variola. 3. These facts certainly favour the opinion of Dr. Thomson ; but, as the above writers have stated, many cogent arguments have been urged against it, especially by Abercrombie, Bryce, Luders, &c. : — 1st, It is very difficult to deter- mine, during a small-pox epidemic, whether the occurrence of that disease among individuals com- ing in contact with persons infected with chicken- pox is rather the result of this communication, than of the variolous infection which at that mo- ment developes the malady on all sides: 2d, Vesicular varicella, properly so called, is not transmitted by inoculation, and never produces variola: 3d, Those persons who consider chick- en-pox as contagious, have confounded it with modified small-pox : 4th, Varicella appears in persons who have not been vaccinated, and who 27 have never had the variola ; consequently, in such cases, it cannot be regarded as a variola modified by the prior existence, either of this dis- ease or of vaccination : 5th, Vaccination practis- ed shortly after the disappearance of varicella pur- sues its course in the most regular manner, which never happens when vaccination follows variola : 6th, The progress of varicella is uniformly the same, whether it occurs before or after vaccina- tion, or after variola: 7th, Variola sometimes reigns epidemically, without being accompanied by varicella ; and, on the other hand, the latter may become epidemic without being attended by the former. In fact, the characters of the erup- tion, and the symptoms of varicella, differ essen- tially from those of variola. 4. I. Description. — A. Of the eruption. Under the name chicken-pox are included differ- ent varieties of eruption, generally characterised by very slight and brief antecedent fever, con- sisting of vesicles or very imperfect pustules which maturate and decline in three, four, or five days, occurring chiefly during infancy and childhood, but also at adult age, and occasionally prevailing epidemically. The generic term, chicken-pox, comprises three species, or rather varieties, which have been distinguished from each other for very many years in different parts of this country, by the popular names of chicken-pox, swine-pox, and hives. These Willan and Bateman dis- tinguished, according to the form of their vesicles, into, 1st, Varicella Lentiformis; 2d, V. Coni- formis; and, 3d, V. Globularis. Dr. Good has adopted these names and distinctions, but has added a fourth, the V. Corymbosa, the cluster- ing or confluent chicken-pox; which, if consider- ed at all as a distinct variety, is not of frequent occurrence; but has occasionally been observed by Bateman, Ring, and myself. Var. i. Lenticular Chicken-pox, Vari- cella Lentiformis ; V. Lymphatica, Plenck. 5. This variety appears, on the first day of eruption, in the form of small red protuberances, of an irregularly circular, or rather tending to an oblong figure, with a nearly flat and shining surface, in the centre of which a transparent vesicle is very soon formed. On the second day ofthe eruption the vesicle is filled with a whitish lymph, and is about the tenth of an inch in diameter. On the third day the lymph is straw-coloured ; and, on the fourth, the vesicles which have not been bro- ken subside, and are puckered at their margins. Few of them are entire on the fifth day ; but the orifices of several which have broken are closed or adhere, so as to confine a little opaque lymph within the puckered margins : on the sixth day, small brown scabs appear in place ofthe vesicles; and become yellowish on the seventh and eighth days, gradually drying from the circumference to the centre. On the ninth and tenth days they fall off, and leave for a time red marks on the skin, without depression. The disease may, how- ever, be longer than now stated, owing to fresh vesicles appearing during two or three successive days, and going through the same stages as tho first. The eruption is usually distinct, is general over the body, and comes out first on the back and breast. The vesicles, even when they sup- purate, leave no cicatrices. The pustules of small- pox break out first on the face, neck, and breast, I and always leave depressions. 314 CHICKEN-POX —Diagnosis. Var. ii. Conoidal Chicken-pox, Varicella Coniformis ; Varicella Verrucosa, Plenck ; Variola Lymphatica, Sauvages; Pemphigus Variolodes, Frank ; Verolette, Fr. ; Rava- glio, Ital. ; Swine-pox. 6. The vesicles of this variety arise suddenly, have a somewhat hard and inflamed base, and are on the first day acuminated, containing a transparent lymph. On the second day they are a little more turgid, their bases more inflamed, and the lymph in many of them is of a light straw-colour. On the third day the vesicles are shrivelled, and those which are broken have their lymph concreted into slight gummy scabs. Such of them as remain entire, and have their bases much inflamed, contain, on this day, a whitish puriform fluid; every vesicle of this kind leaving, after scabbing, a durable cicatrix. On the fourth day, thin dark brown scabs are seen intermixed with others, which are rounded, yellowish, and semi-transparent. These scabs gradually dry, separate, and fall off in four or five days. 7. A fresh eruption of vesicles usually takes place on the second or third day, and has a simi- lar course to the preceding; the whole duration of the eruptive stage being thus six days in this variety of varicella. In some instances minute red tubercles appear, and subside without forming vesicles. The scales last formed are generally not separated till the eleventh or twelfth day. In some cases, when the febrile symptoms have been severe, slight ulceration takes place in the vesicles from which the scabs have fallen off, leav- ing depressions or cicatrices, but only in parts sub- jected to pressure. Var. iii. Globular Chicken-pox, Varicella Globularis ; Hives. 8. The vesicles of this variety are large and globular, but their base is not quite circular. They are surrounded by inflammation, and con- tain a transparent lymph, which is slightly turbid, and resembles milk whey, on the second day of the eruption. On the third day they subside, become shrivelled as in the former varieties, and appear yellowish from the admixture of a small quantity of puriform matter with the lymph; some of them remaining in the same state till the fol- lowing morning; but before the conclusion of the fourth day, the cuticle separates, and thin dark scabs cover the basis of the vesicles. The scabs dry, and fall off in four or five days afterwards. 9. B. Of the constitutional affection. — All these varieties of chicken-pox may attack the same individual at different epochs, and offer the same symptoms, whether before or after small- pox or vaccination. They are frequently associa- ted with the epidemic prevalence of small-pox. They appear principally in the early months of the year, and the spring; seize chiefly young per- sons, and adults sometimes; and each of them, with few exceptions, affects a person only once in their lives. Varicella is preceded, for twenty-four or forty-eight hours, by chills, depression, anor- exia, costiveness, and thirst, with heat of skin, flushed countenance, accelerated pulse, tendency to perspiration, and other febrile symptoms. Sometimes there is nausea, or even vomitino-, with pain at the epigastrium and through the limbs. In some cases, the fever is so very slight as to be overlooked ; and, in infants, is often indi- cated only by heat of skm and fretfulness. The eruption usually commences on the back and breast ; appearing, next on the face, neck, and scalp ; and lastly on the extremities. It is some- times preceded, for a few hours, by a general erythematous rash ; and the vesicles are usually most abundant in the conoidal form ; they being sometimes coherent, or seated close together, but seldom confluent. When thus coherent or clus- tering, they form the fourth variety of Dr. Good (§ 4.). Owing to the itching which accompanies them, children often break the vesicles by scratch- ing; whence proceeds an increased inflammation, forming a yellowish pus, more or less consistent. This happens particularly on the face. The crusts which replace these pustules remain much longer, and leave small cicatrices. As the vesicles ap- pear successively during two or three days, we may perceive the eruption exhibiting its sever- al stages at the same period, in the same indi- vidual. 10. II. Diagnosis. — The vesicle full of ser- um on the top of the pock, on the first day of the eruption, — the early abrasion of many of the vesicles, — their irregular and oblong form, — the shrivelled state of those that remain entire on the third and fourth day, and the radiating furrows of others which have had their ruptured apices clos- ed by a slight incrustation, — the general appear- ance ofthe small scabs on the fifth day, at which time the small-pox pustules are not at the height of their suppuration, — sufficiently distinguish chicken-pox from small-pox. Dr. Willan has pointed out the characteristic circumstance, that variolous pustules are, on the first and second day, small, hard, globular, red, and painful ; impart- ing the sensation, when the finger is passed over them, similar to that which one might conceive would be excited by the pressure of small round seeds under the cuticle. In varicella, almost ev- ery vesicle has, on the first day, a hard inflamed margin ; but the sensation communicated to the finger is like that from a round seed flattened by pressure. As the pustules of small-pox, more- over, become gradually developed, they contain a white thick matter ; the formation of which precedes suppuration, as shown by Dr. Ash bur- ner. When the globular vesicles or hives ap- pear, as is sometimes the case, intermixed with the lenticular or conoidal eruption, they afford a ready distinction from the small-pox, to the pus- tules of which they bear little resemblance. 11. It is not, however, so easy to distinguish varicella from modified small-pox. The symp- toms precursory of the latter are usually intense, which is never the case with the former. In mod- ified variola, the eruption is pustulent, and the pustules are small, circular, and generally depress- ed in the centre. After the scaly crusts drop off, tubercles are frequently seen, which disappear but slowly. In varicella, the vesicles, which are at first transparent, contain a fluid which be- comes sero-purulent; and they are never followed by tubercles, as in modified variola. To this I must add, that varicella is not infectious; whereas modified variola may be transmitted by inocula- tion, and may even, in some cases, occasion a very severe attack of true small-pox. 12. III. The Treatment of varicella is very simple : the patient should remain in bed, in a temperate atmosphere; ought to be placed on low diet, and abstain from animal food for a few days; CHLOROSIS —Causes. 315 should have the bowels duly regulated, and par- take freely of lukewarm diluents. ISiblioo. and Refer.—Vidus Vidius, De Chrystallis. —Ingrussias, De Tumor. Pra-t. Nat. 1. i. c. 1.—Sennertus, Med. Pract. 1. iv. cap. 12.—Riverius, Prax. Med. cap. ii.— Diemerbroeck, De Variolis et Morbis, cap. ii.—Morton, Pvrotolojia, kc p. S8.—Fuller, Exanthematologia, p. 161. 1730.—Heberden, in Trans, of the Coll. of Phys. vol. i. art. xvii.; et comment de Morbis, cap. 96.—Vogel, De Cognos- cend. et Cur. Horn. Morb. § 128. 1772.—Burserius, Inst. Med. t. ii. cap. 9. §305.—Sauvages, class iii. gen. ii. sp. 1. •—Wilson, On Eruptive Fevers, 4th edit. p. 321.—Ring, Med. and Phys. Journ. vol. xiv. p. 141.—Thomson, On Varioloid Diseases, 8vo.—Rayer, Traite de Maladies de la Peau, 8vo. t. i. p. 340.—Cazenave et Schedel, Abrege Prati- que de Mai. de la Peau, 8vo. p. 61. CHLOROSIS. Der. and Syn. From yluypbc, paleness, yellowish green. Pallidus Morbus; Fcedus Virginum Color; Pallor Virginum; Morbus Virgineus; Fcedi Colores; Icterus al- bus; Icteritia alba; Cachexia Virginum vel Muliebrum ; Febris Amatoria ; Chlorosma, fyc. Auct. Var. Chlorose; P&les Couleurs, Fr. Die Bleichsucht, Ger. Green Sickness, Eng. Classif. 2. Class, Nervous Diseases; 2. Order, From Defect of Vital Energy (Cullen). 5. Class, Diseases of the Sexu- al Functions ; 2. Order, Affecting the Or- gasm (Good). I. Class, II. Order (Author, in Preface). 1. Defin. Pale yellowish green complexion, languor, debility ; depraved appetite, with oc- casional nausea or sickness, and disorder of the sexual secretions; generally occurring about pu- berty, or soon afterwards. 2. Chlorosis has been very generally consider- ed as a variety merely of amenorrhoea, particular- ly by Cullen, Pinel, and Frank, although they have classed it as a distinct disease. As to its occurrence independently of retained or sup- pressed menstruation, there can be no doubt, although it is frequently connected with such dis- order. It is also similarly related to dyspepsia, and to anaemia ; Dr. Young classing it with the former disease. Sauvages includes, as a va- riety of chlorosis, the cases of anamia which oc- cur in infants and children, denominating them the chlorosis infantum. But, although several such cases are met with in practice, they seldom pre- sent the yellowish green tinge of this disease, being usually of a white or exsanguineous pale- ness, unless when complicated with jaundice, which is but rarely remarked. They are entirely referrible, in respect of their pathological relations and terminations, to anamiia (see Blood—De- ficiency of); and are sometimes, owing to the exhaustion attendant upon their last stages, mis- taken for hydrocephalus. Sydenham considered chlorosis as a variety merely of hysteria, connect- ed with a cacochymia,—its frequent complication with that disease being evidently the source of this fallacy ; and, lastly, Van Swif.ten viewed it as a form of cachexy. These opinions serve to show the propriety of considering it as a dis- tinct disease, but more or less intimately related to those complaints, owing to the circumstance of them all originating in a nearly similar state of vital energy, particularly as manifested in the organic nervous system ; specific differences be- tween them consisting in the particular viscus or part more especially affected, and the grade and mode of such affection. 3. Dr. Good divides chlorosis into two species, the atonic and entonic ; but this is an unnecessary refinement, no phenomena which warrant such a distinction presenting themselves in practice. In- deed, the entonic only consists of a state rela- tively of less deficiency of vital power than the atonic, and is, in many cases, merely the first stage of the disease ; particularly when it occurs in tolerably strong females, and whilst the torpid function has not as yet extended much further than the sexual organs, in which it originated, the digestive, assimilating, and vascular organs not having sustained much disorder. Dr. Gooch has likewise made mention of an acute chlorosis, occurring chiefly in married women. But the state of disease thus designated by this physician, is simply that chronic disorder, often attended with slight irritative fever, following large losses of blood, which are not readily supplied by the di- gestive and assimilating functions; and is in all re- spects a state of anasmia. (See Blood, §34. etseq.) 4. I. Causes. — A. Predisposing causes. Chlorosis is most frequent in girls about the age of puberty ; either previously to the appearance of the menses, or when they are retained, or occur irregularly, or with difficulty. But married women, particularly widows and those who have not borne children, are not exempt. It is even met with in males, although rarely, about the period of puberty ; as remarked by Hamilton, Blane, Desormeaux, Roche, and myself in two or three cases. When observed in this sex, it is apparently connected with protracted evolu- tion of the sexual organs ; and one or two of the young females of the same family are sometimes also affected. The lymphatic and melancholic temperaments ; feeble and delicate constitutions ; residence in cold, moist, and miasmal localities and climates ; insufficient, unwholesome, innu- tritious, and watery vegetable food ; inattention to the digestive functions, particularly those of the bowels ; the abuse of diluents, of acid weak wines, or of spirituous liquors, early in life ; too great indulgence in warm bathing ; prolonged sleep ; tight lacing at an early age ; and what- ever debilitates and relaxes the system ; predis- pose to this disease. The most frequent causes in this country are sedentary occupations in crowd- ed and ill-ventilated manufactories and towns, especially those employments which require a stooping position, and are prosecuted by females at a very early age, or before the frame is de- veloped. 5. B. The more common exciting causes, are longings after objects of desire ; depressing pas- sions and affections, especially unrequited love, or unfortunate or imprudent attachments; long entertained feelings of sadness or anxiety, par- ticularly when caused by removal from friends, and the scenes of recent happiness and affection. According to MM. Desormeaux and Roche, privation of the physical gratification of love is a very frequent cause. Retention, difficult and imperfect occurrence of the menses, have very generally been enumerated amongst its causes ; but the uterine disorder is rather a coincident ef- fect of the same pathological state that produces chlorosis (§ 12.). Suppression of the menses, excessive menstruation, and manustupration, are sometimes concerned in its appearance; the latter acting chiefly by debilitating the frame generally, I by exhausting the energy of the 6exual organs, 316 CHLOROSIS —Diagnosis—Prognosis. and thereby assisting the operation of other caus- es, particularly when the functions of the stomach and bowels are torpid, or otherwise disordered. The influence of constipation, and faecal collec- tions in the caecum and colon, in occasioning the disease, cannot be questioned, although somewhat exclusively insisted upon by Dr. Hamilton, in opposition to the opinion of Dr. Cullen, who re- ferred it chiefly to an inactive state of the ovaria. It seems, however, quite as evident that the tor- por of the digestive organs, especially of the low- er bowels, and the inactivity of the uterine organs, depend upon the state of the organic system of nerves, Which supply not only those viscera, but also those concerned in assimilation and circula- tion,—all those functions presenting more or less disorder in the course of the disease. 6. II. History and Symptoms.—Chlorosis presents two stages ; the incipient, and the fully developed or confirmed. It also manifests various morbid associations or complications. A. The incipient stage commences insidiously, and almost insensibly. The patient is at first languid, listless, weak ; loses her complexion ; has no disposition to amusement, if it require mental or physical exertion ; is often without appetite, or craves for particular, and sometimes unwholesome, kinds of food; the bowels are costive; bodily exertion soon occasions shortness of breath, and fatigue ; the breath is offensive ; the tongue is white or pasty; sleep is disturbed or unrefreshing, and oppressive in the morning ; she often complains of intermit- tent headach, pain of the left side, and palpita- tions, which are induced by the slightest cause ; the pulse is quick, weak, and small ; and the catamenia are either retained, or are scanty, and of a pale colour : all these symptoms gradually increase, and the countenance becomes more and more pale, and assumes a greenish yellow tint. 7. B. The fully developed disease presents its characteristic complexion—the pale greenish yel- low of an etiolated plant. The lips, gums, in- sides of the cheeks, are pale; the eyelids are livid, sometimes oedematous, particularly in the morn- ing ; the conjunctivas are remarkably white ; the soft solids flaccid ; the extremities cold ; and the ankles oedematous. The tongue is usually pale, soft, flabby, and indented at the edges by the teeth ; sometimes it is smooth, glossy, and fissur- ed. The appetite is more and more capricioua and morbid ; sometimes with pica, or a desire for pickles and acids ; and nausea and vomiting, es- pecially in the morning, and cardialgia or gastro- dynia after meals, not infrequently occur. If the menses have already appeared, they become gra- dually more difficult, and scanty ; are attended with syncope or pain ; are of short continuance, pale, or watery ; recur at longer periods, and at last disappear. The patient is often sad ; enter- tains depressing and sinister ideas ; prefers soli- tude, and is capricious. In the more advanced or inveterate cases, the finger nails are brittle, dry, and split or break off; the hair is weak, falls out, is lank, dry, and splits at its extremities. The abdomen is often tense, distended, and slight- ly painful. A constant pain is complained of un- der the left breast, sometimes with a slight cough; the constipation alternates with diarrhoea ; some degree of emaciation takes place ; the oedema ex- tends, or assumes the form of anasarca or ascites; various irregular states of hysteria occasionally appear during the course of the disease; and some one or two symptoms become prominent, occa- sionally deceiving both the patient and medical attendant by their severity. Thus the headach, pain of the side, palpitations, cough, &c. occa- sionally lead to the apprehension of inflammatory states ofthe brain, or of the pleura, of disease of the heart, or of phthisis. 8. C. Terminations and complications.—When the disease becomes inveterate from neglect, in- efficient treatment, or the continued operation of its causes, &c, it often assumes diversified forms, owing to morbid associations. The continued dis- order and debility ofthe digestive organs, and the consequent insufficient supply of healthy chyle to the blood, as well as the imperfect sanguifaction of what is supplied to it, sooner or later gives rise to anaemia, which, in its slighter grades, owing to the causes hereafter to be noticed (§ 12.), even accompanies the early stage of chlorosis. In fe- males who have been married, or in those who, previously to the appearance of the disease, had the uterine functions and discharges regularly and fully established : hysteria, in some one or more of its numerous states, is commonly observed. Chlorosis is sometimes also complicated with swellings ofthe glands, or with chronic cutaneous eruptions, or with haematemesis and malaena ; and occasionally terminates in dropsy of either the thoracic or abdominal cavities. Mania and delirium rarely ensue in the course of its advanc- ed stages and inveterate forms. 9. III. Diagnosis.—Chlorosis is most inti- mately related, in its symptoms, and the nature of the changes which constitute it, to anaemia. Indeed, the advanced stage of the former is often identical with the latter; the chief differences con- sisting in the pale, greenish, or greenish yellow tint of the countenance, the torpor or disorder of the uterine functions, and affection of the stomach in chlorosis. It also often resembles other chronic diseases, particularly those seated in the stomach, and tuberculous affections ; but not so closely as to be mistaken for them. Neither the nervous headach, nor the hysterical pains, particularly those complained of in the left side and under the left breast, nor the palpita- tions of the heart, can with due attention be con- founded with inflammation or organic change iu these situations : yet I have seen these mistakes made, and nearly fatal consequences ensue,— the practitioner having been deceived by the fre- quency of the pulse in such cases. In this, as well as in other diseases, much advantage will accrue from recollecting that the most acute pain is generally owing to a pathological state the re- verse of inflammatory ; and that the most fre- quent pulse is very far from indicating a necessity for blood-letting, which, if practised in such cases, will increase the morbid sensibility and the vas- cular irritability, even when it does not hasten a fatal termination. 10. IV. Prognosis.—Chlorosis is always chronic; is generally cured, particularly in its sim- ple form ; but sometimes also terminates fatally, owing to the associated lesion of various functions and organs. Recovery may be confidently ex- pected, when it is incipient or uncomplicated, and none of the internal viscera betray marked disease ; especially if it have not continued longer CHLOROSIS —Pathology—Treatment. 317 than two or three months, and the menses have not appeared. If it occur in married women, sterility is often the consequence ; or, if children are borne, they are generally feeble and unheal- thy. Chlorosis should be viewed in a serious light, if it have been of long duration; if the cat- aineuia, after having appeared, are gradually sup- pressed; more particularly if the signs of anaemia to a considerable degree be present; if emacia- tion be rapid, with quick respiration and cough; if the cedema of the extremities extend; if symp- toms of effusion of serum into the cavities super- vene; if hasmatemesis or malaena occur; and if it have resisted, in its early stage, a judicious treat- ment. In the advanced progress of the disease, especially when it is complicated, death some- times takes place unexpectedly, but seldom with- out evidence of excessive depression of the organ- ic nervous influence, and of great deficiency of the circulating fluid. (See Blood, § 42. et seq.) 11. V. Pathology.—A. Morbid appear- ances. The adipose substance is sometimes not much diminished ; but the rest of the soft solids is flaccid and pale, from a deficiency of the red blood. Effusion of serous fluid is commonly met with in the large cavities, particularly those of the pleura, pericardium, and peritoneum, and occa- sionally also in the ventricles of the brain. The lungs are frequently oedematous, or studded with tubercles; the liver is often enlarged, and some- times pale or tuberculated ; the stomach small, pale, and contracted ; the mesenteric glands slightly enlarged ; the ovaria and uterus, in some instances, are imperfectly developed, or contain small tumours ; the cavities of the heart are oc- casionally somewhat enlarged, and their parietes are generally flaccid and pale, or slightly atro- phied; the blood is commonly pale, aqueous, and deficient in coagula,—those which are found in the large veins and auricles of the heart being of a very light colour, and small. These are the most common lesions ; but others are sometimes noticed, both in the organs now mentioned, and in different parts, as in the spleen, pancreas, gall- bladder, kidneys, &c. In some cases but little change beyond the exsanguineous state of the va- rious structures are observed, as in those recorded by Lieutaud. 12. B. Nature ofthe disease. — It has been considered by many writers, and amongst others by Wedel, Korte, Cullen, Desormeaux, and Roche, that chlorosis is chiefly dependent upon debility or torpor of the nervous influence developing and actuating the ovaria and uterus. Hoffmann, Darwin, and Saunders connect it more immediately with obstructed function of the liver. Hamilton refers it chiefly to torpor of, with accumulated sordes in, the digestive or- gans, particularly the lower bowels; and Andral, to the deficient and morbid state ofthe blood. If we reflect upon the character of the associated phenomena constituting the disease, in relation to their causes on the one hand, and to their conse- quences and terminations on the other, we must necessarily arrive at the inference, that all the organic functions — those of digestion, assimila- tion, sanguifaction, nutrition, and generation,— are inadequately performed ; and, as the organs devoted to these offices are intimately connected one with the other, and actuated by the organic nervous system, that consequently the vital ener- 27* gy of this system is insufficient for the purposes it is destined to perform. We know that the evo- lution of the sexual organs is owing to the state of vital power; and that, by a reciprocal influence, the activity of those organs increases all the other functions of the frame. Therefore, as we com- monly observe this disease at the period of puber- ty, and associated with imperfectly developed or performed function of the sexual organs, we must necessarily infer, that the defective energy of the organic nervous system delays or arrests their de- velopement, and weakens their functions ; the whole frame being thereby deprived of the stimu- lus they impart to it. Consequently, if the causes continue to operate, or if this system experience no salutary or natural excitement, all the organic functions languish more and more ; the chyle is imperfectly prepared ; and sanguifaction and as- similation are inadequately performed ; all the phenomena of an advanced state of the disease being the result. 13. VI. Treatment. — A. In its first stage, this affection is generally soon removed, 1st, by a due attention to the causes, — particularly the mental or moral causes, — and by removing or counteracting them as far as possible; 2d, by eva- cuating all morbid and accumulated sordes from the alimentary mucous surfaces, and regulating the alvine secretions and excretions; and, 3d, by imparting vigour to the digestive and organic functions, and exciting at the same time the tor- pid or imperfect actions and secretions of the ute- rus. It will generally be necessary to ascertain the causes of the affection, or to direct the atten- tion of the friends of the patient to their nature, tendencies, and the best means of counteracting them. The medical treatment may be commenc- ed with a moderate dose of calomel or blue pill, and a few grains of powdered ginger, given at bed-time ; and the following morning the secre- tions should be more fully promoted and evacua- ted by a dose of castor oil, or of the compound decoction of aloes. After the bowels have been freely evacuated, the following pills, or Form. No. 877. should be taken daily, either during or after dinner : — No. 115. R Aloes Socot., Ferri Sulphatis, aa gr. ij., Gum. Maslich. gr. j.; Pulv. Capsici gr. ij.; Syrup. Simp. vel Olei Caryopn. q. s. M. Fiant Pilulae duae. During the use of these, it will generally be re- quisite to promote the functions of the liver, and excite the bowels, by the occasional repetition of the calomel and ginger at bed-time, and the pur- gative draught the following morning. In some cases, the operation of the medicine may be very advantageously promoted by an enema. In many instances, nothing beyond what is now recom- mended will be necessary ; but, in addition, a course of chalybeate mineral waters may be di- rected ; and, under every circumstance, exercise in the open air, particularly on horseback, change of air to the sea coast, a light nutritious diet, and warm clothing, especially of the lower extremi- ties, should be recommended. Flannel drawers will be found of service in winter. 14. B. In its second stage, or in the more ob- stinate cases, or when the affection is attended with difficult or scanfy menstruation, the tinct. ferri ammoniati, or the tinctura guaiaci ammo- niati, and the phosphate of iron, are preferable to the sulphate of iron, — the compound aloetic de- 318 CHOLERA — History and Symptoms. coction being the most suitable aperient. When pains of the head, or of the left side, or other symptoms of hysteria, or palpitations, are com- plained of, these medicines will be advantageous- ly associated with camphor and hyoscyamus. When the torpor ofthe uterine system is evident, conium will, however, be preferable in such cases to hyoscyamus, and may be given either with these medicines, or with any of the ammoniated spirits. In a few obstinate cases of the disease, I have prescribed, with marked advantage, small doses of the extract of nux vomica, and the strychnine, as in Formulae 542. 565. and 907. 15. If the disease still persist, if the ankles swell, or if dropsical symptoms come on, and the menstrual evacuations continue suppressed, ad- vantage will sometimes accrue from rubbing the loins assiduously every night with either of the liniments, Form. No. 296. and 311., and acting gently on the bowels by means of the following pills : — No. 116. R Pilul. Aloes cum Mvrrha gj.; Saponis Castil. !$ss.; Olei Crotonis Tiglii Tt| iij. Contunde bene simul, et divide in Pilulas xxiv., quarum onini nocte capiat unain, binas, vel tres. 16. In the course of practice, I have seen three cases of the disease complicated with swelling of the parotid and submaxillary glands. In order to remove these tumours, I prescribed iodine in- ternally, in small and frequent doses, giving also at bed-time the aloes and myrrh pill. In these instances, the menses gradually came on, and all disorder vanished. I have on other occasions observed a very marked emmenagogue, as well as tonic effect, produced by the preparations of iodine; and from these effects, as well as from their efficacy in the above cases, I consider them calculated to prove of use in certain states of ob- stinate chlorosis. On some occasions, particular- ly when chronic eruptions appear in the course of the disease, sulphur will be found the best aperient, and the following pills will be produc- tive of benefit; but, in addition to those already particularised, several recipes will be found in the Appendix suited to the different forms and com- plications of this affection, as well as of other de- rangements of the uterine functions. No. 117. R Sodas Sub-boracis 9ij.; Sulphur. Praecip. 3J. •■ Mucilag. Acaciae q. s. Fiant Pilulae xxiv., quarum capiat tres ter quotidie. (See also F. 519.) No. 118. R Sub-boracis £) ij.; Pulv. Capsici Annui 9 j.; Pilul. Aloes cum Myrrha j j. -, Olei Sabinae q. s. M. Fiant Pilulae xxx., quarum capiat binas ter die. No. 119. R Ferri Sub-carbon. 5 j.; Sulphur Depur. 5 j.; Myrrhae Allies Soc, Fellis Taur. Insp., aa Jss. Con- tunde bene simul, et divide in Pil. gr. iv., quarum sumat binas vel tres bis terve in die. (Recommendedby ItlCHTEK.) 17. Electricity and galvanism have been ad- vised by Renaud and. Sigaud la Fond for this disease; and the ammoniated copper, by Bi- anchi. The preparations of iron have very pro- perly been directed, in conjunction with the alka- lies and myrrh, by Willan, with stimulants and bitters, by Sch.effer, with assafrjetida, by Hirschel, and with cinchona and rhubarb, by Ranoe. Marriage has been suggested as a rem- edy for chlorosis, by Wedel, Le Blanc, Korte, and several others. Cold bathing has been recommended by Brandis, and condemn- ed by Darwin; and purgatives have been chief- ly depended upon by Hamilton. The use of mineral waters is certainly of much service in chlorotic cases. Those of Driburg, Pyrmont, Spa, Carlsbad, &c. on the Continent, have been much praised by Bran dis, Marcard, and Kressig ; and the chalybeate springs in this country, by most practitioners. But equal advan- tage will sometimes accrue, in the inveterate forms of the disease, from the sulphureous and saline waters, in addition to a judicious course of medi- cine; and from the Bath and Buxton warm springs, used in the form of baths. Thewarm hip-bath, some salt and a little mustard having been added to the water, isalso beneficial. (SeeMENSTRUATioN.) Bibliog. and Refer. — Hippocrates, De Morb. Mnl. sect. v. p. 125.—Ballonius, De Morb. Mul. Opera, vol. iv. pp. 66. 129.—Le Blanc, Ergo Venus Amantium Ictero. Paris, 1616. — Hoffmann, De Genuina Chlorosis Indole, v. Opera, Supp. ii. part ii. p. 389. — Wedel, De Chlorosi sen Fcedis Virgininm Colorirras. Jenae, 1681.; et De Venere Medica et Morbosa, p. 23.— Korte, De Pallore Virginum, Venerem indicante. Hal. 1759. — Ranoe, in Acta Reg. Soc Med. Haun. vol. iv. p. 114.—Richter, Die Specielle Ther- apie, kc b. iii. p. 752.—Darwin. Zoonomia, vol. iii. p. 157. 8vo. ed. — Brandts, Ueber die Wirkung der Eisenmitte] und, &c. p. 113.—Schaffer, in Hufeland's Journ. der Pract. Arzneyk. b. vi. p. 267. — Bianchi, in Brera, Com. ment. Med. dec. i. t. ii. n. 2. — Cullen, Works by Thomson, vol. ii. pp. 293.384. — Hamilton, Observ. on Purgative Med. &c ch. iv.— Gagnion, Sur la Puberte de la Femme, et surle Chlorosis. Paris, 1809. — Frank, Efemeridi Fisico- Medici, 1805. —Horn, Archiv fur Pract. Med. b. v. st. 1. p. 90.—Desormeaux, Diction, de Med. t. v. p. 166.— Roche, Diet, de Med. et. Chir. Prat. t. v. p. 230. CHOLERA. Syn. Cholera Morbus, Passio Cho- lenca, Diarrhoea Cholerica, Auct. Lat. Cho- leree, Cholerragie, Trousse-galant, Fr. Die Gallenruhr, Brechruhr, Ger. Diarrhoea Cho- lera, Young. Classif. 2. Class, Nervous Diseases ; 3. Order, Spasmodic Affections (Cullen). 1. Class, Diseases of the Digestive Func- tions; 1. Order, Affecting the Alimentary Canal (Good). II. Class, III. Order (Author, in Preface). 1. Defin. Griping pains, followed by vomit- ing and purging, very rarehj with flatulent eruc- tations and dejections, and always with spasms of the extremities, particularly the inferior, and anxiety. 2. I. History and Symptoms.—The term Cholera has been in use since the time of Hip- pocrates, who admitted two species ofthe dis- ease, — one humid, the other dry,— /oXiqa vypfj, YoXtQct k,rjqu. According to Celsus, it is derived from ^ox»;, and qiw, signifying literally bile-flux. Trallian, however, derives it from zot.'ac and Qio>, intestinal flux. Galen, adopting the dis- tinction established by Hippocrates, attributed the humid cholera to the presence of acrid hu- mours generated by the corruption of the food ; and the dry cholera, to an acrid flatus. With very slight modifications, this doctrine was re- ceived by Fernel, Baillou, Sydenham, F. Hoffmann, Bianchi, Sauvages, and Vo- ce l, the difference chiefly consisting in the part they ascribed to the bile, and to the state of this secretion, in the production ofthe disease. Cul- lfn directed attention, more accurately than his predecessors, to its nervous and spasmodic char- acters. Pinel was, however, the first who made any considerable innovation on the opinion of the Ancients as to its nature. He classed it as a species ofthe genus of fevers, to which he applied the term of Meningo-gastric. M. Geoffroy (Diet, des Scien. Mid. t. v.) subsequently attributed to it an inflammatory character; and MM. Broussais and Gravisr afterwards contended that it consists CHOLERA—History and Symptoms. 319 of inflammation of the mucous surface of the di- gestive tube commencing with nervous symptoms. 3. This diversity of opinions will be fully ac- counted for in the sequel ; but I may at present remark, that they may be in many respects re- conciled, inasmuch as the particular form of dis- order, for which each exclusively contends, fre- quently exists as a part of the iiiorbid condition constituting the disease. After having paid con- siderable attention to the literature of cholera, and had much experience of all its forms—of two of them in my own person—I consider that it ad- mits of division into the following distinct va- rieties :—1st, The Cholera Biliosa, or bilious \ cholera ; 2d, Cholera Flatulenta, flatulent chol- j era; 3d, Cholera Spasmodica, the spasmodic cholera, or Mort de Chien. As I believe the disease which has appeared in recent times, and has received numerous appellations, among which that of epidemic cholera has been most common- ly used, to be a different malady from the other forms of cholera, I have treated of it in a distinct article. (See Pestilence.) i. Cholera Biliosa, Bilious Cholera; XoiiQa vygij, Gr. ; Cholera Humida, Lat. ; Cholerragie, Fr.; Die Gallenruhr, Ger. 4. Defin. Copious and frequent vomiting and purging, at first of the alimentary and facal matters, with a redundancy of bile, and spasms of the legs and thighs. 5. Causes, States, 8fc.—This is the most com- mon variety, and presents itself sporadically, en- demically, and in an epidemic form. When it appears sporadically, it is often slight, and of short duration ; but is also sometimes extremely severe, according to the state of the patient, and nature of the exciting causes. In this form, it is not infrequently met with during summer and autumn, and but very rarely in spring. It gener- ally attacks persons whose bowels and secreting viscera have either been, for some time previous- ly, in an inactive state, or become loaded by an accumulation of retained, and thereby altered se- cretions, particularly bile ; and arises from ex- posure to the sun's rays, or to a high degree of temperature, and afterwards to cold, or cold com- bined with moisture, particularly when applied to the extremities ; from sudden atmospheric vicissi- tudes, particularly cold easterly or northerly winds after hot weather; from cold niiasmal night air, and dews, after a warm sun ; cold drinks when the body is overheated, and the incautious use of ices; from cold, indigestible, or unripe fruits, particu- larly melons, cucumbers, pine-apples, and poison- ous or irritating ingesta of any kind ; the excessive use of spirituous or malt liquors, and ingurgita- tion ; from large doses of cathartic or emetic drugs (Henry, Diss, de Choi. Morbo. Hal. 1740.); fright, particularly from thunder (Phil. Trans. 1667.) ; and from whatever occasions a sudden depression of the vital energies of the frame, and irruption of accumulated bile into the duodenum. 6. The intimate relation existing between this species of cholera, and the colica cibaria or sur- feit, in respect of their causes, and several of their symptoms, did not escape the notice of Syden- ham. Dr. Good has also remarked the similarity. But the distinctions are nevertheless sufficiently marked, and more numerous than those writers bave assigned. The spasms of the extremities in the latter; the retraction of the testes, the copious vomitings and alvine evacuations, with redun- dancy of bile, particularly after the vomiting and purging have continued for some time, and the more acute character of the disease, are sufficient to mark the wide difference between them. 7. In the endemic form, cholera is seldom pre- sented to the observation of practitioners in north- ern countries. To certain districts in some soutli- erly climates, particularly between the tropics, bilious cholera may be said, from the frequency of its occurrence, to be strictly endemic, although in a less marked degree than certain forms of fever, or dysentery, or even hepatitis. Accord- ing to my own observation, and that of several friends whose range of experience has been great, bilious cholera is very prevalent in situations which are subject to emanations from decayed vegetable matter, or putrid matter of any description ; par- ticularly from swamps, moist grounds, the banks of rivers, lakes, or canals, &c, and from foul drains or cesspools, during warm seasons, or wide and rapid changes of temperature ; or when the thermometer rises high during the day, and sinks low towards the night and morning. 8. Bilious cholera assumes the epidemic form, sometimes in warm climates, and not infrequent- ly also in temperate countries. In the latter, this form of the disease manifests itself only in the months of July, August, and September,—the number of cases increasing from June to Septem- ber, when they are usually most numerous, and diminishing rapidly in October. The epidemic bilious cholera is generally most remarkable dur- ing very warm summers and autumns, occurring after a very rainy winter and spring, or after a succession of wet seasons ; and when the days have been warm, bright, and sunny, and the nights comparatively cold or chilly, with heavy dews. Owing to this state of season, the atmos- phere is humid, and loaded with the miasms of decayed vegetable and animal matter ; and, ow- ing to this cause, together with the high range of temperature, the bile is secreted in greater abun- dance than usual, and is more liable to become acrid or otherwise altered (see Liver—Dis- ordered Function of the); and the cool nights, particularly if the air be much loaded with ex- halations set free from the soil by the rays of a scorching sun, tend to check the cutaneous ex- halations, and determine the chief current of cir- culation and secretion to the abdominal viscera. The use of fruit, which is usually abundant at these seasons, also augments the frequency ofthe disease, by promoting the operation of the other causes. It increases the acidity of the prima via, as contended for by Bertrand and Linn;eus, renders the contents of the bowels, and the se- cretions poured into them, of a more irritating quality to the nerves of the stomach and intestinal canal, and thereby often promotes the irruption of acrid bile, which had been long pent up in the gall-bladder and hepatic ducts, and which is a great cause of irritation when it is suddenly pour- ed into the duodenum. 9. During states of temperature and of season which favour the extrication of exhalations from the soil, the epidemic visitations of this variety of cholera are more severe. In many cases, occur- ring at these periods, the disease can scarcely be imputed to the state of the biliary secretion mere- 320 CHOLERA — Duration and Prognosis. ly, but rather to the internal congestions occasion- ed by its exciting causes, giving rise to spasmodic contractions of the alimentary canal, to vomiting and purging, and to spasms of the voluntary muscles, &c; the bile accumulated in the gall- bladder and hepatic ducts being let loose and thrown into the intestines only subsequently to the seizure, and owing to the vomitings and purgings which usher it in. In some cases, in- deed, this irruption of bile is prevented from taking place, until an advanced stage, by spasm of the common duct, extended to it from the duodenum, as more commonly occurs in the third variety of the disorder. When the various causes now referred to combine to produce the disease, particularly in persons of a nervous and irritable temperament, and who have neglected, for a considerable time before, the state of the bowels, and secretions poured into them, it can- not be a matter of surprise, that its symptoms as- sume the severe form described by Sydenham. 10. Symptoms.—Bilious cholera, in whatever state it occurs, differs chiefly in its degree of se- verity. It is chiefly characterised by anxiety, and by painful and violent gripings, evidently proceeding from spasmodic contractions of the alimentary canal, taking the duodenum for their point of departure, and occasioning the continued or frequently repeated rejection of their contents by vomiting and purging. Owing to the ana- tomical connection of the great sympathetic or ganglial system with the voluntary nerves and other parts of the frame, the spasms extend to the abdominal muscles, and muscles of the lower extremities,—the testes being forcibly retracted to the abdominal ring,—and are accompanied with great pain. The tongue is dry or clammy ; thirst is very urgent, and the urine scanty and high coloured. The pulse is at first full and fre- quent ; but, as the disease continues, it becomes smaller, weaker, and more rapid. At more ad- vanced periods, the spasms sometimes extend to the arms and hands. The symptoms often con- tinue with little variation for some hours ; but, when the attack is severe, seldom without the pa- tient's strength being greatly reduced ; the coun- tenance at last becoming anxious and collapsed ; the breathing frequent, interrupted, and laborious, and sometimes with singultus ; the pulse feeble, irregular, and intermittent; and the extremities cold or clammy, with leipothymia or fainting. 11. Duration and Prognosis.—The cholera of temperate climates is seldom fatal, unless when it is more than usually prevalent, after very rainy and hot seasons. But, when neglected or im- properly treated, especially at such times, a fatal issue may occur, but very rarely in less time than twenty-four hours. In milder cases, it may extend to two or three days, and then terminate either favourably or unfavourably, most com- monly the former ; the vomiting, purging, and spasms subsiding, and entirely ceasing, the pulse becoming slower and fuller, and the countenance resuming its former expression. An unfavourable issue is indicated by a continuance of the purging and vomiting, particularly after substances°are ' taken into the stomach, a hurried, gasping re- j spiration ; great frequency, feebleness, irregular- ity, and intermissions of the pulse ; collapse and fialeness of the countenance ; coldness and pulse- ' essness ofthe extremities, with anxiety, and fre- I quent faintings, &c. Tn general, however, even when left to itself, the disease operates its own cure in the course of some hours ; or it continues for one, two, or in milder cases for even three days, and ceases by degrees ; the morbid secre- tions which excited the attack having been evacu- ated, and the irritation they occasioned having subsided. Although nature may accomplish this without aid, yet the assistance of art is generally required to ensure its attainment. The febrile symptoms attending the early stage of the dis- ease, unless in some instances of its epidemic prevalence, are merely the consequence of the pain, spasms, vomitings, and general commotion of the nervous system, and usually subside im- mediately these disorders are allayed. ii. Cholera Fi.atulenta, Flatulent Chol- era; /oP.ioa itiqa, Gr.; Ch. Sicca, Lat. 12. Defin. Vomiting and purging rare, some- times retchings; gripings and spasms of the ab- dominal muscles, with great and oppressive flatu- lence, temporarily relieved by eructations, and dejections of flatus. 13. This variety was formed by Hippocrates, continued by Sydenham, and, after having been discontinued by the majority of modern writers, who, if they at all remarked it, considered it rather as a form of colic than of cholera, was again distinguished as a species of this latter dis- ease by Dr. Good. It is very rarely met with in practice ; and generally holds an intermediate rank between flatulent colic and cholera, some- times approaching more nearly to the former. In none of the very few cases of this description which have come before me (not exceeding two or three), have I observed a natural secretion of bile ; but, on the contrary, the liver has evinced signs of great torpor, and the whole digestive organs have been manifestly enfeebled, long pro- tracted dyspepsia and hypochondriasis having ex- isted previous to the attack. 14. This form of the disease is chiefly charac- terised by spasms of the alimentary canal, ap- parently excited by acrid, rancid, and indigestible substances ; and by an irritating gas, either se- creted from the digestive mucous surface, or gen- erated from the decomposition of the imperfectly digested food. (See articles Colic and Flatu- lency.) The painful and flatulent griping is ac- companied with severe spasm of the abdominal muscles, anxiety, occasional retchings, flatulent irritations, and calls to stool, with slight tenesmus, and very scanty, offensive, pale coloured, and watery evacuations, with flatus. Considerable depression of the powers of life, acceleration of pulse, pale, anxious countenance, coldness of the extremities, and sometimes alarming sinking, su- pervene, when the disease has been neglected. 15. Causes.—This rare form of cholera chiefly appears in the debilitated, and those of a melan- cholic temperament ; and is generally excited by a surfeit, by cold drinks when the body is over- heated, by the use of cold or unripe fruits, par- ticularly melons, water-mekihs, cucumbers, un- ripe plums, mushrooms, and animal poisons, es- pecially the rank parts of bacon, or tongues, sau- sages, &c. when kept too long, or insufficiently cured ; also by unhealthy or stale fish, and by cold or moisture after having been exposed for some time previously to a high range of tempera- ture. The author was very recently the subject CHOLERA—Spasmodic 321 of an attack as described above, from having par- taken of tongue kept too long after having been imperfectly cured. In this case the affection was much more nearly allied to cholera than to colic ; and this he is the better enabled to state, from the circumstance of having been the subject of the other varieties of the former disease at different periods of his life. iii. Cholera Spasmodica, Spasmodic Cho- lera ; Mort de Chien, Fr. 16. Defin. Vomiting and purging of watery matters, without any appearance of bile ; spasms violent, and extending generally through the frame ; speedily followed by sinking of the pow- ers of life. 17. This variety of cholera may be said to be endemic in some intertropical countries, particu- larly in the eastern hemisphere, where it has oc- casionally assumed also an epidemic form, nearlv approaching the remarkably fatal pestilential cho- lera, which appeared in Bengal in 1817, and which has subsequently spread over all Asia, Eu- rope, and part of Africa. (See Pestilence.) It has been very imperfectly noticed by Bontius, Curtis, Paisley, Sonnerat, and Girdle- stone ; but its nature and treatment were very im- perfectly known, until Dr. Johnson described its symptoms, and pointed out a more successful method of cure than had previously been employ- ed. Several ofthe cases of cholera, which Syden- ham has described as epidemic in 1669, seem to have been ofthe variety now under consideration. 18. Causes, symptoms, fyc.—This form of cholera proceeds from exposure to cold, or to a cold, raw, and moist atmosphere, or to the night air loaded w ith terrestrial emanations after the prevalence of warm weather, or exposure to a hot sun; or, in a word, it generally results from a more intense grade of the same causes, particu- larly the exhalations from the soil, that produce the bilious cholera. It commonly commences with chilliness, sometimes amounting to a rigor or shiver ; soon followed by gripings, and frequent purging of a watery, slimy, or sero-mucous matter, which is sometimes thrown off with great force. To these succeed nausea and retchings, with the ejection of a watery fluid ; anxiety at the epigas- trium ; spasms of a violent, painful, and tonic character, attacking the muscles of the abdomen, thighs, legs, thorax, and, lastly, the arms and hands; a small, quick, and contracted pulse; great thirst, and immediate rejection of whatever is tak- en into the stomach. As the disease proceeds, the pulse becomes weaker and smaller; the spasms more general ; the purging constant and painful, generally with tenesmus ; the vomitings are re- newed, upon the ingestion of substances into the stomach; and the powers of life rapidly fail. Dur- ing this time, the fluids evacuated from the stom- ach and bowels present no appearance of bile, al- though occasionally bile is seen in the evacuations to a small extent. In the course of a few hours, the features shrink, the hands and feet become cold and clammy, the exacerbation of the spasms force out a cold clammy sweat on the face and breast; the pulse is extremely small and weak, or nearly disappears; — in a case which came before me in Africa, in 1816, the pulse could scarcely be felt four hours from the attack; — the spasms as- sume more of the clonic character; and the con- tents of the stomach are now, in the more dan- gerous cases, sometimes thrown off, without any effort or retching. Commonly, during all this time, fiscal matters, and the biliary secretions are retained, apparently owing to the extension ofthe spasm from the duodenum to the commqn biliary duct, and to spastic constrictions of parts of the colon ; the epigastrium and hypochondria being sore, tense, and tumid. When the disease is treated with decision, the vomitings cease ; free evacuations, with a discharge of bile, take place; and the patient soon recovers. But if neglected, or improperly managed, the powers of life fail very rapidly; the eyes sink, and are surrounded with a livid circle; the countenance assumes a re- markably anxious cast, or is pale, wan, and shrunk; and the spasms extend to the very fingers. The breathing now becomes extremely laborious; the patient is restless; and at last is carried off, some- times in the space of ten or twelve hours. 19. Such is the progress of spasmodic cholera, as it was observed by the writer in the years 1816> and 1817, in an intertropical climate, and as he; then experienced it in his own person. About the same time other cases of a milder form oc- curred, and presented the characters-described as constituting the bilious variety of the disease., with which the writer had also been formerly attacked in this country, in the end of September, 1815, — a season of unusual warmth, — when* he was attended by his friend Mr. Queade- There can be no doubt that the first and third varieties of cholera chiefly differ in degree, and iir. the circumstance of the latter arising, in most cases, from the operation of causes of a more in- tense grade than those which induce the former. But as additional phenomena are developed in the latter variety, and other symptoms assume a* different or modified character, and especially as a distinct method of cure is requisite to its remov- al, the propriety of distinguishing it as a separate form of the disease is manifest. 20. II. Diagnosis.—This disease can be mis- taken only for the pestilential cholera, or for poi- soning by acrid substances. The diagnosis be- tween this and the pestilential malady is fully pointed out in that article. It is often difficult to distinguish between the different varieties of true cholera (the pestilential disease which has been very generally viewed as a form of cholera being, in my opinion, very different in all its relation* from this), and the disorder occasioned by irritat- ing poisons. Dr. Christison, in his very able work on Poisons (p. 93.), has assigned the more rapid termination of poisoning, in fatal cases, as a ground of distuiction. But he supposes that j death from cholera occurs at a later period than it usually does : and, hence, this source of diag- nosis cannot be much relied upon. Death from irritating poisons usually takes place within thirty- six hours, and sometimes within twelve hours; being seldom delayed beyond sixty hours ; but the fatal issue in cholera is very rare, he consid- ers, in less than three days. I believe, however, that, although death from the common cholera of this climate is rare, it more frequently occurs from twenty-four hours to eight and forty, than at a later period. Greater dependence is to be placed upon the appearance of the matters vom- ited, which are more frequently sanguinolent after irritating poisons than in cholera. But the chief diagnostic sign is the sense of heat, acridity, 322 CHOLERA — Causes — Treatment. or burning in the throat, descending in the course of the oesophagus to the stomach, which is so much complained of in poisoning, and precedes the vomiting. In cholera, when a similar sens- ation is felt, it is usually confined to the region of the stomach, and is consequent upon the vomit- ing. 21. The diagnosis between cholera and other diseases which resemble it the nearest is easy. It is distinguished from colic, by the frequency of the vomiting and purging, the spasms ofthe mus- cles of the extremities, and the greater accelera- tion of pulse ; — from diarrhoea, by the vomiting and the spasms; and by the quickness ofthe pulse in the latter stage of cholera; — from dysentery, by the tenesmus, bloody stools, absence of the spasms of the extremities, and of the vomiting ; or the occasional presence merely of this last symptom in that disease; — from ileus, by the ap- pearance ofthe matters vomited, and the obstruc- tion of the bowels constituting that malady; — and from painters' colic, by the absence, or oc- casional occurrence only, of vomiting ; by the constipation, the paralytic signs, &c. charac- terising that disorder; and by the history of the case. 22. IIL Causes and Pathological States. —Tlie remote causes have been already noticed m connection with the symptoms and forms of the disease they occasion. A. As to the morbid appearances, they may be staled as generally being very slight in rapidly fatal cases, and consisting merely of irritation of the mucous surface of the duodenum, stomach, and small in- testines; but without any change of structure. If death takes place at a more or less remote period, injection of me capillaries, with congestion, some- times with ecchymosis, and enlargement of the mucous follicles, is observed more or less exten- sively—either in streaks or patches—in the inner surface of the digestive tube. In fatal cases of the mird variety of the disease, the liver has been found congested, the gall bladder and he- patic ducts filled with dark coloured inspissated bile, and the common ducts sometimes constrict- ed or obstructed. 23. B. The pathological state constituting the disease, seems to consist of irritation of the mu- cous surface of the digestive tube, commencing in the duodenum, and extending in each direction —to the stomach, small intestines, and along the common duct, to the gall-bladder and liver, — with increased action of the muscular coats of these viscera, and determination of the circulating fluid to them. This irritation or morbid excite- ment, owing to the connections of the organic nerves supplying these parts, is propagated to the spinal nerves, by which the muscles of the abdo- men and extremities are affected by painful and violent contractions ; and it is chiefly owing to the exhaustion of the vital manifestations of the organic system of nerves, and to the frequent and profuse discharges, that a fatal issue takes place : the circulating organs, which are actuated by this system, being, in consequence, incapable any longer of performing then functions. 24. A question may arise as to whether the disease commences with the irritation of the mu- cous surface of the duodenum and adjoining por- tions of the digestive tube, or with determination of the circulation to the liver and adjoining vis- cera, and an irruption of bile, which has become more than usually irritating, owing to its reten- tion in the biliary apparatus, or to its formation from redundant or noxious materials accumulated in the circulating fluid (see Blood, § 119. and 120.), during high ranges of temperature, and moist miasmal states of the air. It is not very material which of these phenomena is the first to occur : probably either may precede the other ; and even, in some cases, that both may be near- ly coetaneous. It is, however, most likely that the procession of morbid phenomena described above (§ 22.) obtains in the great majority of cases. 25. C. The different states of cholera may ter- minate differently from either of the ways already noticed (§ 10. 14. 18.): in may pass into inflam- mation of the stomach or of the intestines, or of both; it may also lapse into dysentery, or into a regular attack of gastric, bilious, remittent, or in- termittent fever. The supervention of some of these diseases upon, or their association with, cholera, has been long since noticed by Morton and Torti ; and, more recently, by Jackson, J. P. Frank, and Schmidtmann; and must be familiar to experienced practitioners, particularly in warm, moist, or miasmal climates. In many such instances, this mode of termination is to be imputed to the nature of the exciting causes, the constitution of the patient, and sometimes also to the premature arrest of the evacuation^ by opium, and the neglect, subsequently, of procuring the discharge of morbid secretions by purgatives, &c. 26. IV. Treatment. — Demulcents, diluents, and weak broths or soups, have been very gener- ally given at the commencement of a choleric at- tack, particularly of its fust or common form, since the time they were recommended by Sy- denham. In slight cases, and at its beginning merely, this is as judicious treatment as can be adopted. But in the more severe seizures, and particularly if a delay of two or three hours has taken place in applying for or procuring medical aid, much more decided means should be resort- ed to. In such cases, it is no longer necessary to promote the evacuation of the offending matters, which have generally by this time been expelled. It is preferable, therefore, in these, and, indeed, under most circumstances—1st, To allay the irritable state of the stomach, the spasms, and other urgent symptoms of the disease; 2d, To remove, by appropriate means, as blue pill, dilu- uents, mucilaginous fluids, and deobstruent aperi- ents and enemata, whatever morbid secretions may be retained or re-accumulated; 3d, To pre- vent the occurrence of inflammation of the diges- tive mucous surface, by sheathing the surface of the bowels from the irritating action of the {mor- bid and accumulated secretions during their dis- charge; 4th, To support the powers of life when they appear to sink ; and, 5th, To restore and promote the functions of the various emuncto- ries. 27. A. Opium, generally in the form of pill, is the medicine most to be depended on for the ac- complishment of the first intention, especially in mild cases ofthe first variety. From one to three grains of it may be taken at once; but, in more severe attacks, and in the second and third varie- ties, it is preferable at first to combine it with from ten to twenty grains of calomel, which, in CHOLERA—Treatment. 323 a large dose, is one of the most quickly effica- cious means we possess of diminishing vascular irritation of the internal surface of the stomach and small intestines. When a large dose of these remedies has been given, a repetition may not evpn be required ; but, in the severe states of the disease, it will be necessary to repeat it once or even twice, after an interval of from three to six hours, or even longer, according to the urgency of the case. If the attack require the exhibition of two or three such doses of calomel, little ap- prehension of its affecting the mouth should be entertained, as such a state of disease admits not ofthe retention of the whole of it ; and, when it is necessary thus to repeat it, the biliary organs will derive benefit from it. If the first doses of opium and calomel be not retained, they should be immediately repeated. In plethoric or robust subjects, when the pulse is fully developed, and the spasms severe, especially in the third variety of the disorder, a full or moderate bleeding may be directed ; but it should be performed early, and restricted to young or robust subjects. This practice was employed by Dr. J. Johnson in India ; and subsequently adopted by numerous other practitioners, as well as by myself. I should, however, state, that I have prescribed it only for Europeans who had recently arrived in a warm climate ; but natives, or acclimated Europeans, require a different treatment (§ 30, 31, and 32.). In slighter cases opium, if not too early exhibited, will be sulficient to cure the disease ; and the in- stances must be few, in which its use, in some form or other, can be dispensed with. Its supe- riority to other medicines in cholera has been ad- mitted by Linnaeus (Morbi Naut. India. Vps. 1768.), Thomann (Annalen ad 1800.), Young (On Opium, 8fc. p. 36,), Quarin (Animadver- siones Pract. pp. 204—207.), and by most recent writers. Rf.ide ( View of Dis. of the Army, p. 63.) advises it to be given in copious draughts of tepid diluents ; Percival (Essays, vol. ii. p. 405.), in enemata ; and Sydenham (Opera, p. 177. ed. Lug. Bat.), after diluents and demul- cents had been freely given, and the offending matters removed. When, however, vomiting and purging have existed some time, more par- ticularly in severe cases, opium ought to be im- mediately exhibited ; but in order to secure the effect of it, or of calomel combined with it, the patient should now refrain from diluents, in order that the rejection of the medicines may not be risked by them ; and should merely rinse his mouth frequently with some cooling beverage, swallowing only minute portions of it, at short in- tervals. Sydenham has very justly remarked, —and the importance of the observation has been acknowledged by Frank and Schmidtmann, —that when opium is given too early, much dis- order ofthe bowels and abdominal organs, with more or less fever, continues afterwards to be complained of; evidently owing to the arrest of a salutary effort, and the retention of morbid secre- tions. But the second intention of cure (§26.), and the combination of calomel with the opium, have for their objects to prevent this result in cases where all the morbid secretions may not have been expelled before the opium has been administered. 28. It is not unusual to find, upon being called to a case of the disease, that aperients hud been freely exhibited with the view of promoting the evacuation ofthe offending secretions. But this is a hazardous practice, and is often,as Sydenham has remarked respecting it adding fuel to the fire: its propriety at a later period, when the vomiting and spasms have disappeared, will be admitted. 29. If the spasms, pain at the epigastrium, and internal heat, be severe, very warm fomentations, or the hot bath at about 100J or 102°, are of much service if used early in the attack. But neither these, nor blisters, nor sinapisms, are so instantly and perfectly remedial as the turpentine fomentation applied over the abdomen. (See Art. Cjecum, §32.). Several authors have recom- mended the use of cold or iced fluids, with a view of allaying the heat complained of in the stomach. They deserve notice chiefly from being recom- mended by Aret^us (Curat. Acut. Morb. 1. ii. ch. iv.), Cslius Aurelianus (p. 258.), Lien- ard (Ergo Cholera Morbo Frigidus Potus. Paris, 1626.), Hoffman (De Cholera, obs. v. Opp. iii. p. 173.), Cleg horn (Diseases of Minorca, p. 222.), Pf.nada (Osservazioni, 8fc, Weigel Ital. Bibl. b. iv. st. 1. p. 134.), and Pan- zani (Beschr. der Krank. von Istrien, fyc). Bartholinus (De Usu Nivis Med. p. 141.) ad- vises the application of ice over the epigastrium ; and Birnstiel, cold vinegar to the same region. The nitric acid drink has been much employed in India in cases of cholera. A favourable account of it in this disease was published by Sir J. Mac- grigor, in Duncan's Annals for 1802. And Mr. Hope has recently recommended it conjoined with opium, in the cholera of temperate climates. 30. When the severity or duration ofthe more urgent symptoms has occasioned feebleness of pulse, with cold skin, and other symptoms of ex- haustion, restorative means are requisite. Am- monia, camphor, the aethers, brandy, Cayenne pepper, the various aromatics and spices, are now the most serviceable medicines, and should be given frequently, and in moderate doses, variously combined, and generally with small quantities of opium. Although at an earlier stage it was necessary to prescribe opium in a large dose, yet at this period very small quan- tities only ought to be given, particularly if ex- lubited frequently. Any of the following will be now of advantage :— No. 120. R Aq. Anethi % j.; Majnes. Carbon. 9 j.; Spirit. Ammon. Arom. TT) xxvj.; Pulv. Capsici gr. iij.; Tinct. Opii Comp. (F. 729.) TT) x.; Confeet. Arom. gr. vij. M. Fiat Haustus, secundis horis capiendus. No. 121. R Aa. Menth. Virid. 5 x.; Ammon. Carbon. cr. v.; Magnes. Calcinat. ^ ss.; Tinct. Capsici An. TT) xij.; Spirit. Pimentae 2Jj.: Tinct. Opii. Comp. TT) xij.; Olei Cin- nam. TT) j. M. Fiat Haustus. No. 122. R Infus. Caryoph. 3 x.; Magn. Calcin. 9 j.; Tinct. Cardamom. Comp. % j.; Tincl. Opii Camphor. (F. 728.) 3j.; Syrup. Zingiberis 3 j. M. Fiat Haustus. 31. In this stage ofthe disease, the application of sinapisms or blisters to the epigastrium, as directed by Celsus (1. iv. ch. xi.), Morelli (Nuovo Giornale di Milano, 1792.), and Aas- kow (Acta Reg. Soc. Med. Haun. i. p. 154.) ; of stimulating and irritating frictions of the sur- face, as advised by AretjEus (Cur. Acut. Morb. I. ii. ch. iv.), CiEL-ius Aurelianus (p. 257.), and Alexander Tralles (I. v. ch. vi.), and of warm analeptic and aromatic epithems and embrocations, as prescribed by Morton and Quarin (Animad. Pract. p. 206.), may be re- sorted to. In the third variety of cholera,— which differs from the first chiefly as to severity 324 CHOLERA — Treatment. and the more prolonged obstruction to the flow of bile in its early stages, or throughout its course in fatal cases ;—in addition to the means already stated (§30.), the external measures now men- tioned may be employed ; but they are much less efficacious than the embrocation noticed above (§ 29.). One of our principal objects in this state of the disease is to procure a discharge of bile into the intestines. Large doses of calomel, with opium and camphor, are the internal remedies most to be depended upon for the attaining of this end. But, if the energies of the frame begin to sink before it be obtained, it will be necessary to have recourse to diffusive stimulants in order to counteract the depression: at this period the calo- mel either may be left off, if a sufficient quantity has been taken, or may be combined with full doses of ammonia or camphor ; the stimulants already prescribed (§ 30.), or warm brandy and water, being also given at short intervals, or in larger quantities. The second variety requires the measures now stated, with the addition of purgative and emollient enemata. If the flatulence be urgent, F. 135. 150. will be productive of im- mediate relief. 32. The natives of warm climates, or Euro- peans acclimated in them, require from the be- ginning, that the calomel should be combined as now advised ; and that aromatics, antispasmodics, and anodynes, be given early in the disease. The large quantities of hot spices usually employed by these classes of persons, as well as the nature of the attack resulting from the constitution, natural and acquired, of those affected, render it necessary to prescibe aromatics and hot spices, especially Cayenne pepper, in large proportions, in con- junction with opium, camphor, &c. and to have recourse to the external means already noticed, almost from the commencement of the attack. Afterwards when urgent disorder has subsided, calomel, or blue pill, with aromatics, followed by warm stomachic aperients, and by purgative and antispasmodic enemata, will be required. 33. B. Having relieved the more urgent symp- toms, whether of violent irritation or of conse- quent exhaustion, and having allowed some time to elapse in order that the viscera may recover their functions, it will be necessary to promote the discharge of the secretions which may have accumulated during the calm which had been procured, particularly .when the inordinate action is followed by complete torpor of the bowels. In cases where calomel had been freely exhibited, mild stomachic aperients will be all that is neces- sary ; but they should be given with caution, and at a time when there appears no risk of re-ex- citing the choleric attack, which may be readily done by the too early exhibition of purgatives. It will therefore, at first, be better to trust chiefly to enemata ; to prescribe the mildest aperients only, and when they are absolutely required ; and to administer chiefly mucilaginous fluids, &c. If calomel have not been previously given, a moderate dose, either of it or blue pill, at bed- time, will be even now necessary ; and the latter may be repeated every third night, an aperient draught, or a dose of castor oil, being taken on the mornings following, for some time sub- sequently, until the alvine functions assume a healthy state. But if the stomach still remain irritable, it will be preferable to prescribe merely a blue pill, or the hydr. cum creta, at bed-time, and employ enemata. 34. C. If, during the progress of disease, or when the urgent symptoms have somewhat sub- sided, the pulse continues frequent, sharp, or constricted, with tenderness at the epigastrium, a furred tongue, great thirst, nausea, and retch- ings upon substances being swallowed, and gen- eral uneasiness, we should conclude that inflam- mation of the stomach and upper part of the intestinal tube has come on. In this case, from I twelve to twenty-four leeches should be placed upon the epigastrium, and afterwards a succes- I sion of warm poultices, the last of which should I be followed by the terebinthinate fomentation already noticed. In some cases, it will be ne- cessary, from the severity of this consecutive dis- ease, and the patient's habit of body, to bleed from the arm, previously to applying leeches. In cases where the fomentation is not employed, sinapisms or blisters may be directed, but not until depletion has been carried as far as may be considered either necessary or judicious; and small doses either of hydrarg. cum creta, with magnesia or sub-carbon, of soda, may be given every four or five hours ; or of nitrate of potash, and almond emulsion, or any other demulcent substance, with the frequent use of enemata. The termination of cholera in gastric, bilious, remittent and inter- mittent fever, or in dysentery, and the circum- stances to which I have imputed this occurrence (§ 18.25.) ought not to be overlooked, but should influence our practice both at the commencement and during the course of the attack. When it has passed into these diseases, it must necessarily be treated according to the new form it has as- sumed. 35. An attack of cholera soon occasions great exhaustion ; and sometimes so great sinking, that even fatal syncope has occurred from allowing the patient to remain too long on the night-chair, or suddenly to assume the erect posture. In severe cases, the patient must be kept in a hori- zontal position ; and besides the medical treat- ment already prescribed in this state of the dis- ease, mild demulcent soups, beef tea, chicken broth, jellies, and sago or arrow-root, with wine, may be given him. In cases of this description, the exhibition of aperients by the mouth must not be ventured on during convalescence, at least not for several days ; and even then with circum- spection, and in conjunction with stimulants or tonics. We must endeavour to regulate the se- cretions by gentle alteratives, and to procure their discharge by enemata. During convales- cence from cholera, strict attention should be paid to the state of the digestive functions. The patient ought to abstain from all irritating and in- digestible kinds of food, and heating liquors, and from overloading the stomach. Change of air, gentle travelling, and moderate exercise, are ex- tremely conducive to perfect recovery. Bibliog. and Refer.—Hippocrates, Epid. t. 1144. 1159.—Pietre, Ergo Cholera; Morbo convenit Vena-sectio. Paris, 1624.—Bontius, Med. Indor. cap. 6.—Ballonius, Op- era, vol. i. n. 55. 57. vol. iii. n. 65.—Reidlin, Lin. Med. p. 273. 1695.—Morton, Pyretologia, sive de Morb. Acut. kc. pp. 35—40. 133. 4to. 1696. Genev. edit. — Bianchi, Hist. Hepatica, p. 117.—Hoffmann, De Cholera, Opp. vol. iii. p. 174.—Torti, Therap. Special, ad Febres Period. Perni- ciosas, kc 1. iv. c. 1. p. 250. 4lo. Franc. 1756.—Heberden- Trans, of Coll. of Phys. Lond. vol. ii. p. 153.__Porter Ed. Med. Essays, vol. iii. p. 357.—Stoll, Rat. Med. part iii! CHOLERIC FEVER OF INFANTS—Sfmptoms. 325 p. 64. — Lind, On the Dis. of Hot Climates, kc p. 248. — Cullen, Works, ed. by Thomson, 1E27, vol. i. p. 301., and vol. ii. p. 476.— Di'-k, in Medical Comment, vol. x. p. 12. —Jackson, On Febrile Diseases, vol. ii. p. 27. 8vo. Lond. 1820.—./. P. Frank, De Curand. Homin. Morb. lib. v. part ii. p. 436.— Richter, Die Specielle Therapie, b. iv. p. 157. —J. Johnson, Disease* of Intertrop. Climates, p. 270. 4th ed. — Chisholm, On Dis. of Tropical Countries, &c. p. 85. 8vo. Lond. 1822. — Schmidtmann, Summa Observat. Med. vol. iii. p. 405. Ber. 1826.—Hope, in Edin. Med. and Surg. Journ. vol. xxvi. p. 41. Choleric Fever of Infants. Cholera of Children, Cholera Infantum, Rush and Dewees.—Classif. III. Class, I. Order (Author). 1. Defin. Vomiting and purging, with fever generally of a remittent type, irregular spasmodic convulsions, and rapid emaciation, attacking in- fants and children. 2. I. History, &c.—This disease attacks children during the summer and autumnal months, and sometimes as early as April and May. It oc- curs at any period, from the age of two or three weeks to that of several years. After this age, the same causes which produce it occasion, ac- cording to their combinations and the state of pre- disposition of the patient, either fever of some kind, or cholera, or inflammation of the stomach and bowels. 3. A. Causes.—It is often independent of any disorder from dentition, as shown by the age at which it frequently occurs, and the seasons to which it is almost entirely limited. That it is not always caused by acid, acrid, or stale fruit, and indigestible substances, has been proved by ex- amination of the history of numerous cases; al- though, doubtless, this cause, as well as dentition, will contribute to its occurrence. It is certainly not owing to worms, as far as my own observa- tion may be depended upon; besides, it is often met with at an age anterior to that at which worms form in the intestinal canal; and, in fatal cases, worms are not more frequently expelled from the bowels than in many other diseases, as remarked by Dr. Rush. But it is evidently owing to the influence of high ranges of atmospheric tempera- ture acting upon malarious localities, and upon close, low, thickly inhabited, and imperfectly cleansed and ventilated streets, closes, and lanes, assisted by the above causes, particularly by pre- mature weaning, want of the mother's milk, errors in diet and clothing, &c. That it originates chieflv in an atmosphere loaded with putrid or mephitic effluvia is shown by its occurrence among children thus circumstanced; by its fre- quency during the seasons already specified in temperate climates, particularly in localities which possess the materials or sources of such exhala- tions; by the periods of its prevalence among children in warm climates, and in America; and by its appearance at the same time with the cho- lera of adults, and with remittent and intermittent fevers. This origin is further shown by the cir- cumstance of its being generally accompanied with fever, frequently of a remittent type. In some very unhealthy climates within the tropics, the children born of European parents seldom reach two or three years without having an attack; and, in some places, scarcely one will survive this age, if allowed to remain in them,—this disease cutting them off before they reach a year or two, and often when they are only two or three weeks old. According to Dr. Dewees, it is one ofthe most 28 fatal diseases of children in the large towns of the United States; and it is certainly not an infrequent malady of the same class of patients in this me- tropolis. 4. B. Symptoms.—The choleric fever of infants sometimes begins with diarrhoea; but more com- monly with violent vomiting and purging, which are soon followed by fever. The matters vomited are usually yellowish or greenish yellow; and the dejections are slimy, watery, sometimes offensive, with a sour or putrid odour, and tinged with blood. The natural faeces are generally retained, although small lumps are occasionally passed. In some cases, at an advanced stage, they consist nearly altogether of water, or of substances recently taken. The muscles are irregularly and spas- modically convulsed or contracted; the child is much pained, is restless, and throws the head backwards and forwards, the lower limbs being forcibly drawn upwards. Thirst is intense and unquenchable, cold fluids being eagerly desired. The pulse is small, quick, and feeble. Determi- nation to the brain is soon sympathetically ex- cited, as evinced by increased temperature of the head, and a tendency to stupor. The extremities are commonly colder than usual; and the abdo- men is hot. All the febrile symptoms are exacer- bated in the evening, and occasionally attended by delirium during the night. The eyes are lan- guid and hollow, are half-closed during sleep; the countenance soon becomes contracted and col- lapsed, and the cutaneous surface insensible. In the most acute cases, death may occur in twenty- four hours; but the disease is most frequently of considerable duration, presenting occasional re- missions. Its violence is much lessened by cool dry states of the air, and increased by a close moist atmosphere. In some cases the vomitings soon abate, and it seems to pass into dysentery, or chronic diarrhoea, either with or without tenes- mus, tormina, and occasionally with prolapsus ani. It often runs on several weeks with tempo- rary exacerbations and remissions; occasioning remarkable emaciation, and, lastly, flatulent dis- tension ofthe abdomen, and aphtha? on the tongue, lips, &c. 5. C. The Prognosis will depend upon the effect of the remedies employed, particularly on the state of the discharges. If these become more abundant, of a darker colour, and more bilious; and if the irritability of the stomach, the cerebral disturbance, and the fever, subside; we may expect a favourable issue. On the contrary, increase of restlessness, of the spasms or convul- sive movements, and of the cerebral symptoms, rapid emaciation, small thready pulse, cold damp suiface, watery pink-coloured stools, constant puking, and especially flatulent distension of the abdomen, and the appearance of aphtha) about the mouth, continued stupor, with the eyes half open, and occasional convulsions, are very unfavoura- ble signs. A favourable issue should not be ex- pected with any confidence until healthy bile ap- pears in the stools, and the evacuations assume a natural character. 6. D. In fatal cases, the digestive mucous membrane is commonly found more or less in- flamed, thickened, softened, its submucous surface infiltrated, and rarely ulcerated or excoriated. I he mucous follicles, especially those ofthe small and large intestines, are enlarged or ulcerated; the 326 CHOLERIC FEVER OF INFANTS —Treatment. mesenteric glands are often enlarged; the liver is sometimes darker, and generally much larger, than natural; the gall-bladder is occasionally filled with bile; and the spleen is manifestly congested. In a few instances, the intestines have been found more remarkably inflamed, and adherent by means of exudations of lymph on their peritoneal surfaces. In the more protracted cases, effusions of serum are found within the cranium; but, in recent cases, the brain presents little or no morbid appearances beyond slight congestion. 7. E. Its nature.—The symptoms, and the appearances after death, clearly show that this disease consists of inflammatory irritation, often rapidly passing into inflammation of the greater part ofthe mucous surface ofthe stomach, and of the small and large intestines; frequently accom- panied with depressed vital energy of the frame, congestion of the liver, and a morbid state of the abdominal secretions, and occasioning sympa- thetic disorder either of the functions or of the substance ofthe brain and its membranes. 8. II. Treatment.—At the commencement of the disease, demulcents may be administered. Dr. Rush recommends an ipecacuanha emetic; but Dr. Dewfes disapproves of emetics, — an opinion which is agreeable to my experience. I have usually first had recourse, in the slighter cases, either to hydrarg. cum creta oi calomel, in frequent doses, and combined with magnesia or soda; or to nitrate of potash with the sub-carbon- ate of soda, in demulcents; and to the application of leeches on the epigastrium, whenever tender- ness of this region couid be detected. After a few of these powders have been taken, a dose of calo- mel, sometimes with a grain of James's powder, has been given at bed time, and castor oil the fol- lowing morning: at the same time, oleaginous glysters have been administered, and, as the symptoms abated, those of an emollient kind em- ployed. If the patient be not very young, a few drops of tinct. opii, or a little syrup of poppies, may generally be added to the injection. The warm bath, or the semicupium, should never be omitted in the treatment of this disease, the sur- face being well rubbed with a coarse towel upon coming out of the bath, and the child afterwards placed in warm blankets. These means, if early resorted to, will generally succeed in the less se- vere cases occurring in temperate climates. But, in the more intense states of the malady, medi- cines given by the mouth will not be retained; and such a dose of opium as will not be rejected, may be injurious. In these, it will be preferable to commence with the application of leeches to the epigastrium; and to endeavour to procure more healthy evacuations, and a discharge of bile downwards, by repeated injections, consisting of a solution of common salt (about two or three tea-spoonfuls) in warm water. The frequency of the stools ought not to prevent the administration of the injection; which will generally relieve the vomiting and other symptoms as soon as bilious or ftccal evacuations are procured. 9. When the disease appears to be brought on by improper ingesta, the vomiting may be pro- moted by diluents. But the object should be to quiet the stomach as soon as possible. For this purpose Dr. Dewees recommends, for very young children, as well as for those who are older, a tea-spoonful of strong coffee, without sugar or milk, every fifteen minutes. Of this treatment I have had no experience. In cases where the more bulky medicines are not retained, the plan of giving minute doses of calomel, adopted by Dr. Dewees, may be followed. He directs a quar- ter of a grain of calomel intimately mixed with half a grain or a grain of sugar, to be placed dry, every hour, upon the child's tongue, until the stools become more copious, less frequent, and of a dark green colour. When this change is effect- ed, the powders are to be given less frequently. After the bowels have been well evacuated, he prescribes an injection in the evening, with a few drops of laudanum, according to the age of the child; and if the disorder is not much abated, he recommences with the calomel powders as above, on the following morning, repeating the injection at night. I have never tried this practice, having found the means recommended in the preceding paragraph (§ 8.), with those about to be noticed, generally successful. 10. In the more acute cases, especially when fever is early developed, and much heat of the abdomen or of the head is complained of, the dis- ease should be viewed as being entirely dependent upon inflammation of the mucous surface of the digestive tube, and affecting the brain sympa- thetically. In these, leeches must be placed upon the epigastrium, or behind the ears; if applied to the former situation, a succession of warm poul- tices should follow them, a full dose of calomel, intimately mixed with a little sugar, be exhibited, and, soon afterwards, an oleaginous injection (olive oil or castor oil, or both, in gruel, strained mutton broth, or any other demulcent vehicle) thrown up. If these measures fail of producing the advantage expected, the back, loins, or insides of the thighs, should be rubbed twice or thrice daily with either of the liniments F. 296. 300. 311., particularly upon coming out of the warm- bath, or semicupium, which ought to be employed once or twice daily, and rendered more efficient by adding salt or mustard, or both, to it. The application of blisters for two, three, or four hours, and re-application of them for an equally short time in another place, may be subsequently had recourse to, when the preceding measures do not answer the purpose for which they were di- rected. In the more severe cases, particularly when the motions are bloody, a mucilaginous draught, with castor oil and two or three drops of laudanum, may be given; and, if it be not re- tained, an enema, consisting of the same ingre- dients, may be administered, or any of the ene- mata contained in the Appendix suited to the circumstances of the case, and proportioned to the age of the patient. 11. In the advanced stage ofthe disease, espe- cially when it passes into a dysenteric state, and when the exhaustion is great, and the stools are offensive, small doses ofthe chlorate of lime, or of potash, in an aromatic water, or in mucilaginous draughts or injections, will be very serviceable. In this chronic period, when the disorder lapses into the form of diarrhoea, proceeding from chro- nic inflammation of the intestinal mucous surface, the following powders may be given alternately with the chlorates, or either before or after they have been tried: — No. 123. R Fhdrarg. cum Creta gr. j.; Maen. Ust* gr. iij.; tium. Acacia; et SaCch. Albf, aa gr. v. j Tinct. CHOREA—Symptoms. 327 Opii Comp. TT)j—ij. Fiat Pulvis, quovis in vehiculo idoneo iiuneudus, his terve in die. N». 124. R Sod* Sub-carbon, gr. iv.; Pulv. Acacia gr. xij. ; Aquae Cinnam. 3 vj.; Syrup. Papaveris 3 ss- M. Fiat Haustus. 12. It will often be of the utmost service, even at this advanced stage, to give a full dose of calomel, and, if there still be fever, a grain of James's powder, at bed-time; from half a drachm to a drachm of the spirits of turpentine occasion- ally, with an equal quantity of castor oil being taken on the following morning in some aromatic water, or in milk : or, from five to twenty-five drops of the spirits may be prescribed three or four times daily in any suitable vehicle. During this period of the complaint, small quantities of rhubarb, magnesia, and ginger; lime-water with milk, the preparations of columba with soda, those of catechu with chalk, the hydrarg. cum creta with Dover's powder, the decoction of pomegranate bark, or small doses of the sulphates of iron and of potash, may severally be employed according to circumstances. If pain be still com- plained of, small doses of the compound tincture of opium, or of Dover's powder, or of syrup of poppies, become absolutely necessai'y. In this chronic state of the disease, the sub-borate of soda given internally, either alone, or with an equal quantity of supertartrate of potash, has proved extremely useful in my practice at the Childrens' Infirmary; either of the liniments, No. 296. 300. 311., being rubbed daily over the ab- domen, and a flannel roller afterwards placed around it. In this stage of disorder, Dr. Chap- man recommends the following : — No. 125. R Ferri Sulphatis gr. ij.; Acidi Sulphur, gtt. x.; Sacchar. Albi T, j.; Aq. Fontan. 5 j. M. Capiat 5 j. ter quaterve quotidie. 13. The febrile nature of the disease, and its evident connection with inflammation of the mu- cous surface of the stomach and bowels ought not to be overlooked. In its early stage, there- fore, cooling febrifuge medicine and beverages may be allowed the child, in order to assuage the thirst. With this view the liquor ammon. acet. with nitre, and spirit, aether, nit., may be given, with aq. foeniculi, at short intervals ; and, in the more advanced stage, when the irritability of the 6tomach has subsided, small doses of the sulphate of quinine, either in syrup or in compound infu- sion of roses; or the infusion of cinchona, with a few drops of liquor potassae, or of the sub-car- bonate, may be directed. When the stomach will retain it, this infusion, with liquor ammon. acet., very small quantities of nitrate of potash, and the spirit, aether, nit., has proved beneficial. 14. Regimenal and Prophylactic Treatment.— a. When the disease occurs, as is most commonly the case, in infants under a twelvemonth, the diet should consist, at the commencement of the attack, exclusively ofthe mother's milk, or when it has been recently weaned, a healthy wet-nurse should be procured. If, however, the child will not take the breast, small quantities of diluted sweetened milk may be given, or thin rice or barley-water, with some gum added to it. Be- sides these, soda water, marsh-mallow tea, and the water poured off an infusion of toasted oatmeal, or oat-cakes, may be also tried. In the latter stages of the complaint, the usual farinaceous aliments may be allowed. Dr. Rush attributes much importance to the moderate use of salted provisions at this period, and of port wine; and I have had occasion to know, that both of these are often extremely beneficial when properly restrict- ed. I believe that the want of a sufficient quan- tity of salt in the food of children, in climates and states of the air requiring this condiment, is often concerned in the causation of the disease. For no malady is change of air more necessary than for this. The child should be removed from the crowded town to the open country; an elevated, dry, but not bleak, situation being selected. Re- moval to the sea-side is also very beneficial; or, when a more complete change cannot be enjoyed, a close, low situation may be exchanged, even for a time, for one that is more open and elevated. 15. b. The prophylactic measures may be briefly stated to consist of allowing the infant a healthy breast of milk till it is a year old; of wearing flannel next the skin, and keeping the lower extremities warm; of regulating the diet, and avoiding excess in fruit, and the use of unripe, over-ripe, or stale fruit; and of attending to the state of the gums during the period of dentition. BlBLIOO. AND REFER.— Rush, Medical Inquiries and Observations, p. 131. 2d ed.—Valentin, in Journ. Gen. de Medecine, vol. xxix. p. 459.—Dewees, On the Physical and Med. Management of Children, kc. Lond. ed. 8vo. p. 443. 1826.—Parrish, On the Prophylactic Treatment of Cholera Infantum, &.c, North Amcr. Med. and Phvs. Journ. Julv, 1826. — Billard, Traite des Maladies des Enfans Nouvcau- Qes et a la Mamelle, kc. 8vo. Paris, 1828, p. 414. CHOREA. Syn. Chorea Sancti Viti (from yoqia a dance with singing) ; Saltus Viti, Chorea Sti. Modesti, Choreomania, Ballismus, Orchestromania, Epilepsia Saltatoria, Auct. Var. Choree, Fr. Der St. Veitstanz, Ger. Classif. 2. Class, Nervous Diseases ; 3. Order, Spasmodic Disorders (Cullen). 4. Class, Nervous Affections; 3. Order, Affecting the Muscles (Good). II. Class, III. Order (Author, in Preface). 1. Defin. Tremulous, irregular, involuntary, and ludicrous motions ofthe muscles of voluntary motion, more marked on one side than the other, without pain, occurring in both sexes, more fre- quently in the female, and chiefly between eight and fifteen years of age. 2. This disease was formerly called the Dance of St. Guy by the French, and of St. Weit by the Germans, from the circumstance of it being so prevalent in Swabia, and other parts of Ger- many, during the fifteenth and sixteenth cen- turies, that patients crowded to a chapel near Ulm, dedicated to this saint, who had, by the aid of the priests, obtained great celebrity in its cure. It appears to have been known to the ancients; for the Scelotyrbe of Galen very nearly resem- bles it. The earliest writers, since the revival of letters, who noticed this affection are, Plater, Horstius, and Sennert, under the name of Chorea Sti. Viti. In 1560, Bairo, physician to the Duke of Savoy, mentioned it under the name of " Indispositio Saltuosa Membrorum." But Sydenham was the first author who accurately described it. 3. I. History, &c. A. Symptoms.—The pa- thognomonic characters of chorea consist in dis- ordered movements of parts actuated by the vol- untary order of nerves; the functions of volition and of muscular action being deranged analogously to the manifestations of the mind in mental aliena- tion. The disordered movements vary very con- siderably, in respect ofthe number of parts affect- ed, and of the intensity of the affection: hence it 328 CHOREA —History of, &c. may be partial or general, slight or severe. It is more frequently partial than general, and is very often confined to the muscles of one side of the Jbody. The description by Sydenham has been copied with little alteration by many authors; and, although extremely accurate in respect of some 6tates ofthe disease, it by no means embraces all the varieties : that by Dr. Hamilton is, upon the whole, the best, particularly as respects its fully developed form. 4. This affection is often preceded by more or less marked disorder of the organic functions: the appetite is variable, the digestion imperfect, the bowels costive, the abdomen tumid, and the vivacity and physical activity diminished. To these are frequently added timidity, fretfulness, desire of solitude, sighing, palpitations, concealed mental affection, &c. These symptoms of disor- dered health are followed by slight, irregular, and involuntary twitchings of the muscles, particular- ly those of the face. These motions increase, assume the form of irregular clonic and continued convulsions, and are often attended by increased hardness, or tumefaction, ofthe lower regions of the abdomen, and constipation. Owing to the ir- regular convulsive motions of the face, jaw, head, and neck, of the trunk and extremities, and from the circumstance of these motions taking place at different times, the patient has a jumping, starting, or palsied walk, and cannot perform the usual occupations of the extremities with the steadiness and regularity of health. The characteristic mo- tions vary in degree ; but they are always present during the continuance of the disease, excepting while the patient is asleep, when, in most in- stances, they altogether cease. 5. Different muscles are sometimes successive- ly affected ; but those first convulsed still continue so until the termination of the disease. When the affection is fully formed, articulation is impeded, but seldom completely suspended. Deglutition is often difficult; the eyes lose their lustre and ex- pression; the countenance becomes pale, languid, vacant, and, in the severest and most protracted cases, conveys the idea of imbecility, or even of fatuity. In the course of disorder, the muscles seem much more soft and flaccid than natural, and emaciation takes place : vertigo and headach are often complained of. The pulse is a little ac- celerated; the bowels are always constipated, and the urine is usually pale and copious. The tongue and gums are pale ; the former being occasional- ly protruded, irregularly and spasmodically. In some of the severest cases the mouth is variously twisted, and a drivelling of saliva takes place from it: the eyes are distorted, or rolled in various di- rections, and the sight is occasionally defective. The disposition and temper are unstable or irrita- ble ; the mind is often harassed by various con- cealed mental impressions and ideas ; and the emotions or desires are variously excited, without any sufficient or apparent cause. In some cases, deglutition is much impeded, and fluids are for- cibly thrown up from the pharynx in attempts at swallowing them. Bernt and Frank state, that the urine and faxes are occasionally passed involuntarily during the height of an attack ; but this rarely occurs in simple chorea. There is seldom any pain complained of, and, although the movements cease during sleep, yet the rest is often disturbed. 6. Such is the state of the fully formed disease ; but it presents endless varieties, sometimes in- sensibly lapsing into hysteria, in other cases ap- proaching to paralysis ; now scarcely to be dis- tinguished from convulsions ; in one instance re- sembling tarantulism, and in another being close- ly allied to paralysis tremens. In some cases, the muscles of the face and neck are more affect- ed than those of other parts ; whilst in others, those either of the upper or of the lower extremi- ties, or of one limb only, are most convulsed. 7. B. Duration, complications, and termina- tions.—a. The duration of this affection under treatment is various—from two or three weeks to several months : the most common duration being from one to two months. The shortest period of treatment, in the cases which have occurred to me, was eleven days. Relapses are, however, not infrequent. 1 have seen the affection to re- turn thrice in the same patient. 6. Chorea is very frequently associated with other disorders : in fe- males with chlorosis, retention or suppression of the menses, anaemia, hysteria ; and, in males, with rheumatism, with paralysis, disease of the head, and dropsical effusions in the serous cavities. c. It .also not infrequently terminates in these, and in convulsions, epilepsy, anaemia, dropsy, palsy, hydrocephalus, and complete idiotcy. A return, however, to health is its most common issue. In a case related by Dr. Elliotson, it terminated in apoplexy ; and Dr. Brown refers to three instances in his practice, where it ter- minated in violent convulsions, with cerebral symptoms, coma, and death. 8. Its complication with rheumatism, rheu- matic pericarditis, and disease of the membranes ofthe spine, was first demonstrated by the writer, in a case, the post mortem inspection of which is detailed in the fifteeuth volume of the London Medical Repository ; the connection having been subsequently confirmed by Dr. Prichard and by Dr. Roeser, who have met with similar cases. The association of chorea with hysteria is very frequent about the period of puberty ; and when the former occurs, after this term. Indeed, the majority of cases exhibiting choreal symptoms at or subsequently to the epoch of puberty in the female, parjake more or less of the hysterical character—in many instances to the extent of appearing as a modified form of hysteria, rather than as chorea: and, upon strict inquiry, some irregularity is generally detected in the accession or subsequent occurrences of the catamenia. Females who are attacked by, or have been sub- ject to, chorea anterior to the period of puberty, occasionally experience at this age retention or postponement of the catamenial discharge ; or, if this secretion at all appears, it is scanty and at irregular intervals. Both the chorea and disorder of the catamenia evidently depend upon a similar condition of the vital manifestations of the organic nervous system, and chylopoietic viscera. The following procession of morbid phenomena is not uncommon : chorea with defective action of the digestive, assimilating, and secreting functions, and torpor of the liver ; at a subsequent term, protracted catamenia, or scanty and irregular ap- pearance of the secretion, occasionally with va- rious hysterical affections, seldom amounting to a complete fit ofthe hysteria ; and, lastly, when the 1 catamenia become established, the hysterical af- CHOREA — Diagnosis and Prognosis. 329 fection is sometimes more fully pronounced; and, with the regular establishment of the uterine func- tions, the chorea disappears. Dr. White re- lates the case of a lady, aged 42, who appears to have been the subject of chorea of an irregular or rather doubtful character, and liable to attacks of hysteria. In this case, which has been too readi- ly admitted by Dr. Good as one of chorea, the menstrual discharge is reported to have been re- gular ; but it is probable that in this, as many other instances of diseases occurring in females, a more strict inquiry would have detected some de- rangement in the uterine functions. 9. C. The appearances found on dissection of fatal cases are rather referrible to the complica- tions than to the disease itself. In general, the body is somewhat emaciated, and the muscles soft, flaccid and pale. The stomach, bowels, and as- sociated viscera present only contingent lesions : they are, however, often flaccid and pale, some- times with a slight effusion of serum in the peri- toneal cavity. In a few instances, signs of irrita- tion ofthe uterus have been observed. Dr. Haw- kins, found, in a case he examined, besides in- creased vascularity of the uterus, earthy concre- tions in the pancreas, omentum, and mesentery, with tubercles in the lungs. In the fatal cases recorded by Dr. Prichard, Dr. Rof.ser, and myself, adhesions of the opposite surface of the pericardium, with effusion of serum in it, and slight effusion into the pleura, were observed. In a case which occurred in my practice, the surface ofthe heart was covered in parts with coagulable lymph; its cavities were much enlarged, and their walls thin, pale, and flabby, resembling the mus- cles of white-fleshed animals. !\I. Desperriere met with effusion of serum into the pericardium. Soemmering states, that he detected the results of inflammatory action in the membranes of the brain; and several authors have made mention of small ossific deposits in the arachnoid of the dura mater. Dr. Brown, in the only one, ofthe three cases which terminated with convulsions and coma, that he had the opportunity of examining, found congestion ofthe vessels of the brain, with slight serous effusion between the membranes, and in the ventricles, and a calcareous concretion of a cubic form, and the size of half an inch, in each side, in the medullary substance of the left hemi- sphere, — the convulsive movements having been chiefly on the left side of the body. Dr. Coxe found the vessels of the brain congested, and twelve ounces of serum in its ventricles: Dr. Will an, also, in two instances, observed sever- al ounces of seram in the ventricles of the brain. Dr. Patterson describes appearances of the membranes, consisting of vascular congestion with effusion of serum, and states, that a patient cured of the disease very soon died of hydrocephalus. M. Serres found, in one instance, a fatty tu- mour resting on the tubercula quadrigemina ; in another, appearances of increased vascularity, with sanguineous effusion; and in two others, in- flammation of this part of the brain. He further states, that, in experiments on living animals, he remarked injury of these parts to produce phe- nomena resembling chorea ; but he at the same time admits that he has sometimes met with cases of chorea, in which no diseased appearances in the brain could be detected after death. In a case which occurred to me in 1819, complicated ' 28* or rather alternating with rheumatism, with me- tastasis of this disease to the heart, and subse- quently to the membranes of the spinal cord, in- flammatory appearances, with coagulable lymph, and an effusion of turbid serum, were found through nearly the whole extent of these mem- branes, the patient having died in a state of uni- versal paralysis. Changes in the spinal mem- branes similar to those described by me were ob- served in the four very interesting cases detailed by Dr. Prichard : in these latter, also, more or less congestion of the vessels, with effusion of serum between the membranes, and in the ven- tricles of the brain, was remarked. Dr. Alip- randi has also detailed a case, in which morbid appearances similar to those described by myself and Dr. Prichard were found in the spinal canal. 10. II. Diagnosis and Prognosis.—a. This disease, in its ordinary states, may be distinguish- ed from other affections of a similar kind by the permanency, the clonic, and the partly voluntary nature ofthe movements, and their cessation dur- ing sleep. In convulsions, the movements, how- ever irregular, and in other respects resembling chorea, are not continued, are not even partially under the influence of the will, and are of the most violent or tonic kind. The disease to which the name chorea was originally given approached nearer this latter description, but presented no uniform character, ■— various nervous disorders, very different from each other in many of their essential symptoms and pathological states, as the nervous affections resulting from the bites of the tarantula or other insects, irregular forms of hys- teria, and convulsion, receiving this appellation; and, even at present, many irregular forms of convulsion, particularly those of a clonic kind, are often confounded with chorea. The only other disorder for which it may be mistaken is paralysis tremens, which occurs at a later period of life than chorea, is generally more limited to a single limb or part of the body, the movements being more of a tremulous than of a spasmodic kind, and to a much less extent; and not partak- ing of the starting, jumping, twitching, and ludi- crous character possessed by those of chorea. 11. 6. The Prognosis in the simple or uncom- plicated state of chorea is generally favourable. But when it comes on after attacks of rheuma- tism, or in conjunction with this disease ; if it follow the disappearance of the acute or chronic exanthemata and eruptions, or arises from injuries ofthe head, or from manustupration; if it be as- sociated with epileptic convulsions, or with more or less complete paralysis of some limb or part; and if signs of anosmia, chlorosis, dropsical effu- sion, affection of the functions of the brain, or idiotcy, manifest themselves, an unfavourable, or at least a cautious, opinion of the result should be offered. It would seem that the disease is more severe or more frequently complicated in large cities, or in some places, than in others, for the very different results of practice cannot otherwise be well explained. Dr. Parr states, that in about sixty cases, in which the treatment very generally employed by other physicians was re- sorted to, all recovered, and only two had relaps- es. I have met with three or four fatal cases; Dr. Prichard has recorded four; Dr.'Brown refers to three in his practice; and I have occa- 330 CHOREA —Caises—Nature of. sion to know that a similar issue is not rare in cases occurring both in London and in Paris. 12. III. Causes. — A. Predisposing causes. Chorea is much more frequent in the female than in the male sex. According to the experience of Heberden, Thilenius, J. Frank, Reeves, Manson, Elliotson, and mvself, three of the former to one ofthe latter are affected by it. The most common period of life is from seven years to fifteen — from second dentition to puberty; but no age is entirely exempt from it. M. Bout- eille met with it in a lady of 80, complicated with hemiplegia; Dr. Powell and Dr. Maton, in females of 70 ; Dr. Crampton, in a female upwards of 40. I have seen it in a man upwards of 50; and cases sometimes occur as early as five or six years. The nervous temperament, and great sensibility ofthe nervous system; hereditary disposition; constitutional debility from whatever cause, either from original conformation, or from bad or deficient nourishment in early infancy, particularly an insufficient supply from the mother or nurse's breast, or total deprivation of this nu- triment; effeminate education, and premature ex- ercise of the mental powers; precocious excite- ment ofthe desires and affections; debility of the digestive and assimilative viscera; neglected state of the bowels, leading to accumulations of de- ranged secretions in the prima via; torpid func- tion of the liver, and other secreting and assimil- ating organs ; cold and moist climates; confine- ment or sedentary occupations in low, unhealthy, or crowded places; low or innutritions diet, espe- cially vegetable food; impure miasmal air; want of personal cleanliness ; and the ricketty, scrof- ulous, and rheumatic diathesis; constitute the chief predisposing causes of the disease. 13. B. Exciting causes. —These are not often readily ascertained. The most common are the irritation of worms or of morbid matters accu- mulated in the bowels (Stoll, Baldingkr, Wendt), and fright. Dr. Reeves and Mr. Bedingfield state, that the great majority of cases which they treated was attributed to fright; and a nearly similar statement is made by Stoll and Ecker. Injuries affecting some part of the nervous system especially, as fulls upon the head and back (Geash, Frank); the improper em- ployment of lead, mercury, &c. (De Haen); suppressed eruptions, discharges, See. (Thilen- ius, Darwin, and We.ndt), particularly tinea capitis, itch, herpes, perspiration ofthe feet, &c; metastasis, or extension of rheumatism to the membranes of the spinal cord (Ploucquet, Copland, Prichard, &c.) ; previous disease, especially the eruptive fevers, epilepsy, hysteria, and mental disorder (Sallaba); second denti- tion ; suppressed discharges ; anxiety, the dread of impending occurrences, concealed mental im- pressions and moral emotions, and the influence of imagination (Darwin, Haygarth), parti- cularly morbidly exercised imagination in con- nection with sexual desire ; frequently excited jealousy and envy; masturbation, and retained, or difficult, or suppressed menstruation, particular- ly if occasioned by this practice (Richter, &c), and cold long endured, —are all occasionally ex- citing causes of the disease. 14. IV. Nature of the Disease. — Opin- ions as to the pathological state originating chorea Lave been extremely various. Sydenham con- sidered it as a species of convulsion, occasioned by a humour affecting the nerves. Sauvages, Cullen, and many others, ascribed it to general debility, attended by unusual mobility of the sys- tem ; and several writers, among whom I may notice Bouteille, Clutterbuck, Serres, Lisfranc, &c., to inflammatory action of some part of the cerebro-spinal axis; thus viewing it as intimately related to paralysis. Dr. Hamilton attributed it to disordered functions ofthe bowels, affecting the muscular actions sympathetically ; and a very large number of writers, to debility deranging principally the nervous and muscular systems ; the torpid states of the organic func- tions being a related or associated manifestation of disorder. 15. A. The exact seat, as well as nature, ofthe disease can be inferred with accuracy only from attentive observation of the causes in relation to the states ofthe system at its commencement, of the phenomena in its course, and of the structur- al changes existing in cases which have terminat- ed fatally. The writer was the first who demon- strated, by post mortem research, inflammatory appearances of the membranes of the spinal cord; but he cannot on that account infer that the dis- ease is owing to that cause. Indeed, in the case in which he observed it, the affection of these membranes was recognised, during the life of the patient, as a contingent lesion arising from metas- tasis ofthe rheumatism with which it was associ- ated. M. Serres, having found disease of the corpora quadrigemina in four cases, considers these bodies as the seat of chorea, and thinks the results of his experiments, and of those of MM. Flourens and Rolando, on the functions of this part of the brain, countenance this opinion. Other pathologists, particularly MM. Bouil- laud and Magendie, conceive that it is seated in the cerebellum, because the functions which they ascribe to this organ are chiefly affected— the disease, in their opinion, consisting of disorder of the actions of this part. If we reflect, that a number of disorders, more or less resembling each other, have been considered as chorea; that these, as well as chorea itself, are often complicated with, or run into, other affections of an organic or inflammatory kind; and that it is never fatal excepting in consequence of its consecutive and as- sociated changes, especially those affecting the brain and spinal cord ; the diversity of lesion ob- served after death, and of opinions derived from this source chiefly as to its seat, will not appear surprising. 16. I think that chorea, in its simple state, occurs most commonly in persons whose vital powers are depressed,*the whole circle of vital organs performing their functions imperfectly, and thereby occasioning increased susceptibility of the nervous system. This state constitutes the apti- tude to be affected by the exciting causes of this disorder; whether those acting directly upon the brain, through the medium either of the mind it- self or of the senses, as terror, fright, mental im- pressions, moral emotions, &c.; or those which influence indirectly the cerebro-spinal nervous system, by irritating or otherwise disordering the organic nerves, as worms, morbid matters in the prima via. The susceptibility of the frame bavin" been induced, either class of causes may occasion the malady, — the former, by changing the condi- CHOREA AND RELATED AFFECTIONS —History of. 331 tion of those parts about the base of the brain which direct or influence the functions of the spi- nal cord, and, through it, of the voluntary mus- cles,—the latter, by disordering the functions of the organic nervous system, and thereby affecting, through the medium of the branches communica- ting with the ganglia placed on the roots of the spinal nerves, the nerves of voluntary motion: occasioning the irregular muscular movements constituting the disease, in the same manner that irritation of the visceral nerves produces the au- tomatic movements of the fcrtus in utero. In such cases, the disorder of the organic nerves may be extended, by means of the sympathetic, to the spinal nerves either of one side only, or of both, as well as to the nerves and parts about the base of the brain, disease being also subsequently induced in those parts of the brain or spinal cord in which they originate. According to this view, will readily be explained the frequent connection of chorea with hysteria and uterine disorder, as the patient advances through the period of puberty and adolescence, as well as the disappearance of the disease after the developement of the sexual organs, and the healthy establishment of the ute- rine functions—events intimately related with, and necessary to, the due manifestation of vital energy throughout the frame. 17. In other words, therefore, the proximate cause of chorea, in its simple and true form, seems to consist of debility, with some degree of irritation of the organic or ganglial class of nerves, extended more or less to those of volition, and occasioning morbid susceptibility of the nervous system generally, with diminished power, in- creased mobility, and irregular actions of the muscular system, particularly of those muscles supplied with the nerves principally affected. Whilst this appears to be the pathological state of the majority of cases of chorea, yet instances not infrequently occur in which disorder evidently commences in the spinal cord or its membranes, disturbing the functions of the nerves issuing from the affected part. In many cases, the lesion of the cord and of its membranes is occasioned by irritation propagated to the roots of the voluntary nerves; but in those which are connected with rheumatism, as well as in some otherwise related and produced, the mischief evidently originates in the membranes of the cord itself. When, however, the disease commences in the organic nervous system, affecting the voluntary nerves only secondarily, pain is not complained of upon examining the spinal column; but when it is seat- ed in the cord or its membranes, pain or uneasi- ness is felt in this situation, and the disordered motions are more or less limited to particular parts. When the original cause of mischief is seated in the brain, or when the cephalic organs become consecutively diseased, the affection par- takes more of the characters of true convulsion, either with or without hysterical symptoms, but most commonly with such phenomena. 18. V. Of nervous Disorders resem- bling Chorea.—Whilst true chorea, according to the application of the term in recent times, seems to originate in the organic nerves, and to disturb the functions not only of the voluntary nerves, as explained above, but also of those parts of the cerebro-spinal axis in which they originate; the affections I am about to notice, most com- monly depend upon a disordered state either of the mind, or of some ofthe parts within the cranium, and are often attended by more or less affection of the generative and digestive organs. The dis- ease to which the name Chorea Sti. Viti was first applied, very nearly resembled that produced by the bite of the tarantula, as it is described by Baglivi and Sauvages; and, if the description ofthe former disorder furnished by ScheNck, Paracelsus, and Felix Plater had not been confirmed by the more accurate observation of modern practitioners, it might have been viewed as greatly exaggerated, if not entirely feigned, a. The chorea of the writers ofthe sixteenth century appears to have consisted of inordinate muscular exertions and movements in regulated measures, proceeding from an irresistible mental impulse, excited by the influence of music or imitation on the mind. Horstius states, that it sometimes recurred annually at the same period; and that the sound of music often increased it to a state of frenzy, those affected continuing dancing for an incredibly long period, in a most excited manner. It appears to have consisted chiefly of a sort of lascivious dance, kept up an uncommon length of time, until the impulse to excessive muscular mo- tion was subdued by exhaustion, and has not in- appropriately been called Morbus Saltatorius and Epilepsia Saltatoria by later writers, b. Ac- cording to the account given by Baglivi and Sauvages ofthe effects ofthe bite ofthe taran- tula, the patient is seized, a few hours after the injury, with difficulty of breathing, anxiety, and sadness. The violent symptoms of the first days are succeeded by a peculiar melancholy, which continues until, by dancing or singing, it is at last entirely removed. Persons thus affected frequent churchyards and solitary places, lay themselves out as if they were dead, evince the utmost de- spair, howl and sigh, assume various indecent attitudes, run about, or roll themselves on the ground, and are either pleased with or dislike particular colours. Shortly after being stung, they fall down, deprived of sense and motion, either breathing with difficulty aud sighing heavi- ly, or lying as if quite dead. Upon the sound of music they begin to move their fingers, hands, feet, and successively all the parts of the body, sighing, dancing, and assuming a thousand fan- tastic gestures. They continue these motions for several hours, until they are exhausted, and cov- ered by perspiration; but they return again, after some repose, to this violent exercise, which is kept up for ten or twelve hours each day, during four or five, but seldom so long as six days. This affection has received various names from Con- tinental writers, amongst the chief of which are tarantismus, tarantulismus, Choreomania, Me- lancholia saltans, Chorea Sti. Johannis, Chorea Sti. Vulentini, and Damonomania. 19. According to the above account of both affections—the original chorea of the Germans, and the tarantismus of Sauvages — there ap- pears to be but little difference between the latter, at its advanced or second stage, and the former. It is very difficult to believe that the whole, or at least the greater part, of the phenomena in both these affections was not feigned. It is, however, admitted, that the poison of the tarantula spider is most successfully counteracted by the exciting influence of music on the mind, and the profuse 332 CHOREA AND RELATED AFFECTIONS —Treatment or. perspirations produced by continued dancing. A writer in the New York Medical Repository de- tails an instance of a convulsive disorder occasion- ed by the bite of a spider, and cured by music. Mr. Kinder Wood has recorded a case, which originated in disordered menstrual function, with cerebral symptoms and painful affections of the nerves of the face, that resembled in every re- spect the malady to which the German physicians gave the name of chorea. 20. The disorder, also, which has usually been called the " Leaping Ague" in Scotland, seems to be very closely allied to the original chorea. It is described very nearly as follows by a writer in the Edinburgh Medical and Surgical Jour- nal :—Those affected first complain of a pain in the head or lower part of the back, to which suc- ceed convulsive fits, or fits of dancing, at certain periods. During the paroxysm, they distort their bodies in various ways, and leap about in a sur- prising manner. Sometimes they run with great velocity even in dangerous places, and when con- fined, climb or leap from the floors of the cot- tages to the rafters, or swing by, or whirl around, one of them. They often dance or leap about with greater agility, vigour, and exactness than they are capable of exerting at other periods ; the affection apparently consisting chiefly of a morbid and irresistible propensity to dance, tum- ble, and run about in a fantastic manner. Cases of this form of disorder have been detailed by Tulpius, Penada, Rf.il, Bruckmann, Westphal, Crichton, Piedagnel, Lau- rent, and others. In M. Piedagnel's case there was a propensity to run forwards, until the patient, a man, dropped down exhausted. On examining the brain after death, tubercles were found pressing on the anterior part of the hemi- sphere. A similar instance occurred in the father of a medical friend, and terminated in paralysis. The subject of M. Laurent's case was propel- led backwards with considerable velocity. 21. Dr. Watt has given the history of a dis- order which he has called chorea, or periodical jactitation, in a girl of ten years, that was preceded by excruciating headach and vomiting. To this affection of the head succeeded the propensity to turn around in one direction on her feet with great velocity, like a spinning top. _ This pro- pensity subsided after having continued above a month, but was followed by an exasperated re- turn of the headach, and loss of power over the muscles of the neck. She was afterwards seized by a different kind of motion, occurring in fits, which lasted daily, from two or three, to six or seven hours ; this consisted in placing herself across the bed, and rolling rapidly round on her sides from one end of it to the other. When laid in the shallow part of a river she rolled around, although at the point of being drowned. The affusion of cold water did not stop the rotations, wluch were about sixty in a minute. In a little more th;tn a month these movements were re- placed by others of a different kind. She now laid herself on her back, and, drawing her head and heels towards each other, raised her trunk, afterwards fulling with some force on her back by straightening her body. These motions were re- peated ten or twelve times in a minute, were con- tinued for about five weeks, and were then fol- lowed by the propensity of standing upon her I head. Having raised her feet perpendicularly upwards, she fell down as if dead, but instantly I placed herself on her head as before, again fell, | and continued to repeat these movements for fif- j teen hours a day, and as rapidly as twelve or fif- teen times a minute. The affection had resisted emetics, cathartics, local depletion, blistering, setons, &c, but disappeared after a spontaneous diarrhoea. Dr. Watt refers to two similar cases which had come to his knowledge ; and another instance has been adduced by the writer, under the designation of " Inquirer," of an instructive article on the subject, in the third volume of the Edinburgh Medical Journal. Mr. Hunter has also given the particulars of an instance of rotatory affection resembling chorea, in the twenty-third volume of the same work. 22. Dr. Robertson has described a peculiar form of convulsion, in many respects like chorea, which spread at one time (1800) as an epidemic amongst a sect of religious enthusiasts in the states of Tennessee and Kentucky, evidently from the influence of imagination and irritation on morbidly excited minds. The seizure was violent, and distinctly convulsive at the com- mencement, but it usually passed from this state into one more chronic, and more nearly approach- ! ing chorea. Persons thus affected are described I by Dr. Robertson as being continually inter- [ rupted in their conversation by the irregular con- tractions of the muscles, and as having no com- mand over these contractions by any effort of volition ; lying down in bed does not prevent them, but they always cease during sleep. Re- missions and exacerbations are common, but occur [ without regularity. During the remission, a pa- roxysm is often excited by the sight of an affected person, but more frequently by shaking hands with him. The sensations of the patient during the fit are said to be agreeable, and are expressed j by the enthusiastic by laughing, shouting, dancing, &c, followed by fatigue, and a sense of general soreness. The affection at last becomes slighter | by degrees, and finally disappears. Cases of sim- ilar nervous disorders, and apparently interme- diate between chorea and convulsions, and often partaking of many of the features of hysteria, as well as the affection called Malleatio, have been detailed by Tulpius, Horstius, Morgagni, Wichmann, Majendie, and others above re- ferred to (§20.). It is difficult to believe, how- ever, upon perusing the particulars of the fore- going cases, that they are altogether the actual phenomena of disease. It is very probable that the morbid affection of mind,—the disordered state of the desires, or of the mental impressions,—exalts the derangement of the nervous system to that singular pitch, of which these cases are rare ex- amples. (See arts. Convulsions, & Hysteria.) 23. VI. Treatment.—A. Conspectus of the treatment. Purgatives have been recommended in chorea by Sydenham, Whytt, Hamilton, Cheyne, and others. Sydenham, however,did not confide the cure of this affection to them en- tirely, for he also directed occasional depletion, with tonics in the days intervening between the exhibition of the purgatives, and narcotics at bed- time. Emmenagogues, particularly aloes, myrrh, assafcetida, hellebore, savine, castor, the melissa officinalis, spiritus amnionic succinatus, saffron, borax, &c. have been very properly prescribed CHOREA AND RELATED AFFECTIONS—Treatment of. 333 by Richter, Schmidtmann, and several other German writers, particularly when the disease occurs about the period of puberty, and is con- nected with hysteria, or disorder of the menstrual discharge. Anthelmintics are the chief medicines advised by Hufeland and Thilenius. Watt and Sallaba viewed the disorder as possessing an inflammatory character, and therefore directed for it the antiphlogistic regimen. Tonics have found supporters in Dover, Werlhof, Ma- hon, Eckstein, Hildebrand, Elliotson, and many other writers. But they do not agree in the kind of tonic which should be employed : thus, Hildebrand prefers the sulphuric and mineral acids; Werlhof and Mahon, the cinchona bark; Griffith prescribes the bark, with the carbonate of potash. Eckstein, Wendt, and Elliotson recommend the pre- paration of iron, in preference to other tonics. The fixed alkalies have been noticed favourably by Wendelstatt; and the mineral springs at Ems by Bruckmann. Sir Geo. Baker, Na- gel, and Michaelis prescribed the flowers of the cardamine pratensis; the latter in doses of a drachm every six hours. The leaves of the Seville orange tree, in the form of powder, decoction, or infusion, were much praised by De Haen, Wes- terhoef, Werlhoff, and Engelhard. The arnica montana received the commendation of Theussink; and the chenopodiumambroisio- ides, that of Plenck and of Ecker. 24. Narcotics and sedatives have also been prescribed in this affection. The inspissated juice of the root of the belladonna was employed in doses of one sixth of a grain, with apparent ad- vantage, by Stole, Lentin, andKETTERLiNG. Stoll, however, directed at the same time fric- tion with a liniment composed of the spiritus ser- pilli, essentia castorei, and camphor, to which I am inclined chiefly to attribute the benefit derived. M. Allamand has likewise prescribed belladon- na with advantage. Stramonium was used by Sidren; digitalis by Uwins and some others; and opium by Swainston. The prussic acid has lately received the commendation of Mr. Stu- art. He employed it in two cases, after purga- tives had been exhibited in large doses, with de- cided advantage. The prussiates of iron or of zinc are also productive of benefit. 25. Antispasmodic remedies have been resort- ed to by several physicians. Camphor has ob- tained a well-deserved notice from Werlhoff, Mahon, Wilson, and others. The cuprum am- moniatum has been prescribed by Dr. Walker, after alvine evacuations, and found beneficial in cases where bark and other tonics have failed. Will an, U wins, Delarive, and Theussink have also spoken of it favourably; and Merk car- ried it so far as to produce an emetic effect. Val- erian has been recommended by Bouteille, Bernt, Murray, Guersent, &c. After the bowels have been evacuated, it is in many cases an excellent remedy, either given by the mouth, or administered as an enema. The oxyde of zinc has received a very extensive trial in this affection from Hart, Burseri, Thilenius, Senraud, Wright, Hufeland, and Kerst. Stoll, however, states that no benefit is derived from it, although pushed to a great length. I have seen much more advantage produced from the sulphate than from the oxide of zinc. Although the oxide may be given without advantage, and irritate the stomach, the addition of a full dose (gr. ij.) ofthe cuprum ammoniatum in combination with the zinc will be borne without inconvenience. This fact, which was first noticed by Dr. Odier, of Geneva, in a letter to Dr. Duncan, may be ta- ken advantage of in the treatment of chorea; for I am not aware that it has as yet been acted upon in respect of this disease. The nitrate of silver has likewise been fully employed, and certainly with benefit if purgatives have been premised. Franck, Uwins, and Crampton have found it successful in extremely obstinate cases. 26. Arsenic, in the form of Fowler's solution, has also been directed with advantage in severe cases of chorea, especially after free alvine eva- cuations have been procured, by Mr. Martin, Dr. Salter, and Dr. Gregory. Iodine has been given by Dr. Manson, Dr. Gibney, Dr. Peltz, and myself; and, when judiciously pre- scribed, particularly when the disease appears about puberty, and is connected with obstructed menstruation, is often of great service. In cases of this kind, a blister applied over the sacrum, as recommended by Dr. Chisholm and Mr. Swan, and found beneficial by them, has been produc- tive of marked advantage in my practice. The propriety of scarifying deeply the gums, when the affection occurs about the period of second denti- tion, has been very properly insisted upon by Dr. Gregory and Dr. Monro. 27. The cold bath has been much used by M. Dupuytren in chorea, and sea bathing has been recommended by Hufeland and Himly; but the shower bath, or the simple affusion of cold water on the head whilst the patient is seated, is preferable at first, in my opinion. If the shower bath be directed in cases of females, the patient should stand, whilst receiving the bath, in a pan of warm water. Dr. Ferrari prescribed with benefit a solution of tartarized antimony internal- ly, and ice along the vertebral column, followed by immersion daily in a cold bath, and by purga- tives, bitter tonics, and hyoscyamus. Setons, is- sues, and moxas in the neck, or over the vertebrae of the back, have also been employed by several practitioners. Dr. Aliprandi, however, relates a case where issues and moxas proved of no ser- vice. Drs. Physick and Young have made use ofthe black snakeroot, the cimicifuga race- mosa, and experienced decided advantage from it. This substance seems to act more rapidly than others in the cure of the disease, and without any sensible action on the secreting functions. It is given in doses of frbm ten grains to a drachm. The animal oil of Dippel has been found of ser- vice by Werlhof; the cajeput oil by Rams- p e k ; and the cod and tusk-liver oil, and spirits of turpentine by the author, who first prescribed them in this disease. Electricity has been sug- gested by De Haen, Fothergill, Schaef- fer, &c. ; and galvanism by several writers. Large doses of muik were directed by Dr. Ma- ton and Dr. Powell, after free alvine discharg- es had been procured. 28. Respecting the propriety of blood-letting in chorea, much contradictory evidence has been furnished. Sydenham prescribed it as a subsi- diary remedy ; Dr. Cullen states that it was sometimes useful, at other times injurious ; Dr. i Watt obtained, he informs us, decided advan- 334 CHOREA AND RELATED AFFECTIONS —Treatment of. tage from the practice; Dr. Armstrong found it very hurtful ; and Dr. Clutterbuck trusted to it almost entirely, repeating it several times af- ter intervals of a few days. M. Bouteille view- ed the disease as either congestive or inflammato- ry, and commenced the treatment with blood-let- ting, which he generally repeated, and with pur- gatives. M. Serres, having observed vascular turgescence about the corpora quadrigemina in four fatal cases, has recommended leeches and counter-irritants to be applied to the upper part of the spinal column; and M. Lisfranc, also, has directed blood-letting and leeches to the nape ofthe neck. Dr. Hunter and Dr. Harrower have depended upon purgatives and the inunction of the tartar emetic ointment on the scalp and along the spinal column. Aromatic liniments to the spine were directed by Chrestien ; the tur- pentine and camphor embrocation to the same sit- uation, by the author; and tartar emetic plasters by Dr. Johnson, who also advised a grain ofthe nitrate of silver, with two grains of pilul. hydrarg. and five of the extr. colocynth. comp. as a purga- tive. It may further be added, that Ecker justly insists upon the superiority of sulphur as a purga- tive in this disease. The application of blisters to the spine has been recommended; but, in two cases in which I have had recourse to this practice I thought the effect was injurious rather than bene- ficial. 29. B. Treatment recommended by the author. — A careful consideration of the nature of the disease will readily suggest a rational treatment. The first indication is to remove morbid secre- tions and fiscal accumulations, the usual cause of irritation of the organic nerves. The second, to subdue vascular irritation or erythism of the ves- sels of the spinal cord or brain, when the symp- toms indicate its existence. The third, to rouse the energy of the organic nervous system, and the vital actions of the assimilating and secreting organs, and to impart energy to the frame, a. A judicious employment of purgative remedies, va- ried according to the peculiarities ofthe case, and the states of the patient's system, is indispensable to the fulfilment ofthe first intention. When the disease appears previously to approaching puber- ty, it is not very material what kind of purgatives are first prescribed : but it should be recollected, in the treatment of this disease, perhaps, more than in many others, that a judicious combination of purgatives, with tonic, or stimulating, or anti- spasmodic remedies will more rapidly restore the patient than confiding in purgatives merely. In- deed, we are enabled, by such combinations, part- ly to accomplish two indications of cure at the same time; and frequently we secure a more de- cided operation on the bowels and secreting vis- cera by the combined means. It will very gen- erally be necessary to commence with the exhi- bition of a full dose of calomel, either alone or with other purgatives, or followed by them five or six hours afterwards : but the doses of calomel ought not to be frequently repeated in this disease ; nor, in my opinion, will it be found serviceable to continue purgatives long, without either exhibiting them with a bitter tonic or antispasmodic remedy, or with both, or alternating them with these remedies. When purgatives are thus prescribed, they may be continued longer, not only without producing any detriment, but generally with decided advantage. Cases will not infrequently occur, in which little or no benefit can be remarked until they have been given almost unremittingly for a long period __the evacuations being at first nearly natural, but afterwards betraying disorder, arid proving that the repeated exhibition of purgatives was re- quisite to unload the biliary ducts and gall-blad- der, and remove faecal matters retained in the cells of the colon. For this purpose, I have gen- erally preferred the compound infusions of gen- tian "and senna, in equal proportions, with some antispasmodic and a corrigent. This combina- | tion seldom acts frequently, but usually copiously. The oil of turpentine, either followed, soon after its exhibition, by some other purgative, if it does not act upon the bowels, or combined with it, is extremely beneficial; and, whenever the evacua- tions are offensive, or of a morbid appearance, especially if the case be complicated with worms, ought never to be neglected. In such cases, a single dose of calomel at bed-time, followed, in the morning, with the turpentine, combined with castor oil (in the proportion of three parts ofthe former to two of the latter), and floating on the surface of milk, or some aromatic water, is most decided. In this affection especially, the medical attendant should examine carefully the state of the evacuations, and be guided, in a great mea- sure, by their appearance, as to the repetition and selection of purgative medicines. The benefit derived from this class of remedies in chorea was sufficiently demonstrated by Drs. Hamilton and Parr, and, although questioned by several practitioners of the present day, cannot be denied. Instances of their failure have been chiefly owing to the neglect of combining them in the manner insisted upon above, or of exhibiting tonics, stim- ulants, or antispasmodics, in the intervals between their operation. The good effect of treatment, as well as the operation of purgatives, will be much enhanced by rubbing either of the liniments F. 296. 311. on the loins or abdomen, once or twice daily, and by allowing a light nutritious diet, chiefly of animal food. 30. b. Contemporaneously with the fulfilment of theirs* indication, the second should receive due attention. In many cases, the means used to accomplish the former will be sufficient to remove existing irritation about the roots ofthe voluntary nerves ; but when we have marked evidence of irritation of these parts, or of determination of blood to any part of the cerebro-spinal axis or investing membranes, either in the state of the pulsation of the carotids, increased temperature of the head, coldness of the extremities, tender- ness or pain from the occiput along the spinal column, particularly when pressing between the vertebra? on each side of the spinous processes, the application of leeches behind the ears or along the spine, and repeating them according to cir- cumstances, or cupping in that situation, will be requisite, and not incompatible with the use of tonic and antispasmodic medicines, in cases pre- senting symptoms indicating the propriety of re- sorting to them. After leeches, the cold affusion on the head or on the spine, night and morning, or the shower bath; rubefacient liniments to the latter situation, or the tartar emetic ointment or plaster; warm woollen clothing on the lower ex- tremities, and attention to the mental emotions; constitute important parts ofthe treatment. CHOREA AND RELATED AFFECTIONS —Treatment or. 335 31. An accurate idea of the remote causes of the disease, as well as of their probable operation and continued effect, should lead not only to their removal as far as possible, but also to a treatment modified accordingly. The mental impressions and moral emotions are often more or less affected, particularly in those irregular forms of disorder, which have very generally been confounded with chorea. This circumstance should not escape the attention of the physician, as it points to the em- ployment of moral management in aid of medical measures. As the mental affection, when it exists, has generally an intimate relation to the remote causes of the disease, the importance of ascertain- ing the existence of the former, as well as the nature of the latter, as a basis of an appropriate treatment, must be manifest. 32. c. Having removed accumulations of mor- bid matters, and subdued irritation existing about the origin of the voluntary nerves, or in parts of the cerebro-spinal axis, or enveloping membranes, and having excited the actions of the secreting and assimilating organs by the means stated above, the third intention of cure is to be now entered upon in a more decided manner, by the exhibition of tonics combined with antispasmodics, and by due attention to the state ofthe bowels, and func- tions of the secreting viscera and surfaces. The combination or alteration of bitter tonics with aperients and antispasmodics will often be neces- sary during this stage ofthe treatment; or an oc- casional dose of a brisk purgative, or of calomel, will be exhibited with advantage during the em- ployment of tonics. Even when the bowels are so active as apparently to render this interference unnecessary, a dose of the pilula hydrargyri, given once or twice a week, either with or without the pilula aloes cum myrrha, will be found serviceable; As to the choice of tonics, no immutable rule can be laid down. The state ofthe pulse, and ofthe secreting organs, should be the chief guide in the selection of them. Attention to the mode of com- bining them is also of much importance. Bark, in any form, will be beneficial when judiciously prescribed. The following powder will be found serviceable, and may be taken in some aromatic water ; the doses of the ingredients being varied according to the age of the patient, and the state of the bowels :— No. 126. R Pulv. CinchotiT gr. xij.-, Pulv. Rliei er. viij.; Soda: Sub-carb. gr. x.; Pulv. Capsici Annui gr. ij. Alisce. If the decoction be preferred, it will be found most beneficial when given with liquor ammonia- acetatis, and a little of the spiritus ammonia; aro- maticus. The sulphate of quinine is an excellent medicine, especially when the patient is old enough to take it in the form of pill, when it may be most advantageously combined wtth aloes, as in F. 572—577., or with camphor and aloes as fol- lows. In this state of combination a decided ac- tion will be exerted on the bowels :— No. 127. R Camphors- rasa?, Quininae Sulphatis, aa V) j.; Extr. Aloes Purif. f^ss.; Extr. Gentianae (vel Pilul. Ualban. Uoinp.) 5 j.; Svrup. Simp. a. s. M. Fiant Pilula; xxxvj., quarum capiat 6inaa bis quotidie. 33. In this stage of treatment much advantage will often be obtained from valerian, combined with other antispasmodics and tonics, or with the alkalies (F. 269. 368.); from the preparations of iron, as recommended in the article on Chloro- sis, (§ 13.), or in F. 521. 523. ; and from the sulphate of zinc (F. 582—587), or the arsenical solution (F. 364.). As chorea is sometimes com- plicated with disease about the heart, or the roots of the voluntary nerves, or the membranes of the brain or spinal cord, of an inflammatory nature, care should be taken not to exhibit this last active substance, or even the preparations of iron, or of bark, until the symptoms of these complications have been removed by local depletions, cold af- fusions, or the shower-bath, and counter-irritation. A similar precaution is still more requisite in re- spect ofthe employment of strychnine, or the nux vomica (see F. 443. 541, 542. 565. 907.), which I have found of much service in the advanced course of treatment ofthe simple form of chorea, or when it has been associated with rheumatism of the joints or extremities, with chlorosis, hysteria, or umenorrhcea ; in which complicated states of the disease I have likewise found the tincture of iodine, and hydriodate, or ioduretted hydriodate of potash of great service (F. 234. 722.). The formula; for the above medicines given in the Ap- pendix, or the following, may be adopted :— No. 128. R Olei Valerian* TT) xij.; tere cum Sacch. Purincati 3y"-) tuin adde Infus. Valerianae 3 vijss ; Liq. Arsenicalis TT| xv. ad xxx. Misce. Capiat cochlearia duo larga ter quotidie. No. 129. |{ Pulv. Calumhae gr. x. ; Pulv. Valerianae gr. xij.---) j.; Carb n. Ferri Praep. er. x.; I'ulv. Cinnam. er. vj. M. Fiat Pulvis, vel Elerluarium molle cum Svrup. Zingib. q. s., bis terve quotidie sumatur. No. 130. R Carhon Ferri PrVp. 1 ss.; Pulv. Supertart. Potassae ~ vj.; Confection. Sciinjp, Syrup Zingiheris, sia 'jss. Misce. Fial Klectuai 11111, cujus capiat Cochleare unum mini- mum mane nocteque. No. 131. |< Carbon. Ferri; Sulph. Prancip. na ^ ij.; Potassae Supertart. Pulver. ^ v.; Confectionis Sennae et Syrup. Zingiberis aa '- jss. Misce. Fiat Klcctuarium. Su- matur Coch. unum minimum mane nocteque. No. 132. K Sub-boralis Sodie, Supertart. Potassae, aa in Pulv. *, iij.; Carbon. Ferri ^ ij.; Confectionis Sennae 3 ij.; Syrup. Zingiheris q. s. ut fiat Klecluarium molle, cujus Cochleare unum minimum mane nocteque sumatur. 34. During the use of these medicines, the tar- tarized antimonial ointment or plaster may be ap- plied to the spine ; and when the tonics are not combined with aperients, the former may be ex- hibited in the course of the day, and the latter at bed-time, as they may be required. The nitrate of silver may also be tried in doses of half a grain, or a grain, combined with aloes, or the aloes and myrrh pill. 35. C. The treatment of the complicated and irregular states of this disease must necessarily be modified according to the diversified form it assumes. The association of the disease with rheumatism has heen observed by me on several occasions, and, in nearly all, tliere has been a marked disposition of the rheumatic affection to recede from the joints or extremities, and attack the internal fibro-serous membranes, as those of the cerebro-spinal axis and the pericardium. This unfavourable result has generally been promoted by a too lovyering treatment ; but prevented by tonic and stimulating medicines, with due atten- tion to the alvine evacuations. In cases, therefore, complicated with rheumatism, chlorosis, anaemia, or retention ofthe menses, the purgatives selected should be of a warm and stomachic kind, or com- bined with cordial and stimulating substances ; the ammoniated tincture of guaiacum, camphor, serpentaria, and similar medicines, being also em- ployed. In these states of disease, the internal use ofthe cod or tusk-liver oil will be found most beneficial. Having observed instances iu which 336 CLIMACTERIC DECAY—Symptoms. the suppression of the rheumatic affection of the joints by the use of embrocations and liniments was rapidly succeeded by the appearance of in- ternal disease, the application of such remedies to the external seat ofthe rheumatic disorder should not be resorted to. 36. In the irregular forms of chorea, particu- larly those which present more or less of an hy- steric character, the functions of the uterus, and the circulation ofthe brain or spinal cord, or both, are often disordered. In these it will be requisite not only to evacuate the bowels freely, but also to allay uterine irritation, where it seems to exist, by leeches applied to the tops ofthe thighs, or cupping over the sacrum, and to promote the monthly evacuation, when scanty or retained, by purgatives and emmenagogues. In many cases of this description, the application of a number of leeches to the occiput, neck, and behind the ears, the cold affusion on the head, or the shower-bath, with warm clothing on the lower part of the body, and due regulation of the moral emotions, will materially aid the treatment. The more the attack assumes the characters of tonic convulsion, the more requisite will it in general be to have re- course to local depletions, especially if the affec- tion occur after puberty, and be connected with interrupted menstruation. 37. During convalescence, and even in the ad- vanced course of treatment, change of air, agree- able amusement, exercise in the open air, the use of chalybeate or aperient mineral waters, and a light nutritious diet, commencing with warm salt water bathing during the treatment, and con- cluding with cold salt water bathing in advanced convalescence, followed by smart frictions of the surface of the body upon coming out ofthe bath, will materially promote and confirm recovery, as well as prevent a return of the disease. Biblioo. and Keff.u.—Willis, De Morbis Convulsivis, cap. vii. p. 21.—Tulpius, I. i. cap. 10, 17.—Horstius, Kpist. Mod. s. vii.; Opera, 4lo. 2d vol. p. 120.—Sydenham, Opera, p. ICO.—Wedel, l)e Chorea Sti. Viti. Jenr, 1682.—Felix Plater, Observ. 1. i. 130.—Ramspck, Diss. ISiea Heniedior. Pra-stantui. &C. Bas. 1745, p. 35.—Schxunrtz, De Taranlismo ot Clioreo Sti. Viti, kc Vien. 1766.—Fothergi/l, in Philos. Trans, for 1799, part i.—DcHaen, Rat. Med. parti, p. 142., part iii. cap. vi. p. 221.—Burscrins, Institut. vol. iii. p. 212. —Penadu, Saggio d'Osserva/.ioni, n. d.—Merk, Museum der Hcilkunde, b. iv. p. 193.—St<,!l, Hat. Med. pars iii. p. 405., et pars iv. p. 469.—Wendt, Nachiicht von dem Krank- eninstilut zu Erlang. 17f!3.—Baldinger, N. Ma«. b. ix. p. 185.—Ecker, in Pincl's Nosog. Philos. t. ii. p. 91.—Geash, Phil. Tiam. vol. liii. 1763.— Dc Haen, Hat. Med. par. iii. p. 202.—Sidren, Dissert. Morb. Casus, Sp. &c. Upsal. 1785. —Sal/aba, De Morb. Variol. Poslh. Vien. 1709.—P/ou- quet, Obser. Med. Tubine. 1787.—White, Edin. Med. Com- ment, vol. iv. p. 326.—Hurt, in Ibid. vol. i. p. 76.—Odier, in Ibid. vol. iii. p. 191.—Walker, in Ibid. vol. x. p. 238.— Armstrong, in Ibid. vol. ix. p. 317.—Thilenius, Medic, und Ghir. Bemerk. &c. p. 115.—Werlhof, Obs. dc Feb. sect. ii. § 4.—Swainston, Thoughts, Phys. and Pract. &c. York, 1796.—Robertson, On Chorea Sti. Viii, Svo. Philad. 1305! —Hamilton, On Purgative Medicines, ch. vi.__Plenk De Morbis Infantum. Vien. 1807—Richter, Die Spcciclle The- rapie, b. vii. p. 757.— Hufeland, in his Journ. der Pract. Heilk. b. i. p. 152., et June, 1811, p. 88., Mav, 1812 p 12 —Hildenbrand, in Ibid. b. xxiv. st. i. p. 147.—Wen-lehtatt, in Ibid. p. 149.—Eckstein, in Horn's Archiv. &c. b. iii p 241.—Bruckmunn, in Ibid. Jan. 1811, p. 9., et 1812 p 168 " et Journ de Med t. lxxiv. p. 136—Wright, Mem. of Med! Soc. of Lond. vol. in. Ap. n. 24.—.Leuren, Med. Bcmer- kung. tc. 1800. p. 76.— Engelhard, Mus. der Heilk b iv p. 183.—Westphal, Palholo-ia Da-inoniaca, p. 1 —Wich niann, Ideen zur Diagnostik, hi p. 134. 144.-MaAo„, Journ. deMed. t. lvm. t. 553.—Allamand, Journ deMed Cent. L xviii. ? 203.-Frank Acta Instil. Clin.' Vilnensi t 111. p. 51.-Theussink, Beobacht. der K. K. Josephs- Acad-emie, b. 1. n. 5.—Kette,hnr, De Chorea Sti. Viti Erf 1«G3,—Schaeffer, Kinderkrankh. p. 393.—Rei'l Fieberl- ehre,b. iv. p. 636.—Martin, Trans, of Med. and Chirurg Soc. vol. iv. p. 45.—Kinder Wood, in Tbid. t. vii. p. 237.— Watt, in Ibid. vol. v. p. 1.—Salter, in Ibid. vol. x. p. 218. —Gregory, Ibid. vol. xi. p. 299.—Willan, Reports on the Diseases of London, p. 245.; and Med. and Pnvi. Journ. vol. vii.—Coxe, Med. and Phys. Journ. vol. xiii. p. 405., and vol. xviii. p. 221.—Puterson, in Ibid. vol. xiii. p. 119., vol. xv. p. 127., and vol. xviii. p. 234.—Peltz, Ibid. vol. lix. S. 454.—Kerst, DeZinco ejusque Usu prxcipue in Chorea. en. 1812.—Muton, in Lond. Med. Repos. vol. v. p. 148.— Bedinsfeld, Compend. of Med. Practice, Lond. 1816, p. 52.—Copland, in Lond. Medical Repository, kc. vol. xv. p. 23.—Prichard, in Ibid. vol. xxi. p. 1.—Roeser, in Hufe- hind's Journ. der Pract. Heilk. Nov. 1828.—Serres, Lancet, vol. xiii. p. 133.—Aliprandi, in Giornale Analit. di Med. Milano, Guigno, 1828.—Ferrari, in Ibid. Nov. 1828.—Gib- ney, Med. Gazette, vol. i. p. 54.—Armstrong, his Lectures on Medicine, Lancet, vol. viii. p. 70.—Clutterbuck, Lec- tures on Med. Ibid. vol. xii. p. 421.—Piedagnel, in Magen- die's Physiology, translated by Milligan, 3d. edit. p. 189.— Laurent, in l£id. p. 191.—Bouteille, Traite de la Choree, fcc. Paris, 1810.—Powell, Trans, of College of Phys. vol. v. p. 358.—Maton, in Ibid. vol. v. p. 188.—Crampton, Trans. of (he Assoc, of Phvs. of Dublin, vol. iv. p. 111.—Griffith, Philad. Med. Mus. l'806.—Reeves, in Edin. Med. and Surg. Journ. vol. viii. p. 314.—Hunter, in Ibid. vol. xxiii. p. 261. —Jeffreys, Ibid. p. 273.—Stuart, in Ibid. vol. xxviii. p. 271. —Uwins, in Ibid. vol. viii. p. 408.—Swan, in Ibid. vol. xxii. p. 94.—Crichton, in Ibid. vol. xxxi. p. 300.—Manson, Re- searches on the Effects of Iodine, Sic. p. 230.—Elliotson, Trans, of Med. and Chirurg. Soc. vol. xiii. p. 252.; and Med. Gazette, vol. vii. p. 652.—Chisho/m, On Diseases of Trop. Climates, 8vo. 1822, p. 97.—Lisfranc, Archives Gc'ikt. de Med. Sept. 1827.—Hurrower, in Glasgow Med. Journ. vol. ii. p. 212.— Young, in the American Journ. of Med. Sciences, vol. i\. p. 310.—Brown, Medico-Chirurgical Review, fcc. vol. xv. p. 326.—Johnson, in Ibid. vol. xv. p. 481.—Serres, Revue Medicale, 1827. t. iii. p. 518. CLIMACTERIC DECAY.—Climacteric Dis- ease. Classif. 3. Class. 4. Order (Good). I. Class. V. Order (Author). 1. Dkfin. General decline of the vital powers, at the age of senescence, without any evident cause. 2. The ancients believed that very important changes took place in the economy at certain periods ; the first being the seventh year, and the subsequent epochs answering to the" numbers re- sulting from the n.uliplication of three, seven, and nine, into each other : as the twenty-first, the forty-ninth, the sixty-third, and the eighty-first years. The two last were called grand climac- terics, as the life of man was supposed to have readied its allotted term. The doctrine of cli- macteric periods has been traced to Pythago- ras, who derived it from the Egyptians ; and, although its truth has been denied by many emi- nent physicians, it has been believed in by others. The changes which take place at these epochs are of two opposite kinds ; that of renovation, and that of decay. It is the latter of these which will here be considered. 3. Symptoms.—This disease has been very minutely described by Sir 11. Halford. It usually comes on insensibly. The patient first complains of fatigue upon slight exertion ; his ap- petite becomes impaired ; his nights are disturbed or sleepless, and his mornings unrefreshed. The tongue is somewhat white ; the pulse a little accel- erated ; the face extenuated, occasionally slightly bloated ; the body emaciated, and the ankles and legs disposed to swell. The urine is not deficient, but the bowels are sluggish, and pains, with ver- tigo, are occasionally felt shooting through his head and various parts of the body, but are not possessed of the rheumatic character. As the vital exhaustion proceeds, the stomach loses all its powers ; the emaciation is greater ; the lower limbs are more oedematous ; restlessness through the day and sleeplessness through the night in- crease, and all the vital manifestations, mental CLIMACTERIC DECAY — Causes—Treatment. 337 and physical, are gradually extinguished. Such is the usual progress of the simple form of the disease, or rather gradual decay of the vital en- ergies,—a decay which is not peculiar to, but which may occur at any time intermediate be- tween, the grand climacteric periods. This sim- ple form of decay is, however, less frequendy ob- served than its complication with other affections. Persons who, together with the anxieties, griefs, and distresses of life, have been subject to disease of some particular organ, as of the lungs, liver, brain, heart, &c, who are of a gouty, rheumatic, or calculous diathesis, generally experience at these epochs an aggravation of such diseases, which assume a more dangerous character from the vital decay which is thus attendant upon them. Indeed, in most cases, these accidents, moral and physical, constitute the exciting causes or occasions of the appearance of climacteric disease, as well as complicate and aggravate its progress. 4. Causes.—This disease is more common to men than women, probably owing to the more tumultuous and exhausting life passed by them— to their greater exposure, during the preceding terms of existence, to the numerous causes of mental and corporeal exhaustion incidental to the states of modern society and civilisation. It is not infrequently occasioned by the mental depression arising out of pecuniary losses and disappoint- ments, and the death of old and attached friends and relatives. Thus, we sometimes observe it proceed rapidly to a fatal issue, or combated with great difficulty, after the loss of the partner of the principal part of the patient's existence. It may also be caused by a marriage contracted late in life, or by unusual intemperance, or some acci- dental shock or commotion of the frame. 5. As to its nature, climacteric decay is ob- viously the concatenated phenomena arising from that exhaustion of the vital energies which takes place at a more or less advanced age, in conse- quence of the cares, turmoils, and physical exer- tions, attendant on the existing states of society, particularly in the middle classes of life ; the exhaustion manifesting itself especially in these functions which are most intimately related to, and concerned in, the perpetuation of the vital endowment of the frame, and which are actuated by the organic system of nerves. As this decay of the vital energies—this breaking up of the con- stitution, as it is commonly called—is necessarily experienced by the whole frame, it is obvious, that it may not only be hastened by whatever is either mentally or corporeally injurious, as well as by specific forms of disease, but that it will be more or less remarkably evinced in those organs which have especially suffered during attacks of previous illness : hence the complicated states in which senile decay is usually observed, and the rapid progress and unfavourable issue of maladies appearing about the climacteric periods. 6. Treatment.—The simple form of this disease requires tonic and cordial medicines, with generous diet, a dry wholesome atmosphere, change of air, the occasional use of the tonic and deobstruent mineral waters ; agreeable occupa- tions and amusements; and, above all, the conso- lations arising out of the recollection of a well- spent life, and confidence of the future. During the course of treatment, particularly of the co;u- 29 plicated states of the affection, the digestive, se- creting, and excreting functions require to be as- sisted, by means of the warm, bitter, and cordial aperients (F. 86. 214. 266. 572.); and if internal congestions, or sub-inflammatory disorders, mani- fest themselves, evacuations should not be prac- tised without combining or alternating them with restoratives and tonics. The best aperients are, in such circumstances, rhubarb or aloes combined with gentian, quinine, guaiacum, or myrrh, or with the carbonates of the alkalies and the balsams. But, on all occasions, even of acute disease occur- ring at the climacteric epochs, it should be recol- lected, that the vital energies soon feel the shock, not only of the malady, but also of a too active or lowering treatment ; and that, even when such practice is most required, we should endeavour to support the powers of life by means the best cal- culated to fulfil this object, without increasing the morbid action, and to meet the first indications of depression or exliaustion by suitable cordials and tonics. The utmost attention should also be paid to the previous habits and indulgences of the pa- tient ; and if the discontinuance of them is likely to sink the constitutional energies still lower, they ought not to be relinquished. Various instances have occurred, showing the ill effects of want of attention to the above caution, during the course of my practice. 7. A gentleman had been for some years at- tended by the writer. At the age of eighty-one years, during a severe winter, he.suffered much from bronchitis, accompanied with great sinking ofthe vital energies. His habits were social, and he lived highly. He recovered, however, by means of warm diaphoretics, and tonic cordial aperients, with a due regard to his accustomed indulgences, and to the precept of Hoffmann, " ne subilo muta assueta, quia assuetudo est altera natura." The following year he had a similar attack, at his seat in the country. A nearly op- posite treatment to that which was adopted by the writer in his previous illness was directed by his medical attendants on this occasion, and in a few days he expired when seated on the night- stool, (see Hoffmann's treatise " De Situ erecto in Morbis periculosis valde noxio") about half an hour after the physician had left him, and given a favourable opinion of the result to his friends. 8. General------had served nearly all his life in the East Indies, and was upwards of eighty, but of a robust constitution. His ailments, when he was seen by me, could not be referred to any particular organ, and were attributed at the time to senile decay : the liver performed its functions. Nothing beyond the regulation and promotion of the digestive and excreting functions was attempt- ed ; and he was allowed a light and nutritious diet, with change of air, the use of the Bath wa- ter, &c. Under this plan he improved greatly, and was able to travel with ease from one part of the country to the other, and, when hi town, to dine daily at the Oriental Club. The last oc- casion but one on which I saw him, he came to my house, to inform me that his relatives were not satisfied with the progress he had made, and had repeatedly urged him to change his physician. I accordingly retired ; but, a few days afterwards, wis requested to see him. He was then sinking fist, evidently from the effects of a lowering treat- ment and of profuse evacuations upon a decayed 338 CLDIATE — Physical Relations of. frame. Speedy dissolution could not be averted; I therefore declined all interference. He died not many hours afterwards. Biblioq. and Refer.—Codronelii, De Annis C imac- tericis Comment. 8vo. Bon. 1620.—Brendelius, Monument. Fragilitatis Humana; mement.inc.-e Anni Climacterici, 4to. Alst. 1658.—Patin, Ergo ah Annis Climactericis nil metu- endum, 4to. Paris, 1657.—De Filisco, De Fato Annisque Fatalibus tam Hominious quain Regnis, 4to. Franc. 1665.— Salmasius, De Annis Climactericis et Antiq. Astrolog. Dia- tribe, 8vo. Leyd. 1678.—Ziegra, De Annis Cliinac. Vita: Humana;, 4to. Viteb. 1682.—Hoffmann, Annor. Climact. Medica et Rational is Explicatio, Operum vol. v. p. 89., et vol. vi. p. 105.—Hilscher, De Vano .flitatis Humana; Anni 63 Climact. magni vulgd dicti Timore, 4to. Paris, 1743.— Gruner, De Annis Climact. 4to. Jena-, 1792.—Halford, in Trans, of the College of Phys. of Lond. vol. iv. p. 316.— Renauldin, Diet, des Sciences Medicates, t. v. p. 360.— Good, Study of Medicine, edit, by Cooper, vol. iii. p. 226. 3d edit.—Pinel, in Archives Gener. de Mid. t. ii. p. 7.— Foucart, in Ibid. t. v. p. 398. CLIMATE. Syn. (From xXlua, a region).— Climat, Fr. Das Clima, Ger. Clima, Ital. Classif. General Pathology.—^Eti- ology and Therapeutics. 1. Climate, in its rigorous acceptation, means only a district placed between certain equatorial and meridional circles ; but it possesses a much wider signification in medicine, and is more com- monly applied to the conditions of the soil, sur- face, elevation, and position of a country, in con- nection with the general states of the atmosphere, influencing the health of the human species, and of the higher races of the animal kingdom :— " L'ensemble de toutes les circonstances naturelles et physiques, au milieu desquelles nous vivons dans chaque lieu."—Cabanis. 2. I regret that my limits will not admit of en- tering fully upon the consideration of the physical conditions which combine in forming the climate of a country, and not only modify the constitution of men, giving rise to a great part of the most acute diseases to which he is liable, but also assist in removing others of a dangerous tendency. It is obvious, that a knowledge of the elements out of which disease arises, and which may be taken advantage of, and even artificially combined, for its removal, must be of essential advantage in the healing art Indeed, the importance of the sub- ject has been admitted since the time of Hippo- crates, whose treatise ntpl uiytav vd'urujy y.al Tiiioatv will be read, even at the present day, with the greatest advantage. I shall, therefore, draw a mere sketch of the subject, and indicate the sources whence more detailed information may be obtained. 3. I. The Physical Relations of Cli- mate.—The climate of a district or of a country essentially depends, 1st, upon its position, in re- spect of distance from the equator ; 2d, upon its elevation above the level of the sea, and its prox- imity to the shores of the ocean, or the beds of large rivers, &c; 3d, upon the geological and mineralogical formations constituting the basis of its soil ; 4th, upon the nature of the soil itself, its cultivation, and the vegetable productions by which it is covered ; and, 5th, upon the prevail- ing winds or currents of air. Under these heads are comprised a number of subordinate phenome- na, giving rise to important modifications in the climate of a district. In the brief account, about to be given of the subject, the temperature and humidity of a place will be first considered, and afterwards those circumstances which relate more immediately to the nature of its locality. 4. A. Of the temperature and humidity of climates, and their effects.—The temperature of a place influences not only the organization, but also the diseases, of the inhabitants ; and, as it varies with the latitude, physical conditions of a district, state of cultivation, &c, it is evident that the physicians of the northern countries of Eu- rope have to treat different constitutions and states of disease, from those which come before prac- titioners in more southerly regions. The effects of temperature upon the human frame vary re- markably, owing to numerous concurrent circum- stances, and the extent, rapidity, and frequency of its changes. The mean annual heat, the ex- treme range of temperature, not only during par- ticular seasons, but also in each month ; the usual mean of such month, and daily variation ; have altogether a manifest influence upon the human frame. Geographers have divided the globe, in relation to its temperature, into arbitrary divisions, well known as the torrid, the two temperate, and the two frigid zones ; but the climate of the coun- tries placed within these divisions are so greatly modified by other circumstances than by distance from the equator, especially by elevation above the level of the sea, by distance from the ocean, want of cultivation, &c, that many places within the temperate zones, and even in those parts of them which are the nearest the meridian, ex- perience, particularly at one period of the year, remarkably low ranges of temperature ; whilst others, much further removed from the equator, are subjected, during summer especially, to as great heat as places within the tropics. In coun- tries or districts near the ocean, or large lakes and rivers, and particularly in islands or places partially surrounded or indented by the sea, the extremes of heat are moderated, but the air is moist, and the changes of season are uncertain and variable ; whilst in those situate far inland, and removed from lakes or the beds of large rivers, the range of atmospheric temperature is very great, particularly in latitudes above 40° north, or in places considerably elevated above the level of the sea ; and the air is remarkably dry. Even in countries within the tropics remote from the ocean, or having high ranges of moun- tains placed between them and it, that may attract and condense into clouds and rain the moisture carried by the sea winds over the land, the dry- ness of the atmosphere is very great, and, where the currents of air have passed over extensive tracts of arid country, is even extreme. This is well shown by the Harmattan winds, which, having blown over the dry countries of central Africa, visit its western coast, and change the extreme humidity of that part, during their con- tinuance, to a state of remarkable dryness. In the more inland districts, therefore, of large con- tinents or islands, placed without the torrid zone, the depression of the thermometer during their winter months, and elevation of it in summer, are greater than is indicated by their distance from the equator, and the air is much drier than in places otherwise circumstanced. In these latter, particularly insular situations, &c, the climate is more equable but much more humid. In the former the seasons are regular, the change con- stant and rapid ; in the latter they are variable, irregular, their accession slow, and attended by storms and hurricanes. CLIMATE — Physical Relations of. 339 5. The intensity of the solar beams, and con- sequently of light, in warm countries, is very in- fluential iu modifying not only the vegetable and animal creation which inhabit them, but also many of the physical phenomena which con- tribute to the constitution of their climates. It would seem as if the solar beams were decom- posed by the soil and its products, and, whilst furnishing heat and light to objects upon the sur- face of the earth, served to supply or to replace the locomotive electricity, which is constantly cir- culating through, and actuating, not only the crust of the globe, but also the vegetable and animal creations which cover it; passing thence, at last, into the atmosphere. Observation has clearly shown that electrical phenomena are most ener- getic, and of most frequent occurrence, in coun- tries and in seasons in which the solar influence is the greatest; and that, while dryness of the atmosphere causes its accumulation in objects placed on the surface of the globe, a moist state of the air favours its passage thence, and its ex- cessive increase in the clouds, giving rise to va- rious meteorological phenomena. In a dry at- mosphere, particularly in inland districts, thunder and lightning,—the more violent electrical changes occurring in this fluid,—do not take place ; whilst vegetables and animals, as well as other bodies, placed on the earth's surface, are more than usually charged with electricity ; whereas, in a warm and moist atmosphere, especially in mari- time or insular situations within the tropics, these phenomena are very frequent, and the electricity is rapidly carried off from the earth. 6. It is evident that the annual quantity of rain in a particular district is very intimately connected with the nature of the climate ; depending as it does upon the sources and amount of evaporation, and the prevailing winds. In the middle coutitries of Europe, the annual quantity of rain usually ranges from 12 to 18 inches. In the south-east side of this island, and in the vicinity of London, it commonly varies from 20 to 25 inches ; whilst it is nearly double this amount in the western parts of Great Britain and Ireland ; the greatest quantity falling in July, when the mean monthly temperature is highest, and the smallest quantity in February and March. As we advance towards the equator, the annual quantity of rain increases, chiefly in maritime countries, and parts in which ranges of high hills or mountains skirt the sea- coast, and varies from 80 to 120 inches. But the number of dry days is increased, particularly in districts situate inland; the greatly augmented quantity of rain falling at a particular season, and in a much shorter space of time than in colder regions. In cold or temperate maritime places, on the other hand, the rain descends in slighter showers, and much more frequently, although in much less quantity ; leaving fewer dry, and oc- casioning more foggy and drizzling days, than in warm or inland countries. 7. B. Besides the foregoing, there are other circumstances which concur in forming the climate of a place. The chief of these are, the nature of the locality, the soil, the abundance and exu- berance of the vegetable creation, the state of cultivation, the prevailing winds, &c. In the consideration of the locality, elevation above the level of the ocean, proximity to its shores, the vicinity of large rivers or lakes, the condition of the surface, its elevation into hills or mountains, or depression into valleys or ravines, and the state of vegetation and cultivation, are the chief fea- tures that require notice. Places inland, which are elevated high above the sea, or the banks of large rivers or lakes, have their mean temperature diminished, in proportion to the elevation, much below those which, although equally far removed from the equator, are situate near the level ofthe ocean, or the bottoms of valleys ; and the in- habitants thus breathing a drier, purer, and cooler atmosphere than in these latter localities, are more athletic, less subject to febrile diseases of a malignant or severe character, and reach more advanced ages. The influence of elevation above the level of the sea, and other circumstances of locality, upon the health of man, is chiefly shown in warm climates, and the more southerly of temperate countries. In the north of Italy, and in various districts in the south of Europe situate on the sea-coast, near the banks of lakes and rivers, and in low or narrow valleys, where a deep, moist, and rich soil abounds with organic substances in a state of decay, the air is humid, loaded with effluvia ; is much more stagnant and dense ; and, although the heat is moderated, as respects the extremes of its range, much within the limits to which it advances in elevated and inland parts, yet is it more oppressive, the at- mosphere frequently being sultry and relaxing. Hence it is, that in these low situations the hu- man frame is imperfectly or weakly constituted ; a small proportion of the children bom are rear- ed ; visceral and glandular diseases abound ; and the mean duration of human existence is much shorter than in adjoining districts, which are either more highly elevated, or removed from the sources of contamination ; and, from these districts, the diminution of the population of the former, continually occurring, is chiefly supplied. The East and West Indies, and the coasts of South and North America, furnish numerous illus- trations of the influence of locality upon the cli- mate, and thereby upon the constitution and health of the human race. So very different is the cli- mate of Vera Cruz, and places in the vicinity, from other parts in the same latitude, but situated some hundred feet above the level of the sea, that the comparatively robust and healthy inhabi- tants of the latter are more subject to the endemic fevers of the former localities, when they visit them, than the natives ; a continued residence having impaired the susceptibility of the inhabi- tants of the former places. 8. In the consideration of the soil, the geologi- cal and mineral relations of the place can scarce- ly be overlooked. In general, the older forma- tions of rocks, and those of a homogeneous and compact nature, support a finer, a more deep, and more absorbent soil than the sandstone rocks and others, the debris of which form a coarse and gravelly substratum, through which the rain percolates and flows off, it not being retained in the surface to be evaporated, carrying with it into the air a portion of decayed vegetable and animal matter, as in the case of clayey, deep, absorbent soils, that yield by evaporation nearly all the rain which falls upon them. Whilst deep, rich, and moist soils, particularly near the banks or em- bouchures of rivers, on the shores of lakes, on the sea-coast, and near its level, or in low cou- 340 CLIMATE — Physical Relations of. fined valleys, or at the basis of mountains, es- pecially in countries within 40° of the equator, are very productive of malaria ; dry, sandy, or gravelly soils, somewhat elevated above or re- moved from the mouths and banks of rivers, and covering level, gently undulating, or moderately hilly places, are most salubrious. In northern and temperate regions, maritime places are equal- ly healthy with inland districts, or even more sa- lubrious, unless the latter be considerably ele- vated, possess a dry, weil-cultivated soil, and be without marsh lands in their vicinity. But in warm climates, and even in many temperate countries, during warm seasons, places on or near the sea-coast are more productive of insalubrious exhalations than inland districts, owing not mere- ly to their being more nearly on a level with the sea, and subjected to a denser and more moist atmosphere, but chiefly to the circumstance of the soil in soch localities being more deep, rich, and absorbent; more liable to inundations from heavy rains or swollen rivers, and from the sea itself; more fertilised by the decay of vegetable and animal bodies ; and hence more productive of the elements of unwholesome exhalations, when their extrication is favoured by a hot sun, and their retention and accumulation in the air are promoted by its more coustant and greater humidity. Ravines, deep valleys, marsh grounds, the banks of rivers liable to exposure after inun- dations, the banks of lakes or canals similarly circumstanced ; a soil profusely covered by suc- culent plants and other vegetable productions, and not reclaimed by cultivation, or but recently cultivated ; grounds and soils exposed to the ac- tion of the sun, after having been long covered by an exuberant vegetation ; the cultivation of rice, or other vegetable productions, which re- quire occasional inundations or profuse irrigation; the partial admission of sea-water, or its percola- tion through the natural embankments thrown up by the waves in low swampy parts of a coast; and the accumulation of dead vegetable or ani- mal matter, of ordure, &c, in ditches, sewers, or drains, &c.; are the principal sources of those vapours and gaseous emanations which, being extricated by heat, and dissolved in the moisture ofthe air, act unfavourably upon the human con- stitution, and originate several of the most fatal diseases to which it is liable. 9. C. The cultivation of a country has also a marked influence upon the state of its climate. A district covered by a rank and exuberant vege- tation—by extensive forests—is cold and moist, if situate beyond the tropics, its temperature and humidity being many degrees lower than that which a state of high cultivation would produce. A country similarly circumstanced within the tropics is also cooler and more moist than if it were cultivated ; but the air is remarkably close and oppressive ; and teems, as well as the soil, with the lower grades of animal creation, to the generation and nourishment of which its abun- dant wild vegetation chiefly contributes. Whilst the wooded and uncultivated districts of high latitudes occasion coldness and humidity of the atmosphere, abound in miasms from decayed vegetable matter, and produce the diseases usual- ly proceeding from these causes, especially in- termittents, catarrhs, rheumatism, pulmonary af- fections, &c, places covered by an exuberant vegetation within the tropics, particularly those near the sea-coast, and upon its level, abound with the effluvia arising not only from vegetable matter constantly in a state of decay, but also from animal exuviae, and the dead of myriads of insects and reptiles which infest these localities, and occasion malignant and remittent fevers, dysentery, and diseases of the abdominal viscera. 10. Although cultivation renders a climate warmer, drier, and more salutary, especially in temperate countries, yet for many years after the soil is cleared from its more bulky vegetable productions, and when it is first exposed to the action of the sun, especially in low latitudes, its endemic diseases often become more severe than even previously, and not infrequently assume an epidemic or pestilential form. The medical his- tory of the West India islands and adjoining coast of America, as well as ofthe United States, furnishes numerous proofs of this position. The surface of the earth, previously in a great meas- ure protected from the action of the sun's rays by the thick and exuberant vegetation that cover- ed it, and the temperature lowered by a freer evaporation and transpiration from the leaves, yielded a less noxious effluvium than when en- tirely exposed to the sun's rays, and to the free action of air heated many degrees higher by the exposure. In its unreclaimed state, the noxious exhalations proceed chiefly from the decayed vegetable matter covering the soil, a great por- tion of which seldom rises above or extends be- yond the higher foliage of trees ; in its cleared state, the emanations are the product ofthe earth itself, and result from its richer constituents, and those elements of animal and vegetable matter with which a deep absorbent soil abounds, par- ticularly in warm countries. The exhalations from the former source are more constantly and uniformly generated ; but, from the latter, they are only occasionally formed, and require a concurrence of circumstances, especially a high range of temperature, a situation but little ele- vated above the sea, the vicinity ofthe sea-coast, and probably a certain degree of humidity of the air, and peculiar state of its electricity, for then- generation. 11. D. Prevailing uinds have much influ- ence upon a climate. In Great Britain, and most countries forming the north-west of Europe, northerly and easterly winds are frequent during March, April, and May, owing to the current established to replace the warmer air, as it rises from the surface of the Atlantic and more south- erly countries, now warmed by the sun as it passes to the northward of the equator. These winds are generally dry and cold, precipitating the moisture in fogs, and occasioning catarrhal, bronchial, pulmonary, and rheumatic affections, and, under certain circumstances, agues. During summer and autumn, southerly and westerly winds are most prevalent, and the air is more moist, owing to the temperature of the inland countries of Europe being now greater than the surface of the Atlantic ; and to the air, loaded with exhalations from the ocean, rushing to re- place the strata which are constantly rising from the heated surface of these countries, and deposit- ing the moisture in the form of showers, &c. as it passes over the land ; the hills, mountains, and places in their vicinity, which first attract the CLIMATE — Physical Relations or. 341 clouds formed by the exhaled moisture, experienc- ing the greatest fall of rain. During November and December, northerly and easterly winds are again frequent, and the fall of rain is much increased. As the atmosphere receives or dissolves a portion of those fluid or gaseous substances with which it comes in contact, it is obvious that currents of air passing over the sources of the insalubrious exha- lations enumerated above (§ 8.), will be more or less fraught with them. On the other hand, the air readily imparts a portion of those foreign sub- stances dissolved in it, when brought in contact with bodies differently circumstanced. Hence it follows that prevailing winds, whether in north- ern, temperate, or warm countries, will have con- siderable influence on the climate, particularly in the3e last, for there the winds are generally most regular and constant, especially at certain sea- sons : places experiencing the sea breezes, and the winds which have passed over a dry and well cul- tivated country, being favourably circumstanced; but those exposed to currents of air from the sources of disease already referred to, being not much more fortunately placed than if they were immediately surrounded by insalubrious localities. In the case of towns, villages, or dwellings, thus situate, ill effects may be partly guarded against by planting double or treble rows of tall trees in such a manner as to intercept the noxious exha- lations in their passage from the places in which they are generated. In this way the ancients protected their villas and towns from malaria; and it has been shown in modern times, that the foliage of trees attracts and absorbs these exha- lations as they circulate through it, particularly at the season when they are most abundantly ex- tricated from the soil. 12. Maritime places, in warm climates, and the more southerly of temperate countries, whilst they experience in the day-time, during the great- er part of the year, regular sea breezes arising from the current of air replacing that which has been rarefied by the heated surface of the earth, are also subjected to land winds during the nights, owing to the less rapid evaporation and greater heat of the surface of the ocean at this time, the rapid radiation of heat from the soil soon reduc- ing the temperature of its surface below that of the ocean in the same latitude. These wind-* are often fraught with effluvia, which, having been exhaled during the heat of the day into the upper regions of the atmosphere, are at night precipi- tated to its lower stratum, and are very produc- tive of disease in those exposed to them. The currents of air that during the heat of the day passed from the ocean more or less loaded with moisture, return to it in the night, charged not only with humidity, but also with terrestrial ema- nations; thus rendering places situate in the vi- cinity of the sea, and nearly upon the same level, more insalubrious than the elevated districts in- land. Numerous places in the East and West Indies, South America, and Africa, furnish illus- trations of this principle, as well as various dis- tricts in North America, and in the south of Europe, particularly those on the shores of the Mediterranean. 13. General view of the subject. — From the foregoing, therefore, it will be seen that the word climate embraces not only the temperature of a country, and the phenomena which depend upon | 29* the distribution of heat, but all the modifications of the atmosphere by which our organs are sen- sibly affected, particularly states of humidity, va- riations of barometric pressure, changes of electric tension, the admixture of gaseous emanations or substances dissolved in the atmospheric moisture, clearness and serenity, and tranquillity as respects both horizontal and vertical currents. All these exert a powerful influence, not only upon the developement and health of the vegetable and animal structures, but also upon the sensations, the intellectual endowments, and the moral emo- tions of mankind, in the different regions and zones of the world. Comparatively few of these atmospheric changes can be ascertained other- wise than by a long series of attentive observa- tions; and these have been made only at a few parts of the earth's surface; and hence, as re- marked by an able writer, though we know with some precision the general circumstances which modify the distribution of heat, we are still im- perfectly informed as to the influence of local causes of deviation from the mean state that would be attained if the surface of the earth were per- fectly regular, and its power of absorbing and emitting heat and light were every where the same. Europe and Asia are contrasted with each other in respect of many of the circumstances which affect their climate. In a general view, Europe may be regarded as being almost a pen- insula, broken, moreover, and intersected by numerous arms of the ocean and inland seas. Owing to the causes already alluded to (§ 11.), the predominating winds are from the west, and these, for the whole ofthe western portion of this quarter of the globe, are sea winds softened by passing over a mass of water, the temperature of the surface of which, even in the month of Janu- ary, under the mean parallels of 45 or 50 degrees, does not full below 48J and 52° of Fahrenheit. Europe has also the advantage of being placed to the north of immense tracts of tropical land, which, by its diurnal radiation, produces effects very different from an equal superficies of ocean. Masses of heated air are constantly rising from the arid surface to the higher regions of the at- mosphere, and are impelled towards the colder countries of the north. On the northern side of this quarter, circumstances are unfavourable to the accumulation of extreme cold; for a very small portion of land is placed beyond the polar circle, and the whole northern extremity is se- parated from the polar ice by an open sea, the temperature of which is very much higher than that of a continental country in the same latitude. The comparatively high temperature of the sea on the north of Europe is chiefly to be ascribed to the direction of the great oceanic valley which separates Europe from America, and the existence of the gulf stream; the intertropical Atlantic wa- ters flowing from the Gulf of Mexico into the po- lar seas. 14. The circumstances which thus contribute to render the climate of Europe mild, do not exist in respect of Asia, or even of America. Their northern boundaries extend to the winter limit of the polar ice. The north winds, unobstructed by any chain of mountains, blow with unmiti- gated fury over icy plains extending northward to the pole, and eastward to the point of maxi- mum cold, which, according to Humboldt, 342 CLIMATE — Its Influence on Man. and others, seems to be situate near the meridian of Behring's Straits. The refrigerating effects of these winds are not counterbalanced by burning deserts on the southern side of these continents; or, as respects Asia, by any great extent of land placed below the equator; consequently the Asi- atic countries situate in the temperate zone, more especially, are not warmed by ascending cur- rents of heated air, such as those which arise from the deserts of Africa, and are so beneficial to Europe. The position of the great mountain chains of Asia, and the elevation of the country, also contribute to diminish the temperature, they presenting a barrier to the warm winds from the equatorial regions. Elevated plains and groups of lofty mountains accumulate and preserve the snow till late in the summer, and give rise to de- scending currents of air, which cool the circumja- cent countries. Asia, moreover, in the whole extent of Europe, has no sea on its western side; consequently the west, or predominating winds, are, for the greater part of this quarter, land winds; and their severity is increased by the great enlargement of the land towards the north. These circumstances occasion remarkable differ- ences in the climates of Asia and the western countries of Europe. The eastern part of the lat- ter, however, nearly assimilates with the western districts ofthe former; and, with the whole of it, to the north of the 35th degree of latitude, has a climate in which the temperatures of summer and winter are widely different from the mean tempe- rature of the year. At Moscow (lat. 55' 45'), where the mean temperature of the year is only 40° Fah., the mean temperature of the hottest month is 70£°; while at Paris (lat. 48J 50'), 7J farther south, where the mean temperature ofthe year amounts to 51°, that of the hottest month is only about 65£°. In no part of the world, not even in Italy or Madeira, do finer grapes come to maturity than at Astrakan, on the borders of the Caspian; and yet at the same place, or even still farther south, under the latitude of Avignon and Rimini, the thermometer falls in winter to 18J and 22° below the freezing point. On the west- ern coast of France, in the latitude of 48°, the mean temperature of the year is the same as at Pekin, the latitude of which is only 40'; while the temperature of the winter months is 14^° higher in the former. 15. The mean temperature under the equator is not precisely determined; but Humboldt thinks it does not exceed 80° of Fahrenheit. The greatest summer heats are found in countries contiguous to the tropics. On the Red Sea, for instance, and in Arabia, the thermometer is often seen to rise to 110° at mid-day, and to remaio at 94° during the night. A few degrees within the tropics, the sun at midsummer continues for a considerable time to pass daily very near the ze- nith; and the day, increasing with the latitude, is longer than under the equator; so that the amount of nocturnal radiation is diminished. Among the local causes which contribute to give an excessive temperature to the Arabian penin- sula and the north of Africa, the sandy surface almost deprived of vegetation, the constant dry- ness of the air, the direction of the winds, and the quantity of heat radiated from earthy particles carried about in the atmosphere, are the most prominent. 16. II. Influknce of Climatf. on the Human Constitution.—From what has been already adduced, the action of climate on the human frame must be admitted to be extremely complex; the ultimate result arising chiefly from the combined operation of heat, light, electricity, atmospheric pressure, the various emanations arising from the soil, and the productions, vege- table and animal, constituting the food of man. The human species is, in many respects, moral as well as physical, moulded by the climate and soil which he inhabits; and, by this pliability of his functions, under the influence of atmospheric and other vicissitudes, is the only animal that is truly cosmopolite. In considering the influence of cli- mate on man, it will be advantageous to view it, first, with reference to extensive communities and races ofthe species; secondly, as respects the na- ture of the food which different climates provide for the uses of man, and its co-operation with the climate in modifying the human frame, and coun- teracting the effects of rigorous seasons, and the unfavourable influences to which it is exposed in arctic and tropical regions; and, thirdly, as regards the changes produced in individual constitutions after migrating from one climate to another. Neither the limits nor the scope of this work will permit me to consider these subjects in all their relations; I must, therefore, confine myself to such topics as have an evident and important bearing upon practical medicine—in respect either of the causation and nature of disease, or of ra- tional methods of cure. 17. i. Climate in relation to the Va- rieties of the Species and their pre- vailing Diseases. — Although man is more readily assimilated with particular climates than any other animal, yet this faculty is not equally possessed by all the varieties of the species and the natives of every latitude. It is more particu- larly manifested by the inhabitants of temperate climates; probably owing to their greater vital energy, and, to their habitual exposure to alternate extremes of temperature and of season. The na- tives of polar regions on the one hand, and of tropical countries on the other, possess it in a much less remarkable degree; and not only are they speedily cut off by removal from the one climate to the other, but they often suffer greatly from a residence in temperate countries. It should not, however, be overlooked, that man, like many of the individuals below him in the scale of creation, often derives advantage from a change of locality; provided that the change is not made to opposite climates, but to districts of equal or greater salu- brity. 18. It has long been a matter of dispute whe- ther the differences, intellectual and physical, presented by the various races of man, have arisen from the continued, slow, and imperceptible ope- ration of climate; or have been originally impress- ed upon the species. The evidence and arguments connected with this subject fall not within my province. But it is of importance to the practical physician to note what those peculiarities are, that characterise the different races of man; and, whether they be the result of climatorial influ- ence or of original conformation, to consider them in connection with the climates to which we find them more particularly, appropriated in our survey of man in his distribution over the globe. CLIMATE—Its Influence on Man. 343 However cursory this survey may be, there are to which they become exposed: whilst their mala certain facts of the utmost practical importance to every one who entertains philosophic ideas in medicine, which should not be overlooked ; namely, that the slow and continued operation of a particular climate actually changes the human frame in many respects to that state which its in- digenous inhabitants present; and that the con- stitution, thus'assimilated, is necessarily the best suited to the external influences to which it is ex- posed, and the food furuisued by the soil of which it is the native. There are, however, certain characteristics, especially those which distinguish the ^Ethiopian and Mongolian varieties, that a succession of ages has not been sufficient to im- part to different races which had migrated to the climates they inhabit ; and which must, there- fore, be imputed to original conformation. 19. A. The effects of great cold, and of the privation of solar light, during nearly two-thirds of the year, upon the human frame, are observa- ble in the stunted growth and the weak muscular power of the Samoied, the Ostiaks, the Esqui- maux, the Greenlander, and the Laplander, com- pared with the inhabitant of temperate climates. In the arctic regions, the human body, like many of the lower animals, and the productions of the vegetable kingdom, rarely reaches that state of developement it presents in temperate countries : the features and stature retain an appearance of boyhood or youth, almost until marks of age ap- pear ; the complexion is grayish ; the head flat, the face broad, the eyes far apart, and the whole figure squat and unattractive. Female pubes- cence, however, according to the accounts given by Linnaeus, Humboldt, Lyon, Parry, and Franklin, as indicated by the accession of the catamenia, is not delayed beyond the period usual in temperate countries—most probably owing to | the premature excitement of the generative organs in the unrestrained intercourse of the sexes, that takes place at an early age. To this cause, also, j is to be imputed the circumstance of their females j being less prolific than those of temperate climes; whilst, in these races, the instinctive feelings which tend to the preservation of the individual J and of the species are sufficiently strong, the in- tellectual endowments and moral sentiments are remarkably torpid. The benumbing influence of cold, and of the privation of solar light, is also manifested in the functions of the nervous and sanguiferous systems. Diseases generally assume among them an asthenic form ; fevers being of a j low type, and sthenic inflammations of rare oc- ] currence. As long as the natives of arctic regions remain in their own countries, they are exposed ; to but few causes of disease besides cold, the scarcity of provisions, occasional excessive reple- tion, and various contagions. The soil being al- most constantly frozen, even during summer, at the depth of a very few feet, deleterious emana- tions seldom or never issue from it; but infectious maladies, when once introduced, become ex- tremely destructive, and several of them often very prevalent, owing to their low, small, and unventilated dwellings, and their want of personal and domestic cleanliness. When, however, they migrate to more temperate and southerly regions, they are very liable to febrile and sub-inflamma- tory diseases, arising from increased temperature, the vicissitudes of season, and other novel causes dies seldom require, their constitutional powers can but ill tolerate, a lowering treatment, or large sanguineous depletions. 20. B. Although extreme and continued de- pression of temperature produces the above ef- fects, more moderate cold, particularly when alternating with a temperate summer heat, pro- motes the developement of both the body and mind. Countries situate between 45J and 63° of northern latitude are inhabited by the most robust and enduring of our species, in respect to both physical and intellectual powers. It may be stated in general of the northern temperate zone, that the inhabitants of its more southerly coun- tries have made the earliest advances in civilisa- tion, and that those of its middle and more north- erly climates have carried the useful arts and sciences to the highest perfection. Within the range of this zone, man presents the greatest di- versity of temperament, of constitution, and men- tal endowment. Muscular frames, plethoric hab- its of body, and the sanguine temperament, pre- dominate among the natives of the more norther- ly of temperate climates, particularly as regards Europe and its western countries. Affections of the chest and respiratory organs, inflammations, fevers complicated with inflammations of the lungs or of the brain, and rheumatism, are the most prevalent diseases. Epidemics assume most frequently amongst them a phlogistic character : and vascular depletions are more required, and better borne, in the treatment of their maladies. ' Climates which are the most variable, as to both the commencement and the course of the differ- ent seasons, are, notwithstanding the many dis- advantages imputed to them, the most favourable to the advancement of the various bodily and | mental powers. The rapid and frequent vicissi- 1 tudes of weather preclude, as respects the com- | munity generally, the regular adoption of means j to guard the body against their operation : con- sequently the frame becomes habituated to their operation, and thereby fortified against the in- jurious impressions which would be otherwise made by them. That countries thus circum- stanced are benefited rather than injured by this state of weather and season, is shown by the robust frames, the mental activity, and the lon- gevity of their inhabitants. The physical and moral history of the British Isles, Denmark, Sweden, and the more continental districts of western Europe, demonstrate this fact. In the eastern countries of this quarter of the globe, as well as in Central Asia and in North America, the seasons being much more regular in their ad- vent and in their course, measures are more regularly and uniformly adopted to moderate the extremes of temperature and the vicissitudes of weather ; and these have, in many instances, the effect of enervating the frame, of promoting the extension or prevalence of disease, und of thereby diminishing the mean duration of human life. Of this description is the use of excessively warm clothing, and of stoves, which overheat the air of the apartments, without renewing it so rapidly as is often requisite to the wants of the economy. Hence, whilst the external atmosphere is cold, dry, and invigorating to the healthy frame iu a state of activity, the air in-doors is close, warm, and depressing ; the frequent alternation from 344 CLIMATE — Its Influence on Man. the one to the other, or the conslant residence in the latter, being injurious even to those in health, and causing diseases of the thoracic and abdomin- al viscera. 21. While the natives of northerly inland countries suffer more especially from the extremes of temperature and of season, and the circum- stances which arise out of them, they are less exposed to emanations, arising chiefly from the decomposition of vegetable and animal matter— to those endemic sources of disease that produce so much suffering and mortality in low or level districts, and in more southerly climates, where the atmosphere is moist and warm. The inhabi- tants of temperate countries considerably elevated above the level of the sea, and of mountainous places, are generally of a spare, firm, and mus- cular habit of body, and strongly formed; chiefly owing to their active and industrious modes of life, and the pure and light state of the air they breathe. The irritable, sanguine, and nervous temperaments, and quick, irritable, and generous dispositions ; predominate among them. Inflam- matory, hemorrhagic, and spasmodic diseases, particularly haemoptysis, bronchitis, consumption, asthma, inflammations of the lungs and pleura, rheumatism, and disorders of the circulatory or- gans, are most common. Their females are more virtuous and prolific, and the mean duration of human life longer, than amongst the natives of lower districts and warmer climates. 22. C. There are certain peculiarities in the natives of temperate countries, particularly of European countries, that must strike the patholo- gist as intimately connected with the nature and j treatment of their diseases. These are chiefly the complexion of the skin, the large developement of the respiratory, biliary, nervous, and circulat- ing organs, compared with those of the natives of intertropical countries. The skin of the dark | races is not only different in colour-, but is also j considerbly modified in texture, so as to enable it to perform a greater extent of function than the more delicately formed skin of the white variety of the species. The thick and dark rete mucos- um of the former is evidently more suited to the warm, moist, and miasmal climates ofthe tropics, than that with which the latter variety is pro- vided. The skin of the negro is a much more active organ of depuration than that of the white. It not merely exhales a larger proportion of aqueous fluid und carbonic acid from the blood, but it also elaborates a more unctuous secretion, which, by its abundance and sensible properties, evidently possesses a very considerable influence in counteracting the heating effects of the sun's rays upon the body, and in carrying off the super- abundant caloric. Whilst the active functions, aided by the colour, of the skin, thus tend to diminish the heat of the body, and to prevent its excessive increase by the temperature of the cli- mate, those materials that require removal from | the blood are eliminated by this surface, which, in the negro especially, performs excreting func- tions very evidently in aid of those of respiration and of biliary secretion. In the white variety of the species, on the other hand, the functions of the lungs and liver are much more active than in the darker races, changes to a greater extent being performed by respiration in the former than in the latter, as I have proved by experiment. | The liver is also larger, and its secretions more copious in the European than in the negro or Mongol. 23. In the inhabitants of northern climates, and elevuted or cold countries, the functions of the lungs and kidneys are extremely prominent, and those of the skin find liver much less so , eliminating or depurating actions on the blood being performed chiefly by the former organs. But, in the natives of intertropical climates, the skin assumes, as shown above (§ 22.), a more extensive function, and, by its activity, compen- sates for the diminished operation of the lungs, liver, and kidneys, generally observed among them, aided, no doubt, by the secretions from the intestinal mucous surface. In temperate coun- tries, the various emunctories of the frame pre- sent a degree of activity in strict keeping with this general connection of climate with the de- velopement and activity of these functions. In the warmer districts of temperate climates, and especially in those which are subjected to a dense, moist, and miasmal atmosphere, the changes pro- duced by respiration are diminished, and those effected by the cutaneous and intestinal mucous surfaces are increased. If the natives of such districts belong to the white variety of the species, their cutaneous surface not being constituted so as to enable it to perform the compensating action for which the skin of the darker races is destined, a different organ performs this office, and the liver assumes an increased action, combining and eli- minating seveial of the effete constituents or elements as they accumulate in the circulation, and thereby giving rise to an increased and modi- fied biliary secretion. 24. D. If we compare the organization and functions of the negro (and I may add, of the Mongol) with those of the European, the follow- ing general results will appear, and, together with what has been now advanced, will serve as the source of very important pathological and thera- peutical inductions :—The circulating organs, the lungs, the liver, the middle and anterior lobes and convolutions of the brain, the muscles, and the bones, excepting those of the head and face, are very evidently smaller, and their functions less prominent, in the former than in the latter variety ; whilst, on the other hand, the skin and its functions are much more developed. With the activity of function, conjoined with frequent exposure to the action of numerous excitants, the disposition to, and occurrence of, disorder increase ; and, accordingly, diseases of the lungs and circulating organs, of the liver, and of the nervous system, predominate in the white races of man ; and chronic affections of the skin, and those acute maladies which chiefly attack this surface and the intestinal mucous membrane, in the dark varieties of the species. Amongst the latter, fevers are not commou ; and when they occur, they are usually slight, terminate speedily, seldom assume an inflammatory or continued type, often pass off with critical discharges from the skin or bowels, and not infrequently lapse into a state of low or chronic dysentery. The exanthematous diseases generally assume in them a severe and asthenic form, and rapidly spread by infection. Verminous disorders are very com- mon in them ; but affections of the brain and its membranes, and of the teeth, are extremely CLIMATE — Iw relation to the Food of Man. 345 rare; the cranial contents seldom suffering ma- terially in the course of febrile attacks. The remarkable tluckness of the bones of the head, in nearly all these races, protect the membranes and brain from the causes of disorder to which they are liable; and the continued exposure of the head to the action ofthe sun and air, the ab- sence of mental culture, and their modes of life, by no means dispose these parts to disease. In- flammations, particularly those of a sthenic cha- racter, are very rare; and, if vascular excitement attend the early stage of these maladies, it soon exhausts itself and passes into the opposite ex- treme. Disorders, which consist chiefly of mor- bidly increased discharges, from deficient tone of the extreme vessels, and those of a spasmodic form, are not uncommon. 25. E. The organization of the dark races of man, chiefly as respects the state of vascular ac- tion and tone, the developement of the viscera already referred to (§ 22—24.), their food, modes of life, excessive addiction to venereal indulgence, the continued influence of a moist and miasmal atmosphere, and the characteristic features that their diseases consequently assume, generally preclude the employment of large vascular de- pletions. During the progress of febrile and ex- anthematous maladies, critical evacuations from the skin and intestinal mucous surface frequently occur, the latter of which are very apt to assume a colliquative or chronic state, and, if not ju- diciously controlled, to carry off the patient. Hence the propriety of employing free evacu- ations of the prima via, with warm diaphoretics, at the commencement of their diseases, and of supporting the energies of life in the advanced stages. The circumstances now referred to as modifying the constitution and diseases of the dark races of our species, should never be over- looked when devising plans for treating them. Nor should the fact be neglected, that worms, especially lumbrici, in the intestinal canal, are very frequently connected with the origin of many maladies of remote but related organs. Af- fections of the stomach, diarrhoea, colicky pains, leucorrhcea, various spasmodic and convulsive disorders, chronic dysentery, &c. very often arise from this cause; and, no more than the cause itself, will ever be permanently removed, in these races especially, by evacuations alone, but by com- bining them with stimulants, tonics, and anti- septics. Although both the habits and modes of living of the dark races, and the constitution of their digestive organs, require the occasional use of active purgatives, in order to remove the sa- burra and colluvies which so rapidly collect on the intestinal mucous surface, yet those medicines should generally be combined or alternated with substances which exert a cordial and tonic influ- ence, as their vital energies soon sink under fre- quent evacuations when deprived of an accustom- ed or requisite stimulus. (See Art. Disease.) 26. ii. Of the Food of Man in relation to Climate and the Constitution of the Varieties of the Species.—The intimate relation which subsists between the food of man, and the nature of the soil and climate which he inhabits, and the combined operation of both upon his constitution and the character of his diseases, have seldom been considered in a manner deserving ofthe subject. Man, although ' in some measure independent of the nature of the soil or climate in which he lives, is yet, in several points of view, the creature of both. His manifestations, both moral and physical, are moulded by both influences, like the animals which are below him in the scale of creation, although generally in a much less degree. It is the soil that furnishes him food, and the air which he respires derives much of what is noxious to his frame from that source. When- ever, therefore, the natural history and diseases of man come under consideration, they should be viewed in relation to those productions of the soil on which he subsists—with which, in many respects, he may be considered as a fellow product, but holding a superior station, and by which are often caused many of his ailments. As it is beyond the scope of this work to enter fully into the very interesting considerations which this subject involves, I can only point to its more general connections; and I do this more with a view of directing the attention of others to the subject, than of satisfying my own wishes as to its discussion. 27. As the physical and intellectual powers of man enable him to occupy the whole surface of the globe, it follows that he cannot be restricted to any particular kind of food — in other words, he must be naturally omnivorous, as a consequence of his ubiquity. If the wastes of Lapland, the shores of the icy sea, the frozen coasts of Green- land, and the deserts of Terra del Fuego, were destined by nature for the habitations of man, then is he not an herbivorous animal ; nor is even a mixed diet necessary for his support. It would be impossible to procure vegetable productions where the earth's surface is almost constantly either frozen or covered with snow. The con- tinual use of animal food is as natural and whole- some to the Esquimaux, as a mixed diet is to an Englishman. The Russians who winter on Nova Zembla, according to Dr. Aiken, imitate the Samoieds, and eat raw flesh and drink the blood of the rein-deer, in order to preserve their health in these arctic regions. The Greenlander de- vours, with good appetite, the raw flesh of the whale, or the half frozen and half putrid flesh of seals; and drinks the blood of these latter ani- mals, or regales on dry fish and whale oil. 2!). Within the tropics, man is subjected to the continued operation of a high temperature, which excites the nervous functions and vascular action, notwithstanding the provision with which nature has furnished his integuments in order to moderate the animal heat. This provision, as we have seen, consists chiefly of the dark colour ofthe rate mucosum, which speedily gives off the superfluous heat of the body, and of the great activity ofthe perspiratory functions (§ 22.). In- tertropical countries, particularly such as are low or swampy, while they abound with the produc- tions of the vegetable kingdoms, and with nu- merous swarms of insects and reptiles, maintain very few of those gregarious animals which serve as food ; and thus, we perceive that their inha- bitants, unless in elevated and cool situations, as in Abyssinia, Mexico, &c, are obliged, by the scarcity of these animals, to subsist on vegetable productions, and to adopt a system of religion, which, while it tends to prevent the entire de- struction of the more useful species, is sufficient 346 CLIMATE—In relation to the Food of Man. to restrain their numbers within their appropriate means of subsistence, and without encroaching on or impairing the. supply of food with which the vegetable creation furnishes man. Hence, in many places of intertropical Africa, the lower animals, whose numbers are few, are occasionally made sacred by the priests for a time; and in other places of this continent animal food is very rarely enjoyed. In Hindostan, the natives are almost debarred from the use of flesh meat; and the cow is made sacred, evidently to prevent the destruction of a species, whose milk furnishes man with one of the chief articles of diet. 29. But nature provides a more suitable ali- ment to the inhabitants of those climates. The date, the palm tree, the cocoa-nut, the sago tree, the plantain, the sugar-cane, and the banana ; the yam, cassava, ground-pea, and other roots ; a great variety of refreshing fruits ; and, more particularly, the very abundant production of nutritious grains, especially the Indian corn and rice, richly supply the natives of these climates with wholesome food. The general and neces- sary adoption of a vegetable diet within the tropics, from the exuberance of the vegetable creation, and the comparative scarcity of those gregarious animals chiefly destined for the use of man in cold and temperate regions, is neces- sary to the existence of the human species in the higher ranges of temperature, and in the more unhealthy districts in hot climates. The adop- tion of animal diet exclusively, or of too large a proportion of it, disposes the human frame, when exposed to the influence of tropical heat, to those diseases which arise from endemic causes,— viz. the decay of vegetable and animal matters, the exhalations of marshy and absorbent soils, and other emanations accumulated in moist and close situations; and to those which affect the alimentary canal and other abdominal viscera. Various epidemic diseases also often produce their greatest havoc, and assume pestilential characters, amongst those, who, to the predisposition occa- sioned by a high range of temperature, have superadded that arising from a too full animal diet. It appears to be a salutary law of nature, that, in those climates, where animal food would be detrimental to the human race, there the ani- mals usually destined for the purpose are few in number, and stunted in growth. The localities, indeed, which are the most destructive to man, are also the most inimical to these animals, which, if they were chosen as the chief article of food, would both dispose to disease and increase its fa- tality. Thus it appears, that the distribution of the classes of animals over the surface of the globe is so apportioned, and certain of their orders and genera so restricted to particular latitudes and climes, as to be subservient to the wants of man, without becoming hurtful, or endangering his ex- istence in countries in many respects unfavourable to his bodily and mental developement. 30. While the vegetable diet, which the hottest and most unhealthy climates furnish, is the least liable to excite the nervous system, or to over- load the circulating and secreting organs, or to irritate and inflame the excreting viscera, it serves to promote endurance, and, with the hot spices which grow spontaneously in the same localities, to counteract the contaminating changes produced in the body by the vegeto-animal effluvia to which it is frequently exposed. In both Indies, and in intertropical Africa, the in- habitants of low and moist situations live almost exclusively on rice and maize ; with these they consume, as a condiment, a very large quantity of the hottest spices, the stimulating and tonic qualities of which preserve them from the effects of the diminished temperature and terrestrial emanations during, and after, the rainy seasons and monsoons, and in some measure from in- testinal worms and other parasitic animals. To these spices, even the feathered creation, and the lower animals, occasionally resort, especially during the unhealthy seasons. Were the inha- bitants to live chiefly on animal food, and use the strong fermented liquors made in colder climates, the nervous and vascular systems would be inor- dinately excited, irritability being thereby soon exhausted; and they would be as much disposed to, and affected by, disease, as unseasoned Euro- peans, who, partly owing to these causes, so soon become its victims, after having removed to low, moist, and hot situations between the tropics. Nature adapts her productions in every climate to the necessities of man ; and appropriates them to his real, but not his imagined wants, — to his state of constitution, as modified by the operation of soil, air, and temperature ; and no- where is this provision more manifest than in warm countries. There, if the causes of disease be most energetic, as they most indisputably are, she has chiefly restricted them to those which proceed directly from the soil and the climate, while she has confined those arising from the nature and the abuse of food within narrow limits ; as there man is destined, by the circum- stances already alluded to, to live chiefly on a vegetable diet, and is liable only to occasional deficiency of its supply. But even the inflictions which nature thus imposes on the inhabitants of these climates are accompanied by abundant means of preventing their invasion, or arresting their progress. The most unhealthy situations not only abound with suitable means of sub- sistence, but also present spontaneously the most efficacious prophylactic and curative agents for the diseases that are endemic in them. Thus rice, the banana, the plantain, the juice of the cocoa-nut and of the palm, the oil of the palm- nut, &c, are the most wholesome articles of food in the districts wherein they are most abundant The low grounds on which these are produced abound with deleterious miasms ; and the stag- nant water, which there often serves for the necessities of life, contains the ova of insects and animalculae. While the former occasion agues and remittents, the latter gives rise to diseases of the digestive canal, and to the generation of worms ; and both causes combine to produce fevers, diarrhoea, dysentery, cholera, visceral ob- struction, &c. In the above localities grow the different species of the capsicum, — the principal condiments employed by the natives; and these are also the chief prophylactics and remedies for their constitutions, against the diseases now alluded to. By the side of the pahns and the cocoa-nut grow the different species ofthe tamarind and the croton, which are, respectively, the mildest and most cooling aperient, and the most active ca- thartic. Thus nature provides an antidote to the bane which is imposed on the inhabitants of CLIMATE — Effects of Change of, on Man. 347 unhealthy warm climates, and, by adopting the indications she presents, they are enabled to exist without suffering much more from disease than the natives of temperate countries, or having the allotted span of human existence much abridged. It is in no small measure owing to his persisting in the diet, beverages, clothing, and modes of living, suited to a cold or temperate climate, and to which he had become accustomed, that the Eu- ropean is liable to disease when he has removed to a hot country. When travelling in the most unhealthy parts of intertropical Africa, in 1817, I met with an Englishman, who had lived there between thirty and forty years, and was then in the enjoyment of health. The circumstance was singular ; and, in answer to my enquiries as to his habits, he informed me, that soon after his removal to that pestilential climate his health had continued to suffer, when, after trying various methods without benefit, he had pursued as close- ly as possible the modes of life of the natives, adopting both their diet and beverages, and from that time he had experienced no serious illness. 31. In countries approaching the poles, where the continued low temperature, and the want of solar light during two-thirds of the year, tend to diminish nervous and vascular energy and tone, and to lower the whole circle of vital actions, nature has furnished man with those articles of food which are the best calculated to nourish, to stimulate, and impart vitality to the frame, and thus to enable it to bear up against the rigour of the seasons, and the injurious influence of the climate. Without such food, the inhabitants of arctic regions would fall a prey to diseases of debility, and the higher latitudes would soon be- come entirely depopulated. In these, as well as in northerly and elevated parts of temperate countries, nature spontaneously provides man with those substances which are the most ener- getic, both as preventives and as remedies of those diseases which arise from the influence of climate. The various species of pine abound in the coldest regions, and furnish, in numerous forms, the most efficacious internal and external medicines, and even the most wholesome bever- ages in these maladies. Hremorrhagic diseases, low fevers, asthenic inflammations, scorbutic and cachectic affections, the extreme effects of cold upon the extremities, &c, are most successfully prevented or treated by the judicious use of tere- binthinate preparations. This observation is also applicable to the arnica monlana, and other al- pine plants. 32. The temperate zone, whilst it furnishes in its wide range the greatest diversity of climate— in some localities that of the tropics, in others that of arctic regions—provides man with the greatest abundance of animal and vegetable food : thus enabling him to combine both, or to adopt more or less of either, according to the nature of the seasons, ofthe climate, and the particular circum- stances in which he may be placed. Nature is always provident: she takes sufficient care that each particular district or country shall have with- in itself, or be capable of producing by requisite labour, those articles of food which are most ap- propriate to the climate, and thereby the most wholesome to its inhabitants. When commerce or manufactures increase the population of a dis- trict beyond the means of sustenance derivable | from the soil, and lower animals, in the vicinity, the food which is obtained from a similar climate is generally the most wholesome. Various dis- orders originate from the introduction, from re- mote countries, of unsuitable articles of luxury into diet ; aud not a few arise from the improper | mode of preparing food, which would otherwise be wholesome. Thus, the hot spices and the high-seasoned dishes, which, during the tropical rains, would be beneficial to the natives of those . climates, who live chiefly on vegetable diet, fre- quently are productive of disease amongst those I who partake too freely of animal food, or the high-feeding inhabitants of commercial cities. The adoption, also, of highly seasoned dishes, | with an undue quantity of flesh meat,—undue, because exceeding the wants ofthe economy, and | the circumstances of the climate,—and the use of spirituous and fermented liquors, are ferule sources of disease, particularly fevers and affec- tions of the abdominal viscera, among Europeans residing in warm places or during warm seasons. 33. From these and other considerations the following corollaries may be drawn :—That the climate of a country should, in a great measure, guide man in his selection of food; those produc- tions which are most abundant around him being most appropriate to the circumstances in which he is placed : and that the nature of his food thus conspires with the climate to modify his constitu- tion, whilst it serves to counteract the rigours of season, and the unwholesome influences to which he is constantly exposed in very hot as well as in very cold countries. 34. iii. Of the Effects produced on the Human Constitution by Change from one Climate to another of a very differ- ent or opposite Description.—By refer- ring to what has been already advanced respect- ing the physical relations of climate, and the cir- cumstances more immediately connected with cold and warm countries respectively, and by connect- ing these with the peculiarities characterising the races of man inhabiting both, we shall readily perceive that a most important revolution will take place in the animal frame from the change, in whichever direction it may be made ; and that such revolution will be great in proportion to the suddenness and greatness of the change ; it being in either case attended with more or less febrile commotion or other diseased action. 35. 1st. Of change from a cold or temperate to a warm climate.—A. Keeping in view the following characteristics of a cold and temperate climate—viz. its low temperature, the alternations of season, the pureness of the atmosphere, the more nutritious, invigorating, and stimulating na- ture ofthe food, and the effects of warm clothing —and connecting these with the vascular pletho- ra, the active functions of the brain, lungs, liver, and kidneys of its inhabitants, the disturbances which will result when they are subjected to a continued high range of temperature, and to an atmosphere loaded with moisture, and frequently with vegeto-animal effluvia, may be anticipated. It is now fully ascertained that the effects of a high range of temperature, and of moist miasmal air, on the European constitution, are, a diminu- tion of the changes effected by respiration on the blood, an increase of the secreting and excreting functions of the liver and skin, and a decrease of 348 CLIMATE — Effects of Change of, on Man. the urinary excretion. When, therefore, the ple- thoric European migrates to an intertropical coun- try, the functions of the lungs and the pulmo- nary exhalation become diminished ; the requisite changes are not effected on the blood, notwith- standing the excitement of the nervous and vas- cular systems by the increased temperature ; and the already active and developed liver is irritated, and has its functions augmented, by the increase of those elements in the blood, that the lungs and skin cannot remove from it. Hence proceed febrile attacks, particularly when excited by their appropriate causes ; inordinate activity, with a re- lative frequency ofthe diseases, ofthe liver ; the secretion of acrid bile; and the disorders especial- ly affecting the alimentary canal and excreting or- gans. The general adoption of too rich and nour- ishing food and beverages by those who remove from cold to hot climates, tends greatly to increase these evils, as already explained (§ 30.); and the influence of high temperature and of a vertical sun upon the European head is productive of disease both of it and of the liver. To these effects, the mental cultivation and activity of Europeans some- what predispose them ; whilst their heads are not so well guarded from external influences by the constitution of its integuments and hair, and the thickness of the cranial bones, as those of the negro and Mongol varieties of our species. 36. The obvious indications resulting from these facts are, that natives of cold countries migrating to warm climates should, particularly if the change has been made abruptly, live abstemiously, and promote the functions of those organs which per- form the most essential part in excreting effete or injurious elements from the circulation. The head should be kept cool, and protected from the rays of the sun ; the surface of the trunk and lower extremities ought to be preserved in a freely perspirable state, so as to take off the load of circulation, and derive from the excited liver. In order to promote the secreting and depurating functions generally, active exercise, short of fa- tigue, should be taken, without exposure to the causes of disease, particularly those which are endemic. As the maladies which most frequent- ly supervene on change from a cold to a warm climate proceed neither from the increased tem- perature alone, nor from greater moisture of the air, but from these conjoined with malaria, and not infrequently also with wide ranges of tem- perature during the twenty-four hours, especially in high and inland localities—with hot days, and cold, raw, and dewy nights, and with a too full and exciting diet and regimen, causing fevers, dysentery, and diseases of the biliary organs— care ought to be taken to avoid those causes, as well as whatever may tend to assist their opera- tion on the frame, and to protect the system against the sudden daily changes by warm cloth- ing at night, &c. 37. B. The consideration of the effects pro- duced by migration, during a state of disease, from a cold to a warm and moist climate, is of the utmost importance. Keeping in mind its in- fluence upon the healthy frame—chiefly in ex- citing the functions of the skin and liver, and di- minishing those of the lungs—we are led to prescribe it in the treatment of various diseases. In hamoptysis, this change is obviously beneficial, especially as a warm and moist atmosphere, by this mode of operation, lessens the activity of the pulmonic circulation and the disposition to sanguineous exudation from the surfaces of the bronchi. Bronchitis and tubercular phthisis are also often benefited, and the progress of the latter much delayed, by this state of atmosphere, es- pecially when adopted early. Chronic rheuma- tism is sometimes cured by this change, seeming- ly owing to its influence in promoting the biliary and cutaneous functions. Dropsies, particularly anasarca and hydrothorax, have been, in a few instances, removed by a change to a warm cli- mate ; but whilst a moist state of the air is most serviceable in pulmonary and haemorrhagic dis- eases, dry warmth seems more beneficial in drop- sies, dyspeptic affections, and hypochondriasis, evidently from its effects in augmenting the in- sensible perspiration and the pulmonary exhala- tion, and imparting tone to the capillary circula- tion. Besides these, gout, in its early stages, dysmenorrhaa, and scrofula in nearly all its forms, are benefited by a change to a warm, or even a mild and dry, atmosphere. 38. 2d. Of migration from a warm to a cold or temperate climate.—This subject should be viewed in relation, first, to the change as it affects the dark races of man ; and, secondly, as it re- spects those belonging to the Caucasian variety, who have either been born or acclimated in warm countries.—A. If change from a cold to a warm climate is productive of disease and great mortal- ity in the white constitution, the migration of the dark races to a cold or temperate country is not less fatal to them ; and whilst the change pro- duces, in the former case, fevers, diseases of the biliary organs, and of the alimentary canal, it occasions, in the latter, tubercular phthisis, and other tubercular affections, with diseases of the bronchi, &c. When the dark races, particularly the negro, and those of the Mongol variety who are natives of intertropical and low countries, mi- grate to places subjected to a low range of tem- perature during a great part of the year, the de- pressing influence of cold upon the nervous system and vital actions of the lungs and skin, gives rise not only to tubercular formations, but also to in- creased secretion from the internal mucous sur- faces, and they are, in the great majority of cases, cut off", in a few months or years, by diseases of the lungs, kidneys, and bowels. Those, however, who change the climate progressively, or who are born in countries of an intermediate temperature, and who are prov ided with warm clothing and ani- mal or nutritious diet, suffer much less than those who migrate in a more direct manner, even al- though possessed of these latter advantages. The native African who removes immediately to Eu- rope seldom lives over two winters in it; whilst the negro who has been brought to the West Indies, and subsequently to the southern states of North America, previously to his arrival in more northern countries, and enjoys necessary food and clothing, will often not suffer materially from the change. 39. B. Those who have been born of Euro- pean parents, or been seasoned in warm climates, not infrequently suffer after removal to ten perate or cold countries. Even, although the change may have become necessary from chronic affections of the liver or bowels, yet may it for a while ag- gravate or render more acute hepatic disorder, or superadd to it disease of the lungs ; and many CLIMATE — As a Therapeutical Agent. 349 who have experienced only functional disorders of the stomach or liver, or who acquired merelv a tendency to them during their residence within the tropics, have been attacked by active disease soon after their return to Europe. Others, also, who have suffered more seriously, have had their complaints aggravated after a short residence in England, although they were benefited during their voyage home. This result of change to a colder climate proceeds not, however, altogether from the temperature or the state of the seasons, but in a great measure from the imprudence of the patient. Frequently, however, a colder at- mosphere is prejudicial for a time, by constricting the vessels on the external surface, and determin- ing an increased flow of blood to the large internal viscera, and thereby occasioning congestion and obstruction of those organs which have been weakened by previous disease or the influence of climate. Another frequent consequence of change from a warm to a cold country is a diminution of all the secretions, particularly those of the skin and liver: originating vascular pleth- ora and visceral engorgement. In this state of die vascular system, if the cutaneous or pulmo- nary surface be subjected to cold, particularly cold combined with moisture, after the circulation has been determined to these parts by hot rooms and crowded assemblies, or if reaction rapidly follow the impression of cold, the great mass of blood is thrown upon the internal viscera, which, if not relieved by a free secretion, become the seat either of congestion or of inflammation. Hence it is that hepatitis, or dysentery, so fre- quently follows changes from a high to a low temperature. The remarkable liability to dis- eases of tlie respiratory organs, observed in those who have returned to Europe after a long resi- dence in warm countries, is evidently owing, in many instances, to pre-existing disorder of the liver, which has extended thence to the lungs, owing either to the increased action of this latter organ upon removal to a colder climate, or to imprudent exposures to cold, or to breathing a very warm and close air immediately upon com- ing out of a cold and dry atmosphere. 40. In order to counteract these effects of change, warm clothing, particularly of the lower extremities, with the use of flannel next the skin, should be adopted; and exposures to cold and moisture, and the night air be avoided. The diet ought to be light, and of moderate quantity ; the strong wines imported into this country ab- stained from; and, above all, the functions ofthe bowels and abdominal viscera carefully watched, and promoted whenever they seem to flag. It may be of importance to know the most suitable period of the year to arrive in this country, after the frame has become assimilated1, by a long resi- dence, to a warm climate. If an invalid return in winter, the sudden transition from a warm to a cold country may be detrimental; if early in the spring, he is liable to feel the effects of a variable season for some time. The least ob- jectionable period extends from May to Septem- ber; and if the cold of the winter months be found too severe in the more easterly counties, or in the metropolis, the climate of Devonshire or of Bath may be tried with as great advantage as that of most of the southern parts of continental Europe. Old residents in a warm climate will 30 experience much advantage from residing some time in the more southerly parts of Europe, before passing to England or other countries of the north, more particularly if they use a course of the warm mineral waters of Viclii, Carlsbad, or Ems, in their way. 41. The children born of white parents resi- dent in the more unhealthy countries within the tropics, very generally die at an early age if they be not removed to a colder climate. They com- monly sink from the choleric form of fever described in a separate article as incidental to infants; or from diarrha>a, dysentery, or diseases of the abdominal secreting viscera, often assum- ing a remittent form. When, therefore, either of these appears in this class of patients, removal to a temperate climate should be advised when it can be effected; taking care to guard them, by warm clothing, &c, from vicissitudes of temper- ature for a considerable time after the change, and attending to the first indication of pulmonary or tubercular disease, or disorder of the liver and bowels. 42. III. Of the particular Localitiks which are beneficial in Disease, or of Climate as a Therapeutical Agent.— In this part of the subject I shall consider, first, the different parts of Great Britain which may be suitable places of residence for invalids ; secondly, those in the south of Europe and the Mediterranean ; and, thirdly, those in the At- lantic and West Indies. 43. i. Climate of certain places in England.— The chief difficulty in this country is to find a mild and sheltered climate for invalids from pul- monary disease; and it is almost exclusively to the south and south-west parts of the island, in the immediate vicinity of the sea, that we must direct our enquiries. The general use of coal fires in all the large towns in Great Britain, ow- ing to the quantity of sulphur this mineral con- tains, and of sulphuric acid fumes and fuliginous matter generated, renders the air more irritating to the lungs, and increases the risk of a winter residence in these places, to all those who suffer from, or are even liable to, diseases of the re- spiratory organs. This, together with other con- siderations — especially the results of observation — renders it imperative oh the medical attendant to recommend removal to a more salubrious lo- cality. The mild situations I shall notice are in the south, the south-west, and the west of the island. 44. A. The south coast is much milder and more moist than the east and inland parts of the island, during the months of November, Decem- ber, January, February, and March ; but from April till October the temperature of the latter is greater. On this part of the coast, Undercliff, in the Isle of Wight, Hastings, and Brighton, have been recommended as winter residences for invalids, a. Undercliff is the most sheltered and mild of these places in winter, and its air softer and more humid in summer than either. b. Hastings is sheltered, during the winter and spring months, from the north and north-east winds; and, of the various places on this part of the coast, ranks next to Undercliff as a residence for invalids with pulmonary affections, c. Brigh- ton is more exposed than the foregoing to the north and n,orth-east winds, and its air is drier, 350 CLIMATE — As a Therapeutical Agent. and hence more bracing. It is therefore more suitable than they to the nervous, the simply de- bilitated and relaxed, to the dyspeptic, to those affected with chronic bronchitis and asthma at- tended by greatly increased secretion. Dr. Clark very properly suggests that invalids who select the south coast as their winter residence, should pass the autumn at Brighton, and the win- ter at Hastings; the climate of the former being mild to the end of December. 45. B. The south-west coast of the island is very mild in several situations during the winter, and has, therefore, been very generally recom- mended in diseases of the respiratory organs. Dr. Clark estimates the temperature of its more sheltered localities as being 5° higher than that of London, during the winter months; and the tem- perature of the south coast as only 2° higher. But I conceive that there are, at least, G3 and 3°, re- spectively, of difference between these and Lon- don and its vicinity. Besides, it is not only the range of temperature that should be considered, but its greater equality, and less rapid vicissitudes, and the increased humidity, and more soothing influence ofthe air. — a. The places on the coast of Devonshire most in repute as residences for the consumptive, are Torquay, Dawlish, Sidmouth, Exmouth, and Salcombe. Of these, Torquay is the best; and, according to the reports of Dr. Clark, Dr. Foote, and of my friend Dr. W. Hutchinson, who has resided in it, superior to all other places in our island in pulmonary cases. 46. b. Penzance is the principal place in Corn- wall recommended for invalids. Its peninsular situation, and south-west position, give it a re- markably soft, humid, and mild atmosphere; and the equality of its temperature, not only through- out the year, but also during the day and night, renders its climate in many respects superior to that of most places in the south of Europe, and brings it next to Madeira. The quantity of rain that falls annually at Penzance is nearly double that which falls in London; the number of rainy days is much greater ; and the temperature of the air at night at least 7° higher during the winter months. This mildness, equality, and humidity of climate, is, however, somewhat im- paired by its exposed situation, and its liability to high winds. 47. Both the Land's End and the coast of Devonshire, owing to the predominating charac- ter of softness, humidity, and equality of climate, exert, along with a soothing, an evidently relax- ing effect. Hence this coast is best suited to the irritable and inflammatory states of disorders of the respiratory organs, and such as are charac- terised by irritation, but little expectoration, and dryness of skin. In cases attended with a copi- ous expectoration, great relaxation of the mucous surfaces and soft solids, and in nervous debili- tated persons, this climate will prove injurious. Even in those cases where it is evidently indi- cated, and actually proves of service, removal will be necessary to a somewhat drier air during the summer ; and this should not be deferred longer than June, or undertaken before April or May ; the patient generally deriving much be- nefit by returning the succeeding winter. The observations now made upon the climate of the Bouth-west coast apply to that of Jersey and Guernsey, to which islands invalids sometimes repair, and occasionally with advantage. South- west winds generally prevail in them during au- tumn and winter, and cold north-east winds often continue long in the spring. The summer climate of these isles is excellent. Of the two, that of Jersey is preferable. 48. C. The West of England. — The mean temperature of this part of the island is a little lower than the southern coast, but in March and April it rises somewhat above it. Bath and Bristol are about 3J warmer than London during the months of November and December ; but this difference is reduced more than one half during January, February, and March. In this part of the country, the vale of Bristol is the most sheltered and mildest. The climate during the winter is rendered more mild by the vicinity of the ocean, whilst the groups of surrounding mountains attract the clouds and diminish the fall of rain below the current to which its western po- sition would otherwise subject it. Bristol Hot- wells, and the lower parts of Clifton, are the most sheltered spots, and the best suited to con- sumptive patients ; whilst other invalids will find most advantage in the more elevated situations which the latter presents. In general, the climate of this place is perhaps the mildest and driest in the west of England ; and, therefore, one of the best winter residences for invalids. It is drier and more bracing than that of the south-west coast, and therefore not so well suited to consumptive cases, and to those affected by irritative action in the respiratory passages and bronchi. For these, the more soft and humid air of Torquay and Penzance is preferable; but, with the return of summer, the consumptive invalid will relinquish the latter for the former with benefit. Clifton and Bath are certainly preferable places of resi- dence to the south-west coast, in cases of pro- tracted dyspepsia, gout, and scrofula, particularly the last occurring in young persons, and relaxed habits. In these affections, the waters of Bristol Hot-well will, with regular exercise on horseback or on foot, prove extremely beneficial. 49. The more inland districts of this part of England furnish various places which are salutary to invalids during the summer. Malvern, and the surrounding country, with the Malvern wa- ters, are very serviceable in scrofulous and dys- peptic cases; and, for the consumptive and other invalids, various places in Wales, as Abergaven- ny, Aberystwith, Tenby, Barmouth, &c. will be visited during the season with advantage. Where a course of goat's whey may be considered of advantage, a summer residence in Wales will be preferred. There are various other places which, besides their mineral waters, furnish excellent summer residences for the invalid. Buxton, Mat- lock, Leamington, Cheltenham, Tunbridge Wells, &c, independently of the use of their respective mineral waters, prove excellent places of resi- dence for those who are debilitated or exhausted, whose mucous surfaces are relaxed, or whose di- gestive, secreting, and assimilating functions are imperfectly performed, and any of the abdominal viscera congested or obstructed. In these latter circumstances of disease, especially, the appro- priate use of the waters of those places, assisted by regular horseback or walking exercise bv suitable medical treatment, and by mental re- laxation and amusement, will often prove of CLIMATE — As a Therapeutical Agent. 351 great service. In prescribing the mineral waters of any of those places, due reference should be had to the nature of the climate ; and, on the other hand, when directing change of climate, some attention should be paid to the waters which the place may afford ; as the appropriate use of the one, whilst the patient is experiencing the influence of the other, will materially pro- mote the end in view. 50. In a very great proportion of cases, where the state of the patient admits of change of local- ity, much advantage will accrue from passing the autumn on the south coast of the island, as at Brighton, Hastings, or Undercliff, after having passed the summer at the foregoing watering places. In general, when the digestive and gen- erative organs are disordered, frequent change of air, and travelling by easy and short journeys, with gentle exercise, particularly on horseback, agreeable amusement, and regular habits, will prove of marked advantage, and greatly aid medical treatment. 51. ii. Of the Climate of certain parts in Fr'ance.—A. The West and South-west of France furnishes several places, the climate of which possesses the softness and humidity which are requisite in pulmonary diseases. The mean annual temperature of the south-west of France is stated by Dr. J. Clark to be 4 higher than that of the south-west of England ; and the cli- mate of both generaly agree or disagree with the same diseases.—a. That of the south coast of Britany is mild during the winter, and temperate in summer, the mean temperature of this pro- vince being about 5ti^u. its climate is soft and relaxing ; and it is hence suited to dry bronchial irritations, to haemoptysis, and tubercular cases. Laennec found it very favourable to consump- tive patients, and states that the proportion of such in this part of France is very small. In scaly eruptions on the skin, dysmenorrhoea, and in irritable habits of body, this climate will be often of service. 52. 6. Pau, situated at the base of the Pyre- nees, from the account of it given by Dr. Clark and Dr. Playfair, appears to be the best place in the south-west of France for invalids; and yet, in no respects is it superior to the south-west of England in consumptive cases. Its air is still and mild in winter and spring ; the chief advantage it offers being the great mildness of its spring. Dr. Clark gives the following comparison:— Its mean annual temperature is 4^° higher than that of London, and about 3J higher than that of Penzance ; it is about 5D lower than that of Mar- seilles, Nice, and Rome ; and 10° lower than that of Madeira. In winter, it is 2J warmer than London, 3J colder than Penzance, 6^ colder than Nice and Rome, and 18° colder than Madeira. But in the spring, Pau is 6° warmer than Lon- don, and 51-1 warmer than Penzance ; only 2.£J colder than Marseilles and Rome, and 7J colder than Madeira. The range of temperature between the warmest and coldest months at Pau is 32J; this at London, and likewise at Rome, is 26°; at Penzance it is only 18°, and at Madeira 14J. The daily range of temperature at Pau is 7.^-; at Penzance it is 6^°; at Nice, 8]°, and at Rome, 11J. Pau is drier and warmer than the south part of England in the spring, and northerly winds are less injurious. One of its chief advantages is its vicinity to the watering-places among the higher Pyrenees, which are often beneficial places of summer residence to those who have passed the winter and spring at Pau. 53. B. The South-east of France.—The cli- mate of the tract of country extending along the shores of the Mediterranean, from Narbonne and Montpellier to the Var, is warmer and drier, but more exciting, than that of the south-west. It is subject to sudden vicissitudes of temperature, and to cold winds, especially the north-west, or Mis- tral. It is decidedly prejudicial to consumptive patients, especially when the disease has made some progress, and to irritative affections of the stomach, trachea, or larynx; and is service- able chiefly in diseases of debility and relaxa- tion unattended by inflammatory or hsemorrhagic action. 54. Dr. Clark ranks the principal places on the coast of Provence in the following order, as residences for invalids :—Hyeres, Toulon, Mar- seilles, Montpellier, Aix, Nismes, Avignon.—a. Hyeres possesses the mildest climate on this part of the coast, being sheltered from the north winds by a range of hills ; and its inhabitants being comparatively exempt from pulmonary affections. b. At Marseilles the climate is dry, variable, and subject to cold irritating winds. It is therefore injurious to consumptive patients ; and is one of the places in France where pulmonary diseases are most prevalent. Invalids requiring a dry air, and capable of bearing cold winds, may be bene- fited by residing here for some time. c. Mont- pellier has obtained a reputation for salubrity to which it has no claims. According to MM. Four- niek and Murat, more than a third ofthe deaths that occur in the hospital of this city are from pulmonary consumption. The prevalence in this part of the country of northerly winds during winter and spring, both accounts for the fre- quency of pulmonary diseases, and points out its unfitness as a residence for patients thus affected. d. Aix is still more exposed than Montpellier to the Mistral and north winds, and pulmonary com- plaints are very prevalent among its inhabitants. I 55. C. Nice, although situate on the same line | of coast as Provence, enjoys a much milder cli- mate than any part of that province. It is pro- tected by a lofty range of mountains from the north winds ; and the daily range of temperature is there less, than at almost any part of the south of Europe. During winter the weather is settled, and the atmosphere clear, the thermometer sel- dom sinking to the freezing point, excepting at night. At this season, however, as well as in the spring, cold dry winds are not infrequent ; and i the climate is, upon the whole, dry and exciting. Hence it is not favourable to pulmonary consump- tion,—the very disease for which it was formerly very improperly recommended. It is likewise unfavourable to irritable or inflammatory states of the larynx, trachea, and bronchi, attended with scanty expectoration, or haemoptysis. But chronic bronchitis, bronchorrhoea, and humoral asthma, are generally very much benefited by the climate of Nice. It is also serviceable in all cases of debility, torpor, and relaxation cf the mucous surfaces ; in chronic rheumatism, gout, i external scrofula, dyspepsia, and hypochondriasis. 352 CLIMATE — As a Therapeutical Agent. 56. iii. Of the Climate of Italy and Mediter- ranean.—A. Genoa is not favourably noticed by Dr. Clark as a residence for invalids ; but Dr. Johnson, on the authority of Dr. Mojon, speaks of it in more favourable terms. It is best suited to those affected by chronic bronchitis, and dyspeptic and gouty complaints : and to persons of relaxed and phlegmatic habits of body. Pisa, Rome, and Naples are the other places in Italy most frequented by invalids. The climate of Pisa nearly resembles that of Rome, the latter being somewhat warmer and drier in winter. Dr. Clark considers the climate of Rome as one of the best in Italy for consumption, un- attended by haemoptysis. For those, however, who cannot take exercise in the open air, and must confine themselves to sheltered situations, the Lung' Arno in Pisa is the best place of resi- dence to be found in Italy. The climate of Naples is considered by this writer, as well as by M. Lasnyer, more exciting than that of the two foregoing places ; and it is more subject to high winds. The diseases which a residence in either of these three cities will benefit, are those above enumerated. Persons who remain in Italy during the summer, will find Lucca, Sienna, and the vicinity of Naples, the coolest situations. 57. D. There are various other places on the shores and islands of the Mediterranean, the cli- mates of which are suitable to invalids ; but we possess little or no accurate information respect- ing them. Malaga in the south of Spain, Cag- liari in Sardinia, and some parts on the coast of Sicily, afford a mild winter climate, but the diffi- culty of reaching them, and of obtaining in them many necessary comforts and conveniences, al- most precludes invalids from the northern parts of Europe from visiting them. Malta is not open to these objections ; but, according to Dr. Hennen, the quantity of dust raised from its arid soil, and suspended in the air, during dry weather, renders it an unsuitable climate for con- sumptive patients. A considerable number, also, of the inhabitants die of pulmonary diseases. In his work on the medical topography of the islands ofthe Mediterranean, Dr. Hennen states a fact, which is perfectly in accordance with my obser- vation in warm climates, although doubted by Dr. Clark, viz. that those ofthe Ionian Islands, which are decidedly most malarious and remark- able for remittents, have had fewest pulmonary affections amongst the British troops. In re- spect of the health of the troops stationed in these islands, this writer states, that, from an average of seven years, phthisis has borne a proportion to other complaints of 1 to 198t only. At Malta, on an average of eight years, consumption has occurred in the proportion to other maladies of 1 to 93£. Including all pulmonic complaints what- ever, the proportion to others, as regards the Ionian Isles, has been 1 to 20$; and, as respects Malta, 1 to 14. Taking into calculation the whole Mediterranean islands, the proportion of pulmonic, to other diseases, has been 1 to 17' in the British army. 58. iv. Climate of the Northern Atlantic— Under this head the climates of Lisbon, Cadiz, Madeira, the Canaries, the Azores, Bermudas', and the Bahamas, may be arranged ; all of which have been recommended to persons requiring a soft and equable climate, during the winter and spring. 59. A. Madeira is, of all these places, indis- putably the best, as respects both the climate, and the comforts and conveniences within the reach of the invalid. The frequency and ex- cellency, also, of the means of conveyance to and from the island are no small recommenda- tions. From the minute account furnished ofthe climate of this island, by Drs. Gourlay, Hein- eken, and Renton, after a long residence in it, and from the effects I have observed in several persons who had resorted to it as a winter's resi- dence, it may be justly concluded, that it is su- perior to any part ofthe south of Europe for con- sumptive cases. Its central ridge of mountains gives it, in summer, a cool land wind ; and the north trade winds, at this season, render it tem- perate and salubrious. During winter and spring, Funchal, and parts near the sea-shore, are the best places of residence; and, during summer, the more elevated situations in the interior are cool and agreeable. The mean annual temperature of Madeira is about 6° higher than the south-east of France and Italy ; and the heat throughout the year is much more equably distributed. The winter of the former is 12° warmer than that of the latter, and the summer 5° cooler. At Ma- deira the extreme annual range is only 14°, whilst it is double this amount at Pisa, Rome, and Naples. In respect also of the progression and steadiness of its temperature, it excels those places. Rain falls at Madeira on 73 days of the year, and at Rome on 117 days, and chiefly during the autumn in the former. The air is also more soft than at Rome. 60. B. The Canaries possess the next best cli- mate to Madeira. The mean annual temperature, however, of Santa Cruz, the capital of the former, is 71*-; whilst that of Funchal, the capital of the latter, is only 65J. The summer temperature of Santa Cruz is 7° warmer than that of Funchal, and the winter temperature 5° warmer. Hence the mean annual range of temperature is greater in the Canaries than in Madeira; which possesses, in other respects, advantages sufficient to recom- mend it in preference to the former in pulmonary diseases. 61. C. The Western Islands, or Azores, enjoy a climate nearly approaching to that of Madeira. They are, however, more subject to high raw winds, particularly those from the north and north-west, which are often very cold and harsh; and the temperature of winter is lower, and that of summer higher than in Madeira. The air is also more humid. From a very short visit I made to Madeira and the Azores,—to the former in the spring, and to the latter in winter,—I should con- clude the Azores to be much inferior to Madeira as a residence for invalids, chiefly because of the absence of many necessary comforts and con- veniences, of their stormy winters, and the infre- quency and ineligibility of the opportunities of transport between them and this country. The climate of the Bermudas and Bahamas presents no advantages sufficient to obtain for them a preference to those already noticed. They are liable to storms, and to harsh northerly winds in winter, from the American coast, whilst their summers are very hot. 62. v. Climate of the West Indies.—The mean annual temperature of the West Indies, at the level of the sea, is 79°, 80°, and 81-; and during the CLIMATE — As a Therapeutical Agent. 353 winter months, in some places, about 3°, and in others only 2J lower. The extreme annual range is 20J, and the mean daily range about 6J. This continued high temperature exhausts the energies of invalids ; and the clearness of the slues, and great power of the sun, prevent suitable exercise in the open air. A visit to the West Indies of a few months' duration, made either to some ofthe most healthy islands, or passed chiefly aboard ship, will, however, prove of service in several chronic affections, particularly those referred to above (§ 37.), excepting consumption in its more advanced stages. Persons much disposed to this disease, either hereditarily or by the conformation of the chest, &c, or who are threatened by its early stages, will find a removal to the West In- dies one of the prophylactic measures most to be depended upon. When residing some time in an extremely malarious place within the tropics, 1 observed that the most healthy persons in it were those who were constitutionally disposed to pul- monary disease. But I believe, that the observa- tion often made, is perfectly correct, that removal to an intertropical country, when phthisis is far advanced, will only accelerate its progress. It may also be stated, that severe and protracted catarrhs are very common upon entering between the tropics. In gout, chronic rheumatism, scro- fula, and calculous affections, a residence in the West Indies is often productive of advantage. 63. vii. Of residence on the sea shore and voyaging.—There are certain topics connected with change of climate often discussrtl during the course of practice, viz. whether are inland situa- tions, or places on the sea-shore, whose climates are physically alike, most serviceable in pulmo- nary diseases ? .and whether or not sea-voyages possess any advantage over a land residence in these complaints, a. In respect of the first ques- tion, it may be stated, that places on the sea-shore are generally more humid than those inland, and oftener, on this account, preferable in the dry and the hemorrhagic pulmonary affections ; whilst a situation somewhat inland, or not removed above a few miles from the coast, seems somewhat more serviceable in those cases of consumption which are otherwise characterised. But the question has not been satisfactorily determined, and, indeed, is not easy of solution. 64. b. With reference to the second question, it may be stated more confidently, that sea-voy- aging, in a suitable climate, is preferable to land residence in the early stages of phthisis, and par- ticularly when it is attended by haemoptysis. This advantage is evidently to be attributed to the in- fluence of the ship's motion on the sanguineous and nervous systems. This opinion was argued for by Dr. Gregory, in his excellent thesis, De Morbis Cali Mututione Medendis, and has been generally admitted. Cruising in a warm or even temperate latitude, particularly in the Atlantic, is preferable to voyaging, because of its longer dura- tion. Whilst the sun is north of the equator, the climate between the 30th and 50th degree of lati- tude ; and while the sun is south of the equator, that from the 20th to the 35th or 40th degree of north latitude, will be found the most salutary. During winter, voyages between Madeira and the West Indies ; and, in summer, between Madeira and this country, in the vessels constantly trading between England and the West Indies, and which I 30* generally touch at Madeira, might be undertaken with advantage. These vessels furnish tolerable accommodations, which may be easily improved or adapted to the state of the invalid. 65. A. When the winter has been passed in any of the warmer situations noticed above, at- tention ought to be paid to the time of returning to this country. This should not be earlier than the first, or later than the last week in June. If the invalid have passed the winter in the south of France or in Italy, these places may be left early in May, and he may travel cautiously through Switzerland, avoiding exposure to the evening and morning air. During the journey, warm clothing should be resorted to as soon as the temperature falls so low as to become sensibly cold; and a free circulation in the skin and extremities ought to be carefully preserved. 66. B. With respect to the diseases which are benefited by change of climate, it is unnecessary to add any thing at this place, as the climates which seem most serviceable are noticed when discussing the treatment of those diseases in which most advantage is derived from removal to par- ticular climates. The affections for which this treatment may be employed, are scrofula, tuber- cular disease of the lungs, liamorrhage from the lungs, &c, chronic bronchitis, asthma, chronic rheumatism, dyspeptic and hypochondriacal af- fections, urinary calculi, and various cachectic and hydropic affections. (See the treatment of these complaints in their respective articles.) Biblioo. and Refer.—Hippocrates, JI({il Aiqim; vdiXTutv, tunotv, Vander Linden's edit. 8vo. vol. i. p.327. —Cruger, De Zonis et Climatibus, 4to. VVitteb. 1660.—Wer- ter, De Morbis Olimatum, 4to. Duisburgi, 1704.—Burgar, De Melhodo Medendi pro Climat. Diversitate varie institu- enda, 4to. Lugd. Batav. 1724.—Hartmunn, Diss, de Climate, ejusque Notitia Medico admod. necessaria, 4to. Regio, 1729. —F. Hffmunn, De Medendi Melhodo varia pro Cliinatis Diversitale. Halae, 1734.; et in part i. vol. ii. Supp. ejusdem operum. Gen. ed. 1753.—Kruger. De Diversitate Corpor- um Morb. et Curationuni secundum Kegiones Europe, 4to. Halae, 1744.—G. G. Richter, De Insolatione, Opusc. t. i. Goet. 17 7.—De Buhner, De Differentiis Naturarum re- spectu Climatum, 4to. Hala-, 1746.—K. A. Lorry, Sur I'Usage des Alimens, kc vol. ii. Paris, 1757.; Journal de Physique, vol. i. p. 430. Paiis, 1773.; et Ibid. vol. iii. p. 243. Paris, 177 4.—A. Wilson, Observat. relative to the Influence of Climate on Vegetable and Animal Bodies, Lond. 1780.— J. J. Plenck, Broniatologia, s. Doct. de Ksculenlis et Potu- lenlis, kc. Vindob. 1184.—J. L. Schurer, De Atmosphera Eleclrica. Argent. 1786.—Dar/uc, Hist. Naturelle de la Pro- vence. Avign. 1782, t. i. p. 15.—Schneider, De Erncacia Venlorum, Diii-li. 1790.—J. C. Eber'maier, De Luris in Corp. Hum. Vivuin erticacia. Giit. 1797.—E.Horn, He Lucis in Corp. Hum. Viv. praeter Visum einc. Goet. 1797.—Ca- bunis, Rapports du Physique et Moral de I'Homme. Paris, 1802. p. 235.—Gourla'y, On the Climate and Dis. of Ma- deira, Jcc. 1811.—Murut, Topograph. Med. de la Villedu Montpelier, 8vo. 1810, p. 149.—C.K. Weiss, Diss. Cliinatol. Medica Initia sistens. Lips. 1813.—L. Cerutti, Collect, de Telluris in Organism. Hum. Actione. Lips. 1814.—J. En- nemoser, De Montium influxu in Valetudinum Homin. Vita; Genus et Morbos. Ber. 1816.—J. Knirsch, Svnopsis de Cli- mat. Med. Vind. 1815.—Sigaud, Travaux de la Soc. de Mi'd. dc Marseille, 1816, p. 14.—J. Copland, The Medical Topography ofthe West Coast of Africa, in Quarterly Journ. of Foreign Med. vol. ii. p. 1.; Appendix to Richerand's Physiology, p. 582. 627.; and in Griffith's Trans, of Cuvier's Regne Animalc, vol. i. p. 130.—firey, in Diet, des Scien. Mid. t. v. p. 330.—Forbes, On the Climate of Penzance and the Land's End Rvo. 1821—Holland, On the Duration and Distribution of Rain 4cc. 8vo, Lvme, 1828.—Nuumann, Allg. Scniiotik. Ber. 1826, p. 125. el seq.—Hennen, Sketch- es of the Med. Topography of the Mediterranean, kc. 8vo. Lond. )830, p. 221.—A. de Humboldt, Annales de Chimie et de Physique, t. xiv. p. 22.; et Fragmens de Geologie et de Climatologie Asialiques, 2 torn. Paris, 1831, t. ii. Foreign Quarterly Review, Julv, 1832.—Chislm/m, Oii the Climate of Bristol and Clifton, in Edin. Med. and Surg. Journ. vol, xiii. p. 265., and vol. xvii. p. 164.—B. Gaspard, Journ. de 354 COLD — General Effects or. Physiol, t. vii. p. 221.—Fodirt, Hist. Nat. Medicale, kc aux Alpes Maritime*, Sic. Strasb. 1823.—.Rostan, Diet de Medecine, t. v. p. 361.—Heineken, On the Climate and Med. Topog. of Madeira, Med. Repos. hv Copland, vol. xxii. 1824, p. l.—J. Johnson, Influence of tropical Climates on fcurop. Constitut. 8vo. 4th ed. 1827.; and Change of Air, or the Pursuit of Health, through France, Switz., and Italv, kc. 8vo. 1831. p. 235. et seq.—Annesleii and Author, Researches on the Dis. of India and Tropical Countries, &c. 4to. 1828 and 1829. vol. i. p. 661., and vol. ii. p. 6.—Lasnyer, Sur des Olimats d'ltalie, kc dans les Aff. dc Poilrine, &c, in Nouv. Biblioth. Med. Juil. 1829.—./. Clark, The Influence of Cli- mate in Chronic Diseases of the Chest and Digestive Organs, kc. 8vo. 2d ed. 1830. COLD.—(Classif. Pathology. JEtiology and Therapeutics.) 1. Cold is merely a relative term, expressing a sensation produced by the abstraction of heat by any substance of a lower temperature than that of the body or part which feels ; conse- quently this sensation is not always occasioned by the same degree of temperature. Nature has recourse to various means for abstracting animal heat from the body, under circumstances requiring it ; and for preventing the dissipation of it, under other circumstances ; and the instincts and reason ofthe animal creation are often evinced in further- ing these objects. The dark skin of certain va- rieties of our species, and the thin hairy covering of many ofthe lower animals inhabiting hot coun- tries ; the fair well-clothed skins, and the thick coverings of wool or fur with which those of cold climates are provided ; and the construction of the dwellings, &c. in different and opposite cli- mates ; are all provisions intended to accelerate, under certain circumstances, and to delay, the dissipation of animal heat under others. 2. The functions of the living economy can be performed within a certain range of temperature only, for any considerable time. Above or below this range, they will more or less rapidly cease, according to the extent to which the change may be carried in either direction, and the rapidity with which it is effected. Whilst the abstraction of heat is produced more rapidly than it is sup- plied, either in a part or in the whole body, de- pression of the vitality takes place co-ordinately with the rapidity ofthe loss of temperature ; but, on the other hand, when the abstraction of heat is altogether prevented by living in a medium of equal or greater temperature, excessive vascular excitement, rapidly exhausting the sensible and irritable properties of the tissues, and thereby terminating human existence, is the consequence. The heat of the human body seldom varies, in health, above 100° or below 96° of Fahrenheit's thermometer ; and although man may live in a I lower temperature than the zero of this scale, : when suitably fed and clothed, owing to the I activity of the respiratory and heating functions, yet, in consequence of the nature of these func- I tions, he cannot exist for any considerable time in a mean range of temperature above that of his own body. In no part of the globe is the mean annual range of atmospheric heat within ' twelve degrees so great as that of the livino- frame. 3. L Physiological and Pathological Effects of Cold.—A. A general view of its effect*. In considering, therefore, the effects of cold upon the body, due reference should be had to the state of the respiratory and heating func- tions, which are essentially vital, and active in I proportion to the greatness of the constitutional I powers. The abstraction of caloric, or cold, when carried far, first depresses, and afterwards annihilates, the vital,actions of a part, by de- priving it of that principle which is necessary to preserve the various tissues composing it in a suitable state for reciprocity of action, and which observation shows to be necessary to the healthy performance of the sensiferous and circulating functions especially. When heat is abstracted to a greater extent than it is supplied, sensibility is diminished or numbed ; and circulation, as re- spects both rapidity and size of the current in the vessels, is lessened. This effect may be produc- ed in a part or extremity to the extent of anni- hilating these functions in it, whilst in the internal viscera they either remain entire, or are but little changed. When this is the case, the part affect- ed will permanently lose its vitality, if these func- tions be not soon restored by frictions, and a very gradual admission of heat. A part thus affected by cold is said to be frost-bit,—an accident to which the more exposed parts of the body are liable in very depressed states of temperature. Even friction only may occasion too quick a change of temperature, if it be not made with some substance, as snow, which may prevent the too sudden increase of heat, and the risk of im- moderate reaction. When the vital energies are weak, a less degree of cold will depress them than when they are energetic ; and, upon its re- moval, vascular reaction will be less apparent, or even not at all supervene. If cold be not great, or too long applied, relatively to the vital ener- gies, increased action, as evinced by a glowino- sensation, follows its impression. When, on the other hand, it is excessive, either in degree or continuance, the depression of vital power, es- pecially the manifestations of this power in the nervous and circulating organs, is co-ordinate, the living animal sinking into a state of torpidity from which it is with great difficulty roused. Thus cold, momentarily or briefly applied, when the constitutional powers are not very much impaired, proves, if not excessive, an excellent invigorating or tonic agent, owing to the reaction which fol- lows ; but when acting energetically, or for too long a time relatively to the state of those powers, it will produce one of two effects, according to the circumstances attending it, or following its application : either it will depress the vital actions beyond the power of recovery, the system sinking into a comatose state, or struggling" between this state and partial or irregular reaction ; or it will be followed by increased or even uncontrollable vascular action, soon exhausting the vital mani- festations of the vessels and the irritability of the frame, or of the part principally exposed, and occasioning dissolution of the blood. While the continued action of that degree of cold, which may be endured for a short lime, very often pro- duces the former result; the momentary exposure to excessive cold, or the injudicious application of heat in an inappropriate or too rapid a manner, after the more moderate but prolonged action of this agent, is usually followed by the latter. In- flammations are not infrequently induced in this manner in the organs to which cold has been directly applied, as in the case of inflammation of the lungs coming on after passing into a warm apartment immediately from a cold atmosphere In other cases, the impression of cold when pro- COLD — Its particular Effects. 355 longed, although moderate, may, by diminishing vital action in the parts on which it acts, so deter- mine and increase it in distant or even opposite parts or surfaces, as to give rise to inordinate se- cretion or vascular action in the latter. Such being the more general effects of cold upon the system, it will be advantageous to examine its mode of operation more closely, in order that we may be enabled to form accurate ideas as to its influence in the causation and removal of disease. 4. B. Particular effects of cold. — a. The primary effects of the abstraction of heat from a part, to the extent of producing a decided sensa- tion of cold, appear to be exerted upon the ner- vous system, whose sensibility and vital manifes- tations it lowers, and, when excessive, entirely annihilates. These effects are obvious in both the organic and voluntary classes of nerves; and are at first attended by an alteration of their sen- sibility of a slightly painful kind, often followed by loss of their functions. Thus, cold will occasion- ally give rise to local paralysis. When an in- tensely cold substance is applied to a living tissue, the rapid abstraction and passage of its caloric through the living surface intervening between them, cause similar effects to those following the rapid communication of caloric by a heated bodv, and thereby momentarily excite the nerves and vital turgescence of the intervening parts. Thus, intense cold will produce vesication, inflammation, &c. of the skin. 5. b. The action of cold, when slowly or mo- derately applied, in diminishing vital turgescence, the bulk ofthe tissues, aud the activity ofthe cir- culation, seems coeval with the effects produced by it on the nerves. By this action the small ar- teries, veins, and secerning pores are constricted, and the communicating canals between the ex- treme arteries and radicles of the veins are ren- dered smaller and less pervious. Hence, when cold is applied to the surfaces of the body, the circulation there and in the vicinity is diminished, and the blood is driven thence, and accumulates in the large veins ofthe internal viscera. Owing partly to this operation, and partly to the sedative effects of cold upon the nervous system, the whole circulation becomes weakened, and congestion of the large vessels and internal erectile tissues takes place. If the impression of cold is only for a short period, the vital energy not being at the time ma- terially deficient, the heart and large vessels are enabled to react upon the load that oppresses them, and an increase of the circulating functions ensues. But when the impression of cold con- tinues, circulation becomes less and less active, with at first slight or inefficient efforts at recovery, and at last ceases entirely. 6. c. Muscular parts are very sensibly affect- ed by cold, in consequence of its effects upon the nerves supplying them, and of the diminution of the circulation in them. Nervous energy, there- fore, being depressed, and the circulation weak and insufficient, muscular contractions also be- come weak and tremulous; and the muscles sub- sequently stiff, or altogether rigid, frequently with cramps or spasms intervening between these states. A share of these extreme effects is, doubtless, owing to the vascular congestion pro- duced on the cerebro-spinal axis, and on the origin of the nerves supplying the muscles. The cramps often occurring after plunging into cold > water, or while swimming, are illustrations of the effect on the muscular system of moderate cold suddenly applied to the surface, and of its action thereon, through the medium of the nervous and vascular systems. After the power to make muscular exertion ceases, in consequence of the continuance or increase of cold, remarkable stiff- ness and rigidity of the voluntary muscles super- vene, sometimes extending to the respiratory muscles, and producing asphyxy. In many cases, where cold acts intensely or suddenly upon the surface of the body, rigidity takes place with re- markable celerity, as stated by Quintus Cur- Tius,and MM.Parat,Martin,and Beacpre, to have occurred in the expedition of Alexan- der, and the retreat of Napoleon from Mos- cow. Trismus and tetanus have followed, in some cases, a moderate decrease of temperature, and difficult articulation is not an uncommon ef- fect of this cause. 7. d. The influence of cold upon the respira- tory and calorific functions is very manifest. When atmospheric cold is moderate, and suf- ficient exercise is taken in it, and the cutaneous suiface and extremities are sufficiently clothed, then respiration is energetic, the changes pro- duced on the blood are complete, and animal heat is freely generated, and is sufficient to sup- ply the continued loss of it from the surface of the lungs. But when cold depresses the nervous power, owing either to its excess, or to the cir- cumstance of its acting simultaneously upon both the cutaneous and pulmonary surfaces, or to the circulation being unaided by muscular exertion, then respiration becomes laborious, quick, and painful; and the production of animal heat is in- sufficient to preserve the fluids and soft solids in a suitable state for reciprocal action, rigidity, fol- lowed by congelation, first ofthe extremities, and subsequently of more central parts, taking place. As long as the nervous energy and the circulation are unimpaired, animal heat is freely developed; but it becomes co-ordinately depressed with the failure of these, and returns in a proportionate de- gree with their restoration. When cold has acted for a considerable time upon the frame, animal heat is either restored with difficulty, or it con- tinues to vacillate and sink with the nervous and circulating functions until death supervenes. It is chiefly during the period which elapses between the exposure to cold, and restoration from its ef- fects, that diseased action commences, or is de- veloped. Too long continuance in a cold bath, wet clothes, and numerous other means of refi it- erating the body, will produce a loss of tempera- ture that may never be recovered. Dr. Currie found that a man with a temperature of 98°, three hours after cold bathing and exposure to a north wind, had not recovered his natural heat, although warm stimuli, frictions, &c. had been employed. During such states of protracted restoration, vari- ous morbid states are apt to originate and to give rise to a train of diseased actions, varying in al- most every case with the constitution, tempera- ment, predisposition, and habit of body ofthe in- dividual. Even after reaction has taken place, some particular organ or part may suffer especially owing to these predisposing circumstances; and infiammation, with effusion, disorganization, &c. may be the result. 8. e. The effects of cold upon the brain and the 356 COLD—Pathological Effects or. organs of sense and voluntary motion, are similar to those already described. Hearing, sight, touch, &c. become imperfect, the functions of mind im- paired, and insensibility, somnolency, delirium, and convulsions supervene. The somnolency, and indifference to the consequences of indulging it, when long exposed to cold, have been well known since the accounts given of the cases of Dr. So- lander and Sir J. Banks, in Terra del Fuego, of .Maupertuis in Tornea, and of Captain Parry's associates in the north-west expedition. But the fullest description of its effects upon the senses and cerebro-spinal centres is given by Beaupke. The same degree of cold, according to the state of the system and the extent to which the surface is protected, will cause either delirium of a quiet comatose kind, or raving madness, or convulsions, passing into tetanic rigidity. Great insensibility and somnolency will also often steal upon their victim, without any other mental dis- turbance; and occasionally they will be preceded by tremors, delirium, and convulsions. 9. /. Cold produces very decided effects upon secreting organs and surfaces. When it acts directly upon either of these structures, it dimin- ishes or entirely suspends their functions, owing both to its sedative action on the nerves and cir- culation, and to its constricting influence upon the canals and pores of the part, it thereby lessening vascular turgescence and vital manifestation. Cold air or cold fluids acting upon the external surface interrupt the functions of the skin, par- ticularly if the cold be combined with moisture. A similar effect is produced upon the pulmonary mucous surface, only if the cold be intense, and if it be at the same time humid. As long as the cutaneous surface is protected, and the vital ener- gy of the frame is unsubdued, the exhalation of vapour from the lungs, and the other changes in the blood that take place in this organ, are not materially interrupted until the temperature of the air falls much lower than can be endured by the external surface. When, however, the air is very humid as well as cold, the aqueous exhala- tion from this organ also is much lessened. The remarkable tolerance of cold by the lungs during exercise and a protected state ofthe external sur- face, is evidently owing, 1st, to the circumstance of the quantity of air received at each inspiration being a part only of the whole air contained by them; and, 2d, to the changes in the capacity of the circulating and respired fluids for caloric, by which the respiratory actions are attended. Whilst the nervous and circulating functions are unimpaired by cold, diminution of the cutaneous and pulmonary exhalations is compensated for, and injurious plethora of the vascular system prevented, by a proportionate increase of the se- cretions from the kidneys and intestinal mucous surface. Owing to this activity of the internal secretions, and centralisation of vital energy, the appetite Ls also increased — sometimes rendered even ravenous—digestion is accelerated, and the stomach enabled to dispose of substances which would otherwise be rejected from it. When cold acts upon the frame for some time, and is great relatively to the condition of the digestive oro-ans or vital power, a nearly paralytic state of\he nerves ofthe alimentary canal may ensue, giving rise to interrupted secretion, to flatulent dilation of large portions of it, either with or without spastic constriction of other parts, and to painful and anxious suppression of all its functions. 10. C. Ofthe effects of cold in various states of the system.—a. It has already been stated that the injurious effects of cold are great in proportion to the depression of vital power at the time of its action. When the suiface of the body is warm, or even overheated, but not perspiring, when vascular action is energetic, or the nervous power excited, cold is well and safely borne; but when the body is perspiring freely, and at the same time exhausted, or the depressing mental passions are in operation, it produces a much more in- tense and rapid effect, not only by obstructing the cutaneous perspiration, but also by occasion- ing either interruption of the internal secretions, followed by febrile action, or a morbidly in- creased flow of some one or more of these secre- tions, according to the state of the body at the time. The experiments, however, of Fordyce, Blagden, and Dobson, and the practice ofthe Russians, show that the free perspiration produced by heated air and the vapour bath, as long as the excitement of the nervous and vascular systems occasioned by these continues, may be checked with impunity, and even give rise to a salutary re- action. 11. b. Exposure to cold and wet, in cases of shipwreck, &c, particularly in winter, is produc- tive of bad effects, great in proportion to the rapidity with which evaporation of the moisture from the surface of the body takes place. As the temperature of the sea, in winter, is always high- er than that ofthe air, and is not lowered, as that of the air is, by evaporation from the wet clothes of the person thus exposed, so has it been ob- served on numerous occasions, and particularly in the instance recorded by Dr. Currie, that persons who have remained almost wholly im- mersed in sea-water have always lived longer than those who were exposed to the refrigerating action either ofthe wind only, or ofthe wind as- sisted by evaporation from the wet surface and clothes. Protracted immersion, also, is not so injurious in salt as in fresh water. This is chiefly owing to the higher temperature of the former than of the latter, and partly, perhaps, to the stimulating effects of the salt's dissolved in sea- water on the skin. In cases of shipwreck it is not unusual to find, that those who had taken spirituous liquors to excess during the period of their peril are the first to fall victims to the effects of cold. This, most probably, is owing to the exhaustion consequent upon the excitement pro- duced by spirits; to the fluxion and centralisa- tion of vital power in the parts on which the stimulus directly acts; and chiefly to the circum- stance that such excesses cooperate with cold in producing congestion of the vessels within the cranium, and apoplectic lethargy. 12. c. During states of morbidly excited vas- cular action, unattended by free excretion, or a perspiratory state of the skin, the external or in- ternal application of cold is beneficial, by lower- ing the nervous and vascular excitement to that state which is requisite to a due performance of the secreting and excreting functions. But in or- der that this effect should be obtained, it will gen- erally be necessary to continue the application of COLD — Pathological Effects of. 357 cold for some time, or frequently to repeat it after short intervals, as reaction usually follows a brief use of it ; but as soon as the disposition of the morbidly increased action to recur no longer is evinced, a prolonged application of cold may be injurious by depressing the vital energy so low, that recovery either of the part on which it di- rectly acted, or of the system generally, may be a matter of difficulty. In many of such cases, rigors will follow the too protracted or intense operation of this agent, and be the means of bringing about reaction, which, however, may assume irregular or excessive states, or produce a new or modified train of symptoms. 13. d. During the exhaustion following muscu- lar exertion in hot weather, and while the surface is freely perspiring, cold in any way is most in- tensely and rapidly injurious, particularly when it is applied to the stomach. The ingestion of a large quantity of a cold fluid in this state has been speedily followed by death. This extreme effect has not been satisfactorily explained. That inflammation may be so quickly induced cannot be admitted. It seems more probable that the sudden impression of the cold fluid upon the nerves of the stomach, together with the rapid distension of the organ, paralyses the system of nerves which supplies the digestive organs, and which is evidently that part of animal organiza- tion on which the vital manifestations through- out the frame more immediately depend. Even when cold, owing either to the less bulk of the cooling body, or to the state of the stomach and system at the time, is not quickly or intensely in- jurious, still it may be productive of injury by fa- vouring the developement of inflammatory action in the stomach or liver, or by interrupting the se- creting actions of these and adjoining viscera. 14. D. Changes observed in cases of death by cold.—Quel in alz found the vessels ofthe brain turgid with blood, and the large veins and arteries filled by polypous concretions ; and he refers the sopor preceding death to congestion of blood in the cerebral vessels, and effusion of serum in the ventricles ofthe bruin. Rosf. n also observed the vessels within the cranium engorged with blood. Cappel states that he found the blood and fluids accumulated chiefly in the pectoral and abdominal viscera. Dr. Kkllie detected, in two cases examined by him, the same appearances as were remarked by Quelmalz, Rosen, and Cap- pel ; and noticed, in addition, a bloodless state ofthe scalp, engorgement ofthe sinuses, integrity ofthe substance ofthe brain, remarkable redness of the small intestines from turgescence of the blood-vessels, and absence of tympanitic disten- sion. 15, E. Of cold, or undue abstraction of ani- mal heat, as a cause of disease.—Cold is either a predisposing or an exciting cause of a very great number of diseases, particularly among the poor, and during the winter and spring seasons, as J. P. Frank and Sir G. Blane nave demon- strated. The injurious effects of this agent on infants and children are great in proportion to the earliness of the age at which they are exposed to it I believe that more than one half of the deaths, and two-thirds of the diseases, that occur among the children of the poor, are more or less caused by it Cold will produce modified and even opposite effects, according to iti intensity j [ and duration. It has already been shown, that, during the integrity of vital power, a brief or moderate impression of cold is an indirect stimu- lant, and an excellent tonic remedy ; whilst a very intense or prolonged action of this agent is a direct deprivement of the vital energies, even al- though the rapid abstraction of much cold may inflame and disorganize the parts through which it is caused to pass. Hence it must be obvious that cold will be either a predisposing or an ex- citing cause of disease, according to the intensity, duration, and manner of its operation, to tlie con- stitution of the person on which it acts, and to the other causes and influences which cooperate with it. The same circumstances will also ex- plain the great diversity of its effects, and its op- eration in determining the characters and compli- cations of numerous maladies, even after their career has commenced. 16. After what has been advanced respecting the physiological and pathological action of cold, I need not add any further observations on the manner in which it operates in the causation of particular diseases. It will be sufficient to enu- merate those which it most frequently produces, either by its unaided operation, or in conjunction with a pre-existing disposition or disorder, and with other morbid influences. Fevers, inflam- mations of the individual viscera, dropsies of the shut cavities and anasarca ; catarrhal and bron- chitic affections, haemorrhages ; diarrhoea, dysen- tery, and diabetes ; rheumatism and gout; apo- plexy and paralysis ; tetanus, and other spas- modic and convulsive maladies ; the obstruction of secreting and excreting functions—of the bile, of the urine, of the catamenia, and of the intes- tinal excretions ; scrofulous, scorbutic, and chlo- rotic complaints, hardening of the cellular tissue and oedema, chilblains, and congestions and ob- structions of glandular and secreting parts, are among the most common consequences of this agent. Fevers occasioned by cold alone are generally ephemeral, or of short duration, when no particular organ or function is already in fault; and the reaction—generally ushered in by rigors —is of a salutary tendency when kept within due bounds : but cold favours directly and indirectly the spread of typhoid infection ; and its action on the frame during the progress of all continued and exanthematous fevers is very often injurious, unless judiciously regulated and employed, and is productive of many of the dangerous complica- tions which frequently arise in their course, as well as of the local affections that appear during or after convalescence from them. Such is more remarkably the case in respect of the exanthema- tous fevers. Dropsical and hamiorrhagic effu- sions, although obviously depending, in many cases, on pre-existing organic change, yet often, even in these instances, have been determined by this agent. The greater prevalence also of dropsies, particularly after the exanthemata, in cold than m warm climates ; and the paucity of pulmonary, hasmorrhagic, and diabetic complaints in hot countries, ought not to be overlooked. The frequency of dysenteric, tetanic, and spas- modic affections in warm climates is no argument ugain?t their production by cold, inasmuch as they there arise chiefly from a relatively great depression pf temperature The influence of cold in occasioning apoplexy and paralysis, particular- 358 COLD —Prevention and Tr: ly in aged persons, has been long admitted and satisfactorily proved by Wepfer, Zacutus, Cullen, Fothergill, Marcard, Penada, Walther, Thilenius, Weber, and others; and scrofula is almost entirely a disease of cold and moist countries. 17. F. Circumstances often favouring or deter- mining the injurious action of cold.—a. Weak- ness of constitution favours the injurious action of cold upon the frame. Infants, convalescents from disease, and aged persons, are more injuriously affected by cold than those in whom the nervous, circulating, and respiratory functions are fully developed and unexhausted, and who are thereby enabled to generate vital heat to supply the loss of it going forward on all the exposed surfaces. b. Exhaustion by excesses is one of the most common predisposing states to the injurious oper- ation of cold. The violent or fatal effects of a cold bath at a moment of exhaustion by muscular labour have been well known, at least since the time of Alexander the Great, who nearly perished from this imprudence. The exhaustion consequent upon venereal excesses renders the system remarkably sensible of depressions of temperature, as well as disposes it, in an uncom- mon degree, to the ill effects usually resulting therefrom. The same remark applies to the de- pression consequent upon the excitement of spirit- uous liquors. The habitual indulgence in warm apartments, and sleeping in close chambers, with too great a quantity of clothes on the bed, are very injurious, especially to females, c. The internal determination of the fluids accompanying cer- tain diseases, as chronic bronchitis and diarrhoea, chronic inflammations ofthe viscera, cachectic af- fections, &c, and even that attendant upon a full meal, or the occasional or repeated indulgence in exciting beverages, or the operation of cathartic medicines, favour the injurious operation of cold upon the frame, particularly in delicate constitu- tions. 18. ii. Treatment of the ill Effects of Cold.—A. Means of prevention and coun- teraction, a. Vascular and mental excitement, and physical and moral courage, are among the most powerful aids to the resistance of cold. To these should be added, when within reach, warm woollen or fur clothing ; exercise ; warm dilu- ents, as tea, coffee, chocolate ; gently stimulating cordials and tonics, and warm nutritious diet. All vinous and spirituous excitants are injuiious when used against intense or prolonged cold, as they occasion internal fluxion and exhaustion. If re- sorted to at all, they should only betaken in small proportions, and in large quantities of hot diluents. This opinion is founded on repeated observation, and agrees with that advanced by Dr. Clendin- m.NG, who has paid much attention to this sub- ject. According to the experience and practice of northern nations, and of those in warm coun- tries who use either no clothing, or but little, the anointing of the cutaneous surface with oleaginous substances tends greatly to retard the refrigeration of the body. 19. b. When cold has produced incipient ill effects in the frame, indicated by horripilation, trembling, rigors, &c, a warm bed; hot diluents; stimulating diaphoretics, especially large doses of the spiritus oether. nitricus (from ?, j. to " iij. for a dose), either alone, or with the nitrate of potash iatment of its ill Effects. and camphor ; the repeated exhibition of ammo- nia, camphor, and opium—the last in small quan- tities ; the warm or vapour bath, followed by friction of the suiface ; warm spices and cordials, are among the most certain means of restoration. It should be kept in recollection, that the sooner we succeed in counteracting the directly sedative effects of cold, the less violent will be the conse- quent reaction, and the less injury will ultimately result to the economy. As soon os reaction be- gins to appear, the treatment should be modified; and the means used to determine to the skin should be of a less stimulating kind ; as the preparations of antimony and ipecacuanha ; nitre, with cam- phor, and either of these substances ; Dover's or James's powders, &c. &c. Whenever cold has caused shiverings or rigors, with pains in the head, back, and limbs, free reaction not having yet supervened, we may be satisfied that this state of system is associated with interrupted secretion and excretion ; and that a quick restoration of these functions should be attempted. Therefore, if there be no symptom to forbid it, an emetic, followed by warm diluents, and the warm bath, and these by a cathartic medicine, should be pre- scribed, in order to restore a salutary reaction, and the suppressed secreting and excreting func- tions. In cases presenting the extreme effects of either very intense or prolonged cold, the means of restoration should be very gentle at first, and very gradually increased, as the chief danger to be feared proceeds from excessive reaction—ex- cessive as respects the depressed state of vital power upon which it supervenes—and the rapidi- ty with which inordinate action exhausts the re- maining irritability and vitality of the frame. The means found most successful in restoring a frost- bit limb, viz. a very gradual increase of tempera- ture and cautious admission of stimuli, are requir- ed in such circumstances. 20. B. The injurious effects from cold fluids taken into the stomach, when the body is per- spiring and exhausted, require instant aid. These effects somewhat resemble those proceeding from an injury sustained upon the epigastric region ; and consist of quick, laborious, or gasping re- ! spiration, remarkable weakness and irregularity of the pulse, great collapse and pallor of the countenance and surface, rapid loss of the animal heat, vertigo, with dimness of vision, loss of hearing, &c, and general torpor, followed by coma and death—the one rapidly succeeding the other. In such cases, warm diluents, with ammo- nia, camphor, and opium ; cordial diaphoretics, frictions of the limbs and surface generally with stimulating embrocations ; hot fomentations, sina- pisms, and cataplasms of Cayenne pepper to the epigastrium, and especially animal warmth ap- plied to the surface, particularly the anterior sur- | face of the trunk, are the chief means of recovery. The remedy much employed in foreign countries in cases of external injury on the epigastrium a obviously appropriate in such cases, viz. the ap- plication to this region of one of the lower ani- mals the instant that it is killed and opened, and before it is skinned, or has lost any of its warmth. 21. iii. Of the remedial Operation of Cold.—It does not come within the scope of this work to enter fully inlo the therapeutical applica- tion of cold ; but 1 will very succinctly notice the subject at this place. A. As respects the effect we COLD — Therapeutical Operation of. 359 wish to procure from it, cold is employed, 1st, in a slight degree, or for a short period, in order to produce its indirectly tonic influence ; 2d, in a greater amount relatively to the state ofthe sys- tem, to procure its directly sedative operation, without inducing in any considerable degree its consecutive or indirect effect; and, 3d, to obtain its astringent or constrictive influence on circu- lating canals and vessels. B. As to the mode of using it in order to produce either of these effects, much importance ought to be attached. It may be directed, 1st, to a part or the whole of the external surface—a. by sponging with, or the employment of a douche, or the affusion of a continuous stream of, cold water locally, or using a cooling lotion ; b. by affusing over all the body some cold or tepid fluid, or by sponging the sur- face generally with it; c. by immersion in a cold or tepid bath: 2d, to the internal surfaces—a. by respiring a cool or even cold air; b. by the inges- tion of cold liquids; and, c. by the injection of cold or tepid fluids into excreting canals or passages. 22. It is obvious, from what has been ad- vanced, that the mode of using cold will determine its therapeutic effects, not absolutely however, but only relatively to the state of the system at the time, and the nature and stage of the complaint in which it is prescribed. Thus, cold air, the cold affusion, shower bath, douche, and plunge bath, will produce either an astringent, or a tonic, or a sedative operation, according to the length of time either of them is employed without re- mission ; a brief or momentary use of either, whether directed to a part only, or to the whole, of the surface, being followed by its indirect or tonic action ; and a prolonged use, by a more or less permanent sedative effect. In the treatment of diseases of debility, or states of depression, we require the former operation, and, suiting the mode of applying the remedy to the nature of the af- fection, resort to it momentarily, and repeat it frequently. In maladies attended with excite- ment, interrupted secretion, &c, we desire the latter effect, and prolong the application till we are satisfied as to the extent to which we have obtained it. In congestion and haemorrhages we wish to obtain the astringent or constrictive ope- ration of cold, and therefore resort to it in a sud- den or impulsive manner, as in affusion, douche, or aspersion ; and as this particular effect of cold appears to be connected, and to commence, with its sedative action, and to terminate with, or to be overcome by, the consecutive reaction, ac- cording as it may supervene, so are we guided in determining the degree and duration of the cold to be employed, in order to aslringe congested or bleeding parts. In the appro pritition of each of the modes of using this remedy, by which very opposite effects are thus to be obtained, the prac- titioner is guided by considerations arising out of its operation upon the various systems and organs ofthe body, by its effects directly exerted on the seat of its application, and by its sympathetic action upon parts remote from thence, and upon internal viscera. It is, therefore, obvious that much advantage in practice will accrue from our entertaining correct ideas as to its action upon internal organs, when applied to a part or the whole of the external surface. I have already stated, that cold—whether cold air or cold water— constricts the whole cutaneous surface, and de- termines the flow of blood into the large trunks from the smaller canals and vessels (§ 5.); and that when directed for a short time, moderate re- action is usually brought about by this internal determination of the circulating fluid, and conse- quent excitation of the centres of nervous and circulating functions. This mode of operation must never be overlooked when employing cold as a remedy. The only question connected with it is, whether this constriction of the vessels near the external surface is limited to it, or extends sympathetically to internal parts. It is obvious, that, when the circulating fluid is propelled from one part, it must be determined to some other ; but, whether does it accumulate in the large ves- sels, or retire both to them and to other surfaces ? Pathological facts clearly show that the latter is most commonly the case. Giannini has, how- ever, argued that the fluids are not driven upon the centre, but that constriction also takes place in internal viscera. That such an effect arises from the sudden and momentary shock produced by cold on the surface, and contributes to bring about the consecutive increased action, may be admitted, especially if it be employed locally, or in the vicinity of a congested or relaxed part; but when its action is of any considerable duration, or is directed to an extensive surface, the internal viscera must necessarily experience a proportion- ate increase of the circulating fluid. Thus, the brief affusion of a stream of cold water on the head, in cases of congestion of the encephalon, will tend to constrict the congested vessels, and remove the morbid condition, whilst a more general or prolonged application of cold will ac- tually produce the very state, which this local use of it, in a sudden and momentary manner, is so efficient in removiug. 23. In many cases, as in the excitement of fevers and acute inflammations, when the skin is hot and dry, we employ either local or general cold, with the simple view of abstracting a portion of the increased heat, which, owing to inordinate vascular action, and to the interruption of the perspiring and cooling function, becomes a mor- bid stimulus, and thus perpetuates the cause that originates it. It is obvious that cold, when judi- ciously employed in such cases, will even favour transpiration, and will lower excitement to that state which is compatible with a return of the secreting functions ; but so much pathological knowledge and experienced discrimination are required to the advantageous, or even safe em- ployment of it, that no surprise can exist as to the disuse into which the practice has fallen. When the stage of excitement of continued and exanthe- matous fevers has been either imperfectly devel- oped, or is about subsiding into collapse ; when internal viscera are weakened and congested, and the skin is about regaining its interrupted func- tion, the employment of cold in any way is at- tended by great risk, more especially when ap- plied to the surface generally. 24. The good effects of cold applied to the head, in those diseases accompanied with an ex- cited circulation in it, have induced various au- thors to recommend a similar practice in acute inflammations of the thoracic and abdominal viscera. There can be no doubt that the strictly local application of cold, as near as possible to the organ affected, can be attended with no dan- 360 COLIC —Its Pathology. ger, particularly when the inflammation is acute, and chiefly attacks serous surfaces; and it may be in some instances productive of benefit; but we are still in want of faithfully observed facts to illustrate the effects of this treatment in a satis- factory manlier. In hemorrhagic affections, a judicious use of cold is often of great service—as the cold affusion or aspersion, the shower-bath, and cold sponging, in epistaxis and haemoptysis ; iced fluids taken into the stomach in haemate- mesis; enemata, and injections per vaginam, of cold liquids, in haemorrhage from the bowels, Menorrhagia, and flooding after delivery. Dr. Drake, i.ixbv ix}.yi}ua, Gr. Colica, Passio Colica, Dolor Colicus, Enteralgia, Colicodynia, Tor- mina, Auct. Var. Colique, Fr. Das Buuchgrim- men, die Kolik, Germ. Dolori Colici Ital Belly-Ach, Eng. Classik. 1. Class, Nervous Diseases ; 3. Order, Spasmodic Affections (Cullen). 1. Class, Diseases of Digestion; 1. Order, Affecting the Alimentary Canal (Good). I. Class, I.Ordkr (Author, in Preface). 1. Dr.riN. Severe griping pains in the bow- els, with costiveness, and often with vomiting. 2. Colic was formerly considered as seated chiefly, if not entirely, in the colon ; but many writers of the last three centuries have applied the term to acute pains of the bowels, attended by costiveness, and unaccompanied by fever, arising either from a primary affection of them, or from disease of some other viscus in their immediate vicinity, with which they are connected, and often sympathetically affected, through the me- dium ofthe ganglial nerves. 3. The first mention made of the disease, by the denomination Colicus Dolor, is to be found in Celsus and Pliny; and, according to Sennert and Tronchin, the same name was used by Thf.mison and Philon, physicians of the Au- gustine age, when, as Sprengel justly supposes, colic must, from the manners of that period, have been a common complaint. But, although the term colic appears not to have been in use, it cannot be supposed that such affections were before unknown. It is more probable that they were included under the general appellation of abdominal pains, in use from the time of Hippo- crates. The greater number of modern writers have divided the disease into certain species or varieties, according to the presumed nature of its exciting causes and pathological states. Sauva- ges presents us, accordingly, with no less than 22 varieties. Dr. Cullen arranges the idiopa- thic states of the colic into, 1st, rlhe Spasmodic, either with stercoraceous vomiting, or with in- flammation superadded; 2d, The Colic ofPoitou; 3d, Colic from continued constipation; 4th, From acrid matters in the bowels ; 5th, From retention of the meconium; fe'th, From stricture of the bow- els; and, 7th, From the obstruction occasioned by calculous formations. Dr. Good adopts a nearly similar division to the foregoing, preserving the 1st, 2d, 3d, and 6th varieties; and substituting for the others, Colic from Surfeit, and Colic from the generation of Flatulence—C. Cibaria and C. Flalulenta. M. Pa riset gives the following va- rieties :—the flatulent ; the stercoraceous ; the bilious ; the inflammatory ; the haemorrhoidal; the menstrual ; the spasmodic ; the metastatic ; from calculous and other hard bodies; the ver- minous ; from organic changes in the bowels ; and from lead. M. Chomel divides the disease into nearly the same varieties, and adds to them that arising from acerb or acid fruits, and fer- mented liquors, or Colique Vegetale. The only additional arrangement of the forms of colic, which deserves being noticed, has been given by Schmidtmann, as follows:—A. Inflammatory colic; B. Sanguineous or plethoric colic ; C. From substances passing through or lodged in the bowels; D. From the metastasis or repression of other diseases; E. Flatulent colic; and F. nervous colic. Each of these comprises several varieties, according to the exciting and proximate causes. 4. Colic, according to the extended accept- ation of the word, arises from so many causes, and presents so many morbid ralations, that a satisfactory arrangement of its different states is by no means an easy matter. I shall, how- ever, attempt to group into distinct species those forms of the disease which resemble each other most nearly, or which arise from intimately re- lated causes, noticing the peculiarities or modi- fications presented by the principal varieties. Those forms of colic which chiefly, or more immediately, depend upon a morbid state of the COLIC—Its Pathologt. 361 intestinal canal will come first under considera- tion; and next, those which are symptomatic of, or complicated with, other diseases. In treating of the former, those states which are the most simple, and apparently consist of functional dis- turbance of the bowels, will be first noticed, and subsequently those which proceed from more complicated or organic causes. As I agree with Burseri, Cullen, Good, Abercrombie, Monro, and others, that ileus is often either an aggravated state, or advanced stage, of colic, or a consequence of organic or other causes affecting the calibre or canal of some part of the small or large intestines, I shall treat of it at this place, and after the more simple or less dangerous forms of colic have been discussed. 5. I. Colic chiefly and primarily from functional disorders of the Bowels. i. Simple Colic. Syn. Colica Convulsiva, Bonet; C. Spasmodica, Hoffmann; C. Fla- tulenta, Good, &c; C. Nerveuse, Chomel; C. Nervosa, et C. Spasmodica, Schmidtmann. ! Classif. I. Class, I. Order (Author), j Defin. Acute pain in the bowels, with occa- j sional partial remissions, flatulent distension, or j spasmodic contractions, or both, at the same time, I relieved by pressure and the expulsion of flatus. I 6. There appear to be three morbid conditions i of the intestinal canal, which more or less exist in the simplest as well as in the most severe and i complicated forms of colic, and which evidently depend upon depressed vital power of the diges- | tive canal: 1st, Morbidly increased sensibility i and irritability of some part or the whole of the j bowels; 2d, Irregular distension and spasmodic | constriction of different parts of their canal; and, 3d, more or less copious generation of flatus in their tract, occasioning great distension and irre- gular reaction ofthe muscular tunics—the second ' morbid condition adduced. According as either of these states predominates above the others, the attack assumes a nervous, a spasmodic, or a flat- ulent character; and it has thus acquired these specific appellations from different authors. 7. A. The nervous form of the complaint oc- curs most commonly in females, and in persons of a nervous and irritable temperament, passing a sedentary or indolent life, and of a costive habit of body; sometimes without any evident cause, but often after inattention to the state of the bowels, exposure to cold, or some mental emo- tion or excitement. The attack is usually sud- den, and the pain is felt in one or more places in the abdomen, but shifts its place frequently, and is exacerbated at irregular intervals. The face is pale and anxious; the abdomen is irregularly contracted, and pressure of it often affords slight relief. During the severity of the pains, a cold perspiration is forced out on the surface, and leipothymia, or sinking, is frequently complained of. The bowels are constipated, and borborygmi are constant. The duration of the attack is usu- ally short — from one to several hours; and it generally terminates favourably; but repeated returns of the affection are very common, upon errors of diet, and from mental inquietude. 8. B. The more flatulent form of colic presents greater distension of the abdomen, the expulsion of flatus giving ease. The distension and pain are often traced along the course of the colon, 31 and are most complained of in the situation of the sigmoid flexure and caseum. The quantity of flatus generated is often very great, and it evi- dently proceeds chiefly from irritation ofthe mu- cous surface of the bowels, giving rise to the separation of a gaseous fluid from the blood by the vessels of this surface; the matters retained m the prima via being insufficient to furnish, by their decomposition,—granting that they undergo this change,—so great a quantity of flatus as "is generally voided. Owing to the irritation produc- ed by the flatus, the bowels are inordinately dis- tended in one part, and irregularly constricted in [ another; the part which was contracted, losing- its tone, and becoming, after a time, greatly dis- tended, and the distended portion experiencing at intervals, irregular spasmodic constrictions. Thus the retained flatus is propelled from one part to the other, occasioning griping, shifting pains, and rumbling noises, or borborygmi, of the abdomen. The bowels are always constipated; and wheii evacuations are procured, they chiefly consist of hard lumps, and are accompanied with the escape of much flatus ; the secreting functions of the bowels being evidently impeded. This modifica- tion of the complaint, as well as the preceding, is frequent in hysterical females, and persons of indolent habits, living much on vegetable diet, whose intestinal and biliary secretions are scanty, acrid, or otherwise vitiated; and their digestive functions weakened by indulgences. 9. C. The more spasmodic form of colic is in many cases merely a somewhat aggravated state ofthe preceding; the extremely painful spasmod- ic constriction predominating above the flatulent distension, and extending more or less to the ab- dominal muscles, giving rise to severe and irregu- lar contractions, often with retraction, of the abdominal parietes. Whilst the two preceding varieties are very seldom attended by sickness or vomiting, unless in the severest states, this variety is frequently accompanied with this symptom; and, in its worst forms, vomiting, upon taking substances into the stomach, is very general. Constipation is also very obstinate; injudicious attempts at relieving it often increasing the vom- iting, and converting simple colic into either en- teritis or simple ileus. This form of colic often attacks those of spare habits of body, of the hy- pochondriacal and bilious temperaments, who live chiefly on coarse vegetable food, and are addicted to fermented or spirituous liquors. 10. ii. Colic from the injurious Nature or Quantity of the Ingesta. — C. Accidentalis, Willis and Cullen; C. Vegetale, Chomel; C. Cibaria, Good. Defin. Severe twisting, griping pains in the abdomen, with vomiting, and rigid contractions of the abdominal parietes, followed, in some cases, by griping alvine evacuations, and loose- ness. 11. A. This species of colic .presents various modifications, according to the nature of the of- fending cause; and it has been accordingly dif- ferently described and named. Its states vary greatly in severity, according to the nature of the ingesta occasioning it, whether those of a solid or fluid kind. It may be here remarked, that the colic of Poitou, or colica Pictonum (which name has been very generally confounded with colica pictorum, or painters' colic), and the form ofthe. 362 COLIC, BILIOUS —History, &c. of. disease endemic in some other countries, although in many respects the same as lead or painters' colic, are evidently partly occasioned by the crude wines, new spirits, and the acerb and acid nature of the liquors in common use, as well as by lead, which is sometimes dissolved in them. (See Lead Colic, §26.) Citesius, Piso, Car- dan, Sennert, Weffer, and many recent authors, have imputed the endemic of Poitou, Madrid, and other places, entirely to the nature of the ingesta, into many of which mineral sub- stances could in no way enter. The evidence furnished by their writings, and in the treatises of Grashuis and Tronchin, and my own expe- rience, favour the opinion that acid and acerb liquors are often concerned in the production of colic, without the aid of lead; to which, however, the most severe cases, and those accompanied with paralysis, are attributable, as shown by Sir G. Baker. Dr. Bateman doubts the power of these ingesta, independently of their impregnation with lead, to produce the disease. His opinion is, nevertheless, opposed by the fact, that a large proportion of the cases of colic which occur in districts where acid and spirituous liquors are much used, is not attended by the paralytic and other symptoms characteristic of lead colic, and that many of them run on to dysentery. Whether or not the colic stated by K^e m p f e r to prevail in Japan, owing to the use of fermented beverages prepared from rice, depended on the presence of lead, cannot be ascertained. I had means of knowing that the colic so prevalent among the natives of Africa is clearly owing to the excessive use, particularly when over-heated, fatigued, or covered by perspiration, of the acid beverages prepared from the juice of the palm and other trees, and in the making of which no sort of metal utensil, or of glazed pottery, is at all employed. LtNNiEus imputes the prevalence of the com- plaint among the Laplanders to the use of stag- nant water, containing small worms, &c. In various parts of the north of Europe, where but- ter-milk whey, and vegetable infusions, are fer- mented into very acid liquors, and used for com- mon drink, most severe attacks of colic follow their ingestion in a cold state, particularly when the body is perspiring. Dr. Chisholm attrib- uted the prevalence of colic in Devonshire to the abuse of cider in summer and autumn, by the la- bourers, when busily engaged in the hay and corn harvest — the cold acerb cider inducing a spas- modic state of the bowels in persons overheated by laborious exertion. 12. B. Various articles of food will occasionally disagree from some peculiar idiosyncracy, the articles themselves not being injurious. Such is sometimes the case, when a person, who has been living sparingly, indulges in a too full meal, or partakes of a substance to which the stomach, the functions of which are perhaps weak, is unaccus- tomed. Pork, cooked very soon after being lulled, particularly if used as an article of diet in warm climates, is very apt to produce attacks of colic, followed by griping evacuations from the bowels. A similar effect often is induced by blown or tainted meat, mildewed wheat or rye, und by cold, acerb, indigestible, or unwholesome fruits, as cucumber, melon, &c. The injudicious use of cold griping purgatives, as senna, &e, will often, if not properly combined with other medi- cines, occasion this state of colic in hypochondria!, bilious, or phlegmatic habits. 13. Most severe effects often follow the inges- tion of poisonous fish, muscles, lobsters, mush- rooms, &c, and of the minute fungi sometimes formed on smoked meat and sausages, or on cheese. But the colic which is produced in these cases is the least dangerous part of the mischief; the affection of the nervous and vascular systems being often of still greater importance. Instead, therefore, of considering the effects of these sub- stances as varieties of colic, as Dr. Good has done, I have viewed the disorder of the stomach and bowels as a part only of the circle of morbid actions they occasion, and have therefore treated of them in the article Poisons. 14. The presence of arsenic in wines, or the fumes of this metal; preparations of antimony, copper, or zinc; and the accidental solution of these, or conversion of them into a salt by sub- stances about to be received into the stomach; are often productive of disorder, of which colic is one ofthe most prominent features, generally attended by vomiting, and sometimes followed by loose- ness, or by tenesmus and dysenteric symptoms. Lead colic is very often occasioned by the inges- tion of the metal in some state or other by the mouth, and should therefore be treated of at this place, but the peculiarities of this variety require for it a separate consideration. Many substances occasion, when taken in hurtful quantities, effects of which colic is among the most prominent; but which, as they present certain diversities, are de- scribed in a separate article. (See Poisons.) 15. C. Infants, especially from birth to the termination of teething, and occasionally older children, are- very liable to this form of colic. The state of the mother's milk, arising from the want of health, or manner of living, the irritation connected with dentition, too early feeding, too much or inappropriate food, acidity of the prima via resulting therefrom, and want of attention to the bowels, are the most common causes of this complaint among infants. In children it is often produced by acerb or unripe fruit, and by cold. In very young subjects it is characterised by more or less flatulence, screaming, tossing ofthe arms, and forcible drawing up of the lower extremities upon the abdomen, with vomiting, costive bowels, and greenish, offensive, and acid evacuations; followed by looseness; or free evacuations at- tended by tormina. 16. iii. Colic from a morbid State of the Se- cretions poured into the Bowels, and Re- tention of the Excretions. — Colica Atra- biliaris, Meyserey; C. Biliosa, Hoffmann; C. Stercorea, Ettmuller, Sauvages, and Cul- len; C. Pituitosa, Sennert, Fernel, &c.; C. Stercorale, et C. Bilieuse, Pariset; C. Can- slipata, Good; C. Biliosa, et C. Stercorucea, Schmidtmann; Hepatic Ileus, Musgrave; Co- lica Madridensis, et C. Hispaniensis, Auct Var. Dry Belly-Ache. Defin. Sevire griping pain, with porraceous or bilious vomitings, constipation, or scanty evacuations, and often with hiccup, tension of the abdomen, and restlessness, the motions pro- cured presenting various morbid appearances. 17. This species of colic has been differently described, and named as above, according to the views entertained respecting its natu^ We COLIC, BILIOUS —History, &c. of. 363 have seen that the first variety ofthe disease con- sists of various morbid states, chiefly characterised by deficient function and altered sensibility of the bowels, &c.; and that the second variety is prin- cipally occasioned by the nature and quantity of the ingesta. The variety which I next have to consider comprises certain forms of disorder aris- ing mainly from the morbid condition of the se- cretions and fecal matters contained in the bowels, but aided by other causes; and it may be divided into, a. The colic of infants, caused by retained meconium ; b. colic arising from accumulated faecal matters in the bowels; and, c. From the irritation of morbid secretions poured into the intestines from the liver, &c. 18. A. The colic which is owing to the reten- tion ofthe meconium (C. Meconialis,Sauvages and Good,) in new-born infants, is chiefly met with in those who have either not been sufficiently early put to the mother's breast ; or who have been suckled by a nurse, or brought up by hand. The milk which is first secreted, possesses pur- gative qualities, intended by Nature to promote the expulsion of the secretions, which had accu- mulated in the prima via during the latter period of fcetal life; and when the infant enjoys not this requisite kind both of nourishment and medicine, the meconium is retained, becomes viscid, acid, and irritating to the bowels, occasioning costive- ness, distention, screaming, drawing up of the lower extremities, sickness, &c. 19. B. It is evident that the retention in the caseum and cells of the colon, of those excre- mentitious matters which require to be thrown off from the bowels, will be productive of more or less disorder. Such retention usually occurs very early, and in advanced life ; in those who pass an indolent existence, or are engaged in sedentary occupations; in persons whose bowels are torpid from debility or exhausted sensibility ; in females who are pregnant, or who are of an advanced age; and in men who have old hernia?. It is often preceded by indigestion, cardialgia, constipation of the bowels, and fulness about the caecum, the sigmoid flexure, and occasionally the whole course of the colon. In many cases, large accumulations in the Caecum or Colon (see these articles), may be detected by manual ex- amination. Sickness and vomiting, however, sel- dom come on until abdominal griping pain has been for some time complained of, and the stom- ach has been irritated by acrid purgatives. Later in the complaint, the abdomen becomes tense, tumid, and painful on pressure; the pulse accele- rated ; and the tongue, which was from the com- mencement loaded at the root, more foul or furred. This form of the disease is very apt to terminate in dysentery, enteritis, or ileus. 20. C. The form of colic which occurs, and even prevails, in some ofthe West India Islands, has often been confounded with lead colic, from the supposition that the new rum drunk in these islands contains lead in solution. Mr. Quier, Dr. CHisHOLM,and Dr. Thomson, who resided long in the West Indies, state that this disease is not so common as formerly in these islands, owing to the improvement in morals, and the use of warmer clothing; and that nothing is more erro- neous than attributing it to the poison of lead. These physicians refer it to the intemperate use of spirits, and to alternations of heat and cold. Mr. Q.uier and Dr. Musgrave, who have given a very detailed account of this complaint, as they observed it in Jamaica and Antigua, where it is of frequent occurrence, state positively that lead is not concerned in its production. From the his- tory they have given of this endemic colic of the West Indies; and from the descriptions of the colic, which is perhaps the most common disease in Madrid and several provinces of Spain, fur- nished by MM. Pascal and Maro_uand, who treated many hundred cases of it in the French army that occupied Spain during the peninsular war, and in 1824—all which accounts are now before me; I conclude that the colic of Spain and that of the West Indies depend upon the same causes—evidently of an endemic kind; are char- acterised by similar symptoms ; run the same course, evince similar lesions, and are cured by the same treatment. Indeed, I have seldom met descriptions of any disease so much alike as those furnished by Dr. Misgrave and by M. Mar- o„uand, who himself had the complaint, the causes and treatment of which he has so ably in- vestigated. After examining the causes to which writers, particularly Hoffmann and Thiery, and others copying them, have imputed this af- fection, viz. to lead and metallic substances dis- solved by acid wines, &e, M. Marquand states those to which the natives attribute it; namely, the use of vegetable acids and unripe indigestible fruits ; large draughts of wine and water, and of much milk; and insufficient clothing on the trunk of the body and abdominal regions. But these causes, he remarks, are in operation in many places of Spain and Portugal whero colic is rare, and therefore some endemic cause not yet dis- covered must be in operation. M. Labrey im- putes it to atmospheric vicissitudes and acid beverages, and designates it " Colique bilieuse rheumatismale," MM. Aulagnier, Libron, and Jacob, who have had extensive experience of this disease in Spain, concur with M. Mar- o_uand in denying the influence of lead in pro- ducing it; and think that its causes are not yet fully ascertained. The negative information fur- nished by these writers, the character of the symptoms, and particularly the appearance of the evacuations, would lead me to infer that, in both the colic of Spain and the colic of the West Indies, endemic causes,—especially those which proceed from the soil, and produce intermittent and remit- tent fevers,—impede the functions of the liver and intestinal surface, and occasion an accumulation in the hepatic ducts, gall-bladder, and prima via, of acrid or otherwise morbid secretions, which, owing to their irritation, or to concurrent or de- termining causes, give rise to a series of painful and diseased actions, and imperfect or abortive attempts at their evacuation. The symptoms re- ferrible to the liver—its congestion—the signs of irritation about the duodenum, the vitiated dark appearance of the stools, and the relief obtained from free alvine evacuations, are proofs of this position. 21. Symptoms.—The patient generally experi- ences premonitory symptoms before the accession of the attack. These consist of dull and pressing pains in the whole course of the colon, but par ticularly in its arch; loss of appetite ; irritability of temper, and difficulty in evacuating the bowels, which, however, are not costive. The patient 364 COLIC FROM LEAD—History, &c. of. has often several evacuations in the course of the day, but in small quantity, and with much fla- tus ; and he experiences less distress in bed than when he is up. The tongue is moist, and loaded only at the root; ,and there is much thirst. These symptoms usually continue two or three days; about the third, the patient has no longer any de- sire to go to stool, and evacuates no more flatus; but the pain becomes more severe, and more fixed and constant at the epigastrium, with a twisting pain at the umbilicus : the countenance is pale, and expressive of pain and anxiety ; the pulse is slow, small, regular, and constricted, but not febrile; the skin is dry, but not hot; and the urine is scanty, but not otherwise unnatural. The patient often sits with his arms crossed over, and pressed upon, the abdomen, and the trunk bent forwards. If he be in bed, the thighs are pressed up upon the belly. Along with these symptoms, and generally soon after the accession of consti- pation, porraceous or bilious vomitings come on, commonly in small quantities, mixed with glairy matters, or those last taken into the stomach, and accompanied with hiccup. There is no sleep, but a continued restlessness: the pain is now nearly constant, and most severe, particularly about the epigastrium and umbilicus, and is not ameliorated by any position. As the malady pro- ceeds, the thirst increases ; and the fluids taken generally aggravate the hiccup, and are soon thrown off. The eyes are sometimes slightly yellow, and the whole surface rather sallow. The patient is distressed by the continued severity of the pain, the hiccup, and the want of sleep; wandering and delirium comes on, sometimes with deafness, epileptic convulsions, and rarely with fssculent vomiting; these latter symptoms generally portending a fatal result. 22. This disease, left to itself, usually runs its course in eight or ten days, and rarely extends beyond the fifteenth. Pain or uneasiness in the right hypochondrium is often felt some time before severity and continuance of singultus ; by dry- ness ofthe tongue, and increased restlessness and tossing. 24. Dissection has thrown little light on the nature of the disease. M. Marquand, whose experience was extensive, considers that what- ever change of structure is observed, is merely a contingent circumstance, or accidental com- plication. M. Pascal states, as the result of the examinations he made of six fatal cases, that little or no lesion was observed hi any part of the alimentary canal, excepting slight redness of the mucous surface of the duodenum : the gall-blad- der was loaded with thick bile ; but the other viscera were natural. He further states, that he found the sympathetic ganglia injected. A pe- rusal, however, of his description of the appear- ances presented by them, impresses me with the belief that what he considered to be unusual vascularity, was not more than they always pre- sent in the healthy state. 25. iv. Colic from the Poison of Lead.— Syn. Colica Saturnina, C. Pictorum, C. Pictonum, Auct. Var. C. Rhachialgia ('oa/iuXyia, Spine-Ach), Astruc, Good; C. du Poitou, C. de Plomb, C. Metalhque, Rachialgie Metallique, Auct. Gall. Bleu colik, Trocken Colick, Germ. Devonshire Colic, Painters' Colic, Lead Colic, fyc. Defin. Dull remitting pain, becoming con- stant and violent, extending to the back and upper and lower extremities ; vomiting, obstinate con- stipation, often followed by paralysis. 26. I have already noticed the fact of this disease being often confounded both with the form of colic produced by acid and acerb in- gesta (§ 11.), and with that depending upon a morbid state of the secretions poured into the in- testinal canal (§ 20.). Lead colic chiefly attacks house-painters and plumbers, workers in the different preparations of lead, glaziers of earthen- ware, miners, ornamental and water-painters, the attack, and occasionally not until the advanced gilders, and rarely chemists and printers. It is progress of it. In some cases, the pain and vom- iting cease, upon the free spontaneous excretion of flatus, with dark, hard motions: but occasion- ally they return after a short time, and black atrabilious matter is thrown off the stomach. The discharge from the bowels is generally very morbid, offensive, and of a dark, blackish, or deep green colour. In other cases, where the patient has been neglected or improperly treated, chronic debility, with marasmus, and, more rare- ly, paralysis, supervenes, and usually terminates fatally. The abdomen is seldom much retracted, excepting about the umbilicus ; but, at the last or fatal stage of the disease, it is much dis- tended. The bowels usually resist the action of the most powerful purgatives at its advanced period, and injections are tluown up or retained with difficulty. 23. Prognosis.—a. A favourable issue is in- dicated by free evacuations, followed by amelior- ation of the abdominal pain and vomiting, by the circumstance of the pulse remaining below 100 beats in the minute, and the non-superven- tion or subsidence of hiccup, b.—An unfavour- able result is preceded by more or less tender- ness, tension, and tumefaction ofthe abdomen- by a pulse above 100 ; by obstinate constipation' and immediate return of the injections ; by the very probable that the colic so prevalent in Devonshire, Poitou, and, according to Tron chin and Wanstroostwyck, in Haarlem and Am- sterdam, arises in some instances from a portion of lead contained in acid beverages, and pos- sibly from the water used for domestic purposes; but that the endemic colic of the West Indies and Spain is occasioned by lead, as many sup- pose, has been disproved, as we have seen, by the more accurate observations of modern en- quirers, especially directed to this point. Lead colic arises not only from the introduction of the mineral into the system along with the in- gesta, but also from its oxides being allowed to remain in contact with the surface of the body; as in the case of workers in lead, as shown by Lentin, Brambilla, Sir G. Baker, and Dr. Reynolds ; and from the volatilised fumes of lead floating in the air, in recently painted apart- ments, as observed by Percival, Henckel, Gardanne, Badeley, and Good. It is ex- tremely probable that lead produces a more in- jurious action upon some constitutions than upon others; and that its oxides and sub-salts are more in- jurious than its super-acetate. The most quickly, and sometimes the most powerfully, injurious operation of lead is when its oxide is mixed prin- cipally with turpentine, for the purposes of house- COLIC FROM LEAD painting. Thi3 spirit carries along with it, during its volatilisation, a portion of the oxide, and thus poisons the respired air, thereby affecting the re- spiratory nerves and even the blood itself Soon after Sir G. Baker's investigation of the effects of lead, and ofthe substances which either contain- ed, or might by possibility contain it, was made public, every thing which came in contact with lead in any form was viewed with suspicion. Dr. Percival first demonstrated the folly of these apprehensions; and although the water which supplies a million and a half of persons in this metropolis passes through leaden pipes, and is long retained in leaden cisterns, which are often allowed to become foul, yet, I believe, that no case of lead colic occurs from this cause, except- ing in those who are affected by lead in a different and manifest manner. Dr. Bateman never met with a case in London which could not be traced to this source; and I certainly never did, notwith- standing the readiness with which the effects of lead are produced in some persons. Although lead is thus the efficient cause of the complaint, it is not always the only cause. Thus, the acid beverages or spirits in which the food is taken may determine its effects ; or an attack may be induced, in a person imbued with the lead poison, by improper ingesta, spirituous liquors, exposure to cold, and by sulphureous waters, or sulphureted medicines, and cold griping purgatives. Cases have been recorded by Dr. Wall and Sir G. Baker, where the external medical use of the preparations of lead occasioned the disease, but such are of rare occurrence. 27. Symptoms.—Lead colic usually commences with obscure pain of the abdomen, which be- comes, at first, at intervals, so severe, that the patient screams, tosses himself about, and vainly seeks a posture that will lessen his sufferings. Some lie for a while on the abdomen, and others press upon or nib this part with the hand. The pain is generally greatest at the pit of the stomach, and as the disease proceeds, extends to the back, upwards to the arms, and downwards to the loins, thighs, and legs. A twisting pain is also general- ly felt about the navel, which is at first drawn inwards ; and cutting pains shoot at times with great violence to both hypochondria and iliac fossae, and through the abdominal muscles. The voluntary muscles often become so sore that they cannot bear the slightest pressure ; and the pain frequently alternates between the stomach and bowels and the external muscles. Sickness and constipation are early symptoms,—the matter thrown off the stomach consisting of a slimy fluid, either with or without acrid deranged bile, which is continually being secreted, accumulates, irri- tates, and is evacuated. To these are generally added bitter eructations, hiccup, severe headach, pains ofthe wrists, hands, ancles, soles ofthe feet, &c.; and frequently of the shoulders and neck. These symptoms are aggravated during the night, depriving the patient of a moment's repose. The pulse is not, at first, affected—sometimes in no measure throughout the disease ; in many cases it is below the usual standard, and in others quicker and weaker, more rarely fuller or strong- er. The tongue is pale, moist, and soft, without erection of the papilla?. The skin is commonly soft and moist; it is rarely hot. The urine is various, but more frequently copious than other- 31* — History, &c. Of. 365 wise. Costiveness continues as the disease ad- vances ; sometimes a griping disposition to stool occurs ; and if any faeces are passed, they are scybalous, hard, resemble sheep's dung, and are mixed with a dirty watery fluid containing a dark slime, and occasionally a little blood. M. Mer- at analysed the matters evacuated, but could not detect any lead in them. The abdomen is insen- sible to pressure ; in some instances rigid and knotted ; but in the latter stage often distended and slightly painful, chiefly from the distension of the bowels, and affection of the muscles. In the cases which have occurred in my practice, distension of the abdomen was as frequent as re- traction, owing evidently to inflation and faecal engorgement of the colon, the course of which could be distinctly traced under the abdominal parietes. M. Andral has also met with a simi- lar state of this cavity. In some cases I have remarked considerable retraction around the um- bilicus, while all the rest of the abdomen in the course of the colon was greatly distended. Dr. Munro states that the sphincters of the bladder and rectum are sometimes so contracted that the urine and faeces cannot be voided. I have ob- served this chiefly as respects the sphincter ani— a clyster pipe being with difficulty introduced. If the complaint be not soon ameliorated, the pains of the back, loins, and limbs become more violent, and are attended by extreme weakness, tremulousness, and even partial or complete pa- ralysis, particularly of the extensor muscles. In some cases, dyspncea, palpitations, and a short dry cough, are complained of, seemingly owing to the pressure of the inflated colon upon the diaphragm; and occasionally epilepsy, coma, or even apo- plexy, supervenes. 28. Duration, Complications, and Prognosis. —A. The duration of the attack varies from two or three to twenty-five days. M. Ranque found that, out of 147 cases, 129 recovered between the second and the thirteenth day of treatment, and the remainder before the twenty-sixth day. But relapses, or rather returns, of the complaint are most common. I have met with instances of a ninth and tenth attack ; and more numerous seiz- ures have occurred in the practice of others. In more unfavourable cases, the disease continues for weeks, or even months, with occasional inter- missions; but such may be viewed as a succession of attacks, and occur chiefly in drunken workers in lead—addiction to spirits aggravating and re- producing the effects of lead on the system. 29. B. This disease is sometimes complicated with epilepsy ; more frequently with palsy, in which it often terminates; and rarely with in- flammation of some one ofthe abdominal viscera, and with mania or delirium. 30. C. The prognosis is favourable when the symptoms are mild, or are ameliorated by treat- ment ; but it should be given with caution and reservation when the attack i3 very severe, is attended by hiccup, by obstinate and continued vomiting, by tremulousness, and by distension of the abdomen. It should be unfavourable, if com- plications (§29.) appear in its course ; or if deaf- ness, blindness, fjecal vomiting, and symptoms of ileus, supervene. 31. Appearances observed on dissection.— Lead colic is most commonly fatal from the com- plications that occur in its course. In its simple 366 COLIC AND LLEUS —Pathology of. state it seldom terminates in death. The exami- nations made by Senac, Astruc, and Bor- dieu, furnish nothing satisfactory. Stoll ob- served the gall-bladder loaded with dark bile : Sir G. Baker describes the bowels as being per- fectly natural throughout, and the muscles pale and wasted. Dk Haen states, that he found contractions of the colon and caecum in all the cases he opened. M. Merat examined seven cases, which he says presented the same appear- ances as those described by De Haen ; whilst M. Andral details six cases, in all of which no such contractions were observed, nor any other morbid change of the alimentary canal. M.Louis, also, found no alteration in the bowels. Most of those who die of this disease are carried off in epileptic convulsions, or have had paralytic symp- toms. The state of the cerebro-spinal axis is hence deserving of examination. M. Andral, however, states, that he detected no lesion of the brain, nor ofthe spinal cord, nor of the voluntary nerves. A case I had an opportunity of exam- ining confirms the observations of Sir G. Baker and Andral.* 32. II. Colic arising most frequently from Change of Structure or re- lative Position of the Bowels.— Classif. IV. Class, I. Order (Author). i. Colic from Mechanical Obstruction of the Canal of the Bowel.—Syn. C. Calculosa et C. Schirrhosa, Bonet, Chomel, Lamotte ; C. Constricta, Good. Defin. Costive, flatulent state of the bowels, attended by passing colicky pains, relieved by liquid, difficult motions, and often accompanied by a sensation of constriction ; tumour or diffi- culty in a particular part ofthe abdomen. 33. Considerable mechanical difficulty is often experienced for some time before a severe attack of colic or ileus takes place. A patient, whom I have long attended for slight colic pains, and irregular state of the bowels, without full or satis- factory evacuations, states, that a sensation of soreness in the situation of the arch, and of diffi- cult passage to the left flexure of the colon, with painful distension about the caecum and right side, are often felt shortly before an evacuation. Dr. Monro remarks that stricture of the bowels in its early stage occasions costiveness, alternating with diarrhma and colic pains. If the obstruction be low in the bowels, solid faeces are either not * Mr. Byam and myself recently examined the body of a painter, wlio died at the age of 78. He had been a very strong man, and in eonslant employment all his life up to "a few days before his death. He died of ha-matemesis, from disease of a branch of the coronary arterv of the stomach. The substance of the heart was soft and flabby. The small and large intestines were sound; the liver was studded with collections of a pultaceous semifluid malter, of a gravish- white colour, contained in very thin cvsts, from the size" of a hazel nut la a walnut, the portions of liver suriounding them being softened and of a dark red colour. The top of the an- terior mediastinum, and space behind the top of the sternum, contained au immense mass, nearly the size of the closed hand, of enlarged glands, of a che!esy consistence and ap- pearance-, and a similar change of the absorbent elands ex- isted behind the arch of the aorta, the superior cava, kc. ex- tending in the form of a long cushion down the vertebra into the abdomen. The small arch of the stomach, the pvlorus, and commeucenieut of the duodenum, were remarkably thickened, from the deposition of adventitious matter, the thickened mass nearly approaching the characters of scirrhus. The coats of the arteries of the stomach were diseased, and contained atheromatous matter. passed, or thev are of small quantity and slender calibre. These strictures are most commonly met with in the colon ; and their situation, in some cases, may be inferred from the sensations of the patient, and the symptoms observed in ex- amining the abdomen : they are fully described in the article on Morbid Structures of the Diges- tive Canal. (See also articles Cscum and In- testines.) When colic is owing to the pres- ence of concretions, stones of fruit, &c. in the bowels, distinct hardness, or even tumour, is sometimes felt ; but, in many instances, no such change can be detected, although the patient generally refers to some part of the abdomen as presenting a fixed pain, or obstacle to the func- tions of the intestines. (See art. Concretions —Intestinal.) In all cases of colic pains arising from the above pathological states, great distension and tenderness of the abdomen often speedily come on, partly owing to inordinate dilatation of that portion of the canal above the obstruction. Sickness also at stomach, and vomitings, gen- erally precede or follow these symptoms, with restlessness and distress ; and the complaint soon assumes all the characters of ileus, unless the re- tained matters pass the obstacle, or the obstruct- ing body itself be propelled downwards and evac- uated, as is often the case in respect of biliary and other concretions. When colic proceeds from in- cipient mechanical obstacles in the intestinal canal, the symptoms are less violent; but they are of frequent recurrence, until the obstruction is re- moved, or they increase so as to produce inflam- mation ofthe bowels or ileus. 34. ii. Colic, with complete Obstruction of the Boxoels, and Stercoraceous Vomiting, Ileus, Volvulus—Syn. ElXlos (from ei&iw, I con- stringe), Hipp. ElXlov (from tlf.ioi, volvo, I roll about—hence, volvulus), Aretaeus. Xv(io- Satpoc (from xopSij, a cord, and «/tto>, I kill), Galen, Morbus tenui Intestini,Ve\sus. Acu- tum Tormentum, Ccel. Aurel. Iliaca Passio, lliacus Morbus, Chordapsus, Miserere, Do- lor Ileus Spasmodicus, Auct. Var. Volvulus, Baillou. Ileus Verus, Sydenham. Ileus Spas- modicus, Sauvages. Colica Ileus, Good. Pas- sion lliaque, Fr. Darmgicht, Ger. Volvolo- passione Iliaca, Ital. Iliac Passion, Eng. Defin. Violent griping pain, obstinate consti- pation, with retraction of the navel, and spasms of the abdominal muscles, tension, tenderness and distension ofthe abdomen ultimately supervening, and generally with stercoraceous vomitings. 35. Galen, and after him, Van Swieten, viewed ileus as merely a form of inflammation of the bowels. Others, particularly Sauvages, Barthez, Cullen, Pinel, and Alibert, ascribed to it chiefly a nervous or spasmodic character. Many writers of the last century have divided it into idiopathic and symptomatic ; whilst M. Raige Delorme, and others, have disputed its idiopathic nature, and particularly its nervous origin, and have considered it, as it, doubtless, most frequently is, a consequence of mechanical obstruction, inflammation, or some pre-existing disease. There can, however, be no doubt, although many of the cases observed may have been merely severe instances of colic, in which the proper symptoms of ileus had not come on, that it sometimes occurs as a simple COLIC AND ILEUS—-History, &c. of. 367 and idiopathic disease, as Barthez, Maxwell, and Dr. Abercrombie have demonstrated; and that dissections of fatal cases sometimes present no morbid change sufficient to explain the symp- toms or to account for the result. In the cases recorded by Barthez and Maxwell faeculent vomiting, and the discharge by the mouth of matter thrown into the colon, are described to have occurred, and yet recovery took place. In many instances, perhaps the majority, ileus su- pervenes on one or other of the forms of colic already described ; or, in other words, certain pathological states commence with symptoms, which, in the tout ensemble, constitute some one of the forms of colic described, and terminate in fully developed ileus. Such terminations are most common in the second, third, and fourth varieties of colic. But in rare instances, ileus comes on suddenly, with the most violent abdominal pain and vomiting, the patient tossing about in the ut- most agony, the other symptoms of the disease rapidly appearing, and most frequently terminat- ing fatally.* 36. History.—Ileus is either preceded by con- stipation and colicky pains, or it is a more intense form of colic from the commencement, the symp- toms differing only in degree. Early in the dis- ease, constipation; twisting and violent pain about the umbilicus, sometimes not aggravated by, but even alleviated by pressure ; constant retchings ; absence of fever, and a pulse not exceeding, or even below, the natural standard, are the usual signs. If relief be not soon procured, the ab- domen enlarges, and becomes tense, tender, and tympanitic ; the countenance is anxious and collapsed ; fseculent matters are ejected by the mouth ; the pulse becomes frequent, small, and constricted, the thirst urgent; and violent tor- mina, with ineffectual attempts at evacuation of the bowels, hiccup, failure of the mental energies and vital powers, with cold, clammy, and par- tial sweats, cold extremities, cold, sunk features, leipothymia, and sinkings, supervene. In many cases, inflammatory symptoms appear early in the course of the malady, and pass rapidly into those indicating the commencement of gangrene. The state of the tongue is different in different cases, and stages of the complaint. It is occa- sionally not materially changed. Often the dis- eiise is referrible at its commencement to no par- ticular region of the abdomen ; but as frequently the patient refers his sufferings to a particular part,—sometimes to the ileo-cascal region, occa- * Professor , of Berlin, during his visit to Londun, was attacked the day after dining with a party of scientific men, when he sat with his'back to a large fire. I was called to him, and found him in the utmost agony, with a pulse of natural frequency; his abdomen tense, tympanitic, and sub- sequently tender to the touch. What he vomited at first consisted of half digested substances; subsequently it was mixed with mailers which had apparently come from the upper part of the small intestines. Calomel and opium were administered, and oleaginous enemata repeatedly thrown up. A flexible boucie was introduced its whole length, and large glysters were fnjecteil without difficulty; but the latter were returned soon after without any effect. The abdomen in- creased in size; mental distress and debility became ex- treme; the matters rejected by the mouth were more ob- viously fa-culent; hiccup and leipothymia appeared, and he died in two days. An examination was not permitted. The characters of the attack suggested the idea of a paralysed state ofthe bowels, with inverted action of their upper portion, gradually extending downwards. The origin of the suffer- ings was not referred to any particular part of the abdomen, nor had any obstruction been previously complained of. sionally to the situation of the sigmoid flexure of the colon ; in some cases, in the course of the right or transverse colon ; in others, above or about the umbilicus, or low in the iliac and pubic regions. In all such cases, we may suspect me- chanical obstruction arising from some one or other of the following causes, which have been repeatedly discovered on dissection :— 37. Changes observed in fatal cases.—1. Great distension, as if from paralysis of the muscular coat of a large portion of the small intestines, without inflammation or any other change. 2. Dilatation, with a cord-like contraction, in either the small intestines, or in the large ; more fre- quently the latter. 3. Dilatation, with inflamma- tion, lividity, and exudation of lymph on the serous surface. 4. This latter state, conjoined with gangrene, and either with or without exuda- tion, occurring in the small or large intestines ; more frequently in the former. 5. These changes combined with contractions,—occasionally only one, often more, the intervening parts being dilat- ed,—in some part of the bowels. 6. Unnatural convolutions, twists, loops, or knots, in some part of the small intestines. 7. Various convolutions, or duplicatures, or twistings in the large bowel, with an appearance of elongation owing to re- laxation or paralysis of the longitudinal bands of muscular fibres. 8. These latter, conjoined with recent or old cellular adhesions of the opposing serous surfaces of the duplicated portions. 9. One or more introsusceptions ; the introsuscepted por- tion being either in a downward or upward direc- tion, sometimes uninflamed, as in infants and chil- dren; frequently inflamed, adherent by lymph, or gangrenous, particularly in adults ; and occurring in any part of the intestinal tube. 10. Old adhe- sions of one part of the small or large intestines to another, or to the parietes of the abdomen, or to the omentum, or some other viscus, without obstruction of the canal. 11. Similar adhesions occurring in reduced or old hernise, or in hernias for which an operation had been performed and the bowel returned. 12. Filamentous or cellular bands confining or encircling a portion of intes- tine, sometimes after reduction of hernia, occa- sionally in a large and irreducible hernia, and even where no hernia had existed (Garthshore, Morf.au, Moscati, Walther, Abercrom- bie, myself, and others.) 13. Adhesions of the appendix of the ccecum to some part, after pass- ing over or around, and strangulating a portion of intestine. (See art. CjEcum.) 14. Strangula- tion of a portion of one side ofthe intestine in the femoral arch, without producing any tumour, and without obliterating, or even sensibly diminishing the canal of the bowel.* 15. Various states and forms of internal strangulation, often produced by old adhesions formed between opposing portions of the serous surface, more commonly low in, or about the middle of the abdomen,—by portions of omentum,—by rents in the omentum, through which a portion of intestine had passed, and by various adhesions, obstructions, and changes in the position of parts of the bowels. 16. Stran- gulation in the mesentery, owing to partial adhe- sions (Swammerdam). 17. Various states of contraction in the small and large intestines from * This occurred in a female servant of the author, who was siezed with ileus, without any antecedent disorder. 368 COLIC AND ILEUS —History, &c. of. organic changes in their coats, more particularly 1 about the caxuni, sigmoid flexure ofthe colon and rectum, as scirrhus, fungus, soft cancer, &c. (De Haen, Rhan, Hodges, Thomann, How- ship, Annesley, Abercrombie, Travers, &c). 18. Internal polypous or malignant excres- cences, or external diverticula (Portal, Clo- o.uet, Copland, Hutchison, &c). 19. Ob- structions of the canal of some part by biliary and intestinal concretions, stones of fruit, bones, in- durated faeces, and balls of worms. 20. The pressure of encysted or other tumours, abscesses, &c. in the pancreas, kidneys, omentum, uterus, ovaria,* or between these latter and the rectum. 21. And lastly, The circumstance of ileus being roduced by herniae, both of the more common inds, and of those that are uncommon, as hernia ofthe ischiatic notch, diaphragmatic hernia, &c, should not be overlooked. Of these, and even of other internal changes productive of ileus, nu- merous instances are to be found in the works to which I have referred at the end of this article, at the places pointed out. (See also articles Cecum, Colon, Constipation, Digestive Canal, Intestines, &c.) 38. Of Volvulus, or Ileus arising from intus- susception.—a. The invagination of one or more portions of intestine is not infrequently met with in post mortem examinations; and on some occa- sions its existence may be known during the life of the patient. The number of intus-suscepted portions may vary from one to ten ; the greater number being most frequently met with in chil- dren, amongst whom invagination is also most common. In this class of patients it is frequently unconnected with any marks of inflammation ; and, from the healthy appearance ofthe part thus affected, and the facility with which the invagina- ted portion is replaced, it seems probable that in- tussusception has taken place, either very shortly before, or at the period of death. In the majori- ty of instances it is an accidental consequence of pre-existing disease, most frequently of the intes- tinal canal, arising from an irregular action ofthe muscular tunics, occasioned by irritation of the mucous surface. Thus worms have been found in or near the invaginated part: and in adults it is generally observed in connection with inflamma- tory action of some one ofthe intestinal surfaces; and as a consequence of dysentery and chronic diarrhoea, particularly the dysentery of warm cli- mates ; a considerable number of the dissections which Mr. Annesley made in this disease in the East Indies presenting one or more invaginations, commonly in the small intestines. I have also not infrequently found it in fatal cases of inflam- mation ofthe brain, or its membranes, in children. Although generally a fatal occurrence, intussus- ception is not necessarily such. I believe that it sometimes occurs in infants, without being pro- duced or followed by inflammation ; gives rise to symptoms of ileus, or merely to slight colic ; and, either with or without the aid of medicine, some- * A lady, to whom I was called, had inflammation of the uterus, and an abscess formed between the upper part of the vagina and rectum, pressing upon the latter so as to prevent the evacuation of the bowels and injection of glvsters. Colic, followed by ileus, took place. During an attempt to throw up au enema, by passing a male catheter up the rectum, the abscess burst into the rectum, and a large quantity of pure piii, followed by copious f«culent motions, came awav, when all the dangerous symptoms disappeared. I times is restored to its natural position. In adults, however, even when it occurs without pre-existing inflammation, it almost always causes the most acute inflammatory .action, often terminating b the accretion of parts, or in gangrene, chiefly owing to the strangulation of the invaginated part. Many cases, however, terminate fatally before sphacelation takes place ; whilst in" others, gan- grene occurs during life, and the invaginated part passes off by stool ; union of the opposing ex- tremities of intestine formed by the separation of the dead invaginated part, and the ultimate re- covery of the patient sometimes being the result. 39. One of the most common causes of inva- gination of the intestines is the inappropriate use of drastic purgatives. In all the cases of inva- gination observed after death from dysentery, that I have perused, purgatives had been unsparingly and unnecessarily exhibited. M. J. Cloo.uet has published a case, wherein a female died of enteritis consequent upon invagination of about fourteen inches of the ileum, occasioned by a polypous excrescence arising from the mucous surface, and which, having been pushed onwards by the peristaltic action of the intestine, had drag- ged the part to which it was attached along with it. Costiveness is often a prelude to this change, hardened faeces, &c, producing local irritation. Intus-susceptions are most frequently downwards, and but rarely upwards. Dr. Monro thinks that an inverted action of the bowels is requisite to the production of the latter. They are most common at the termination of the ileum in the caput caecum. The quantity of intestine that passes within the other varies from one to thirty inches, or even more. In an infant, to the ex- amination of which I accompanied Mr. Alcock, nearly the latter extent, including the ileum, caecum, and ascending colon, was invaginated. In some rare instances, the ileum, ca?cum, as- cending and transverse colon, passes into the sig- moid flexure, or even as low as the rectum ; or the caecum and colon only (Whately, Monro, &c). I have met with two or three such cases in infants and children. In rarer instances, a portion of the colon and ileum has passed out at the anus. 40. Diagnosis.—Is it possible to distinguish volvulus or ileus owing to intus-susception, from colic or ileus arising from other pathological states ? I think that symptoms may present themselves, which will, in some instances, lead the observing practitioner to infer the existence of invagination. The sudden invasion of the symptoms of severe colic or ileus after a violent straining at stool ; and, subsequently, the con- stant desire to go to stool, attempts at evacuation being accompanied with violent tormina and te- nesmus, and either unattended by evacuation, or followed by the discharge of a little bloody mu- cus, and these by symptoms of enteritis ; are amongst the most constant concomitants of inva- gination. In some instances, also, the sudden oc- currence of an elongated tumour, in addition to these symptoms, and before abdominal distension comes on, will further guide the opinion ; particu- larly if the invagination be extensive, and seated in the caecum or course of the colon. Much will, however, depend upon the precision and tact with which an examination of the abdomen is made. In all such cases, the rectum should be examined COLIC—Sympathetic and Complicated Forms of. 369 the finger; and the extent to which enemata may be thrown up observed as an additional means of information; for whenever the intus-susception is in the colon, as much fluid cannot be thrown up as in health. Hiccup and a small irregular pulse cliaracterise the advanced disease, and indicate the existence of inflammatory action in the in- vaginated bowel. When a portion of intestine is discharged by stool (as is rarely the case, the patient even recovering and enjoying health after- wards) , there can be no doubt of the nature of the malady. Dr. Monro mentions an instance of double intus-susception, or intus-susception ofthe invaginated part, communicated to him by Mr. A. Burns. I once met with such an occurrence in a child a few months old. 41. III. Of the Sympathetic and Com- plicated Forms of Colic ; or, Colic owing to morbid States of associated Viscera.—Colic, in one or other of the forms already described, but most commonly in its first or simple state (§ 5. et seq.) is not infrequently caused by some other disease. Many of the au- thors of the last two centuries, and several con- temporary Continental writers, have treated of colic when thus originating or associated as essen- tial forms of the complaint. Although obviously only a symptom, or, at most, a part, of an im- portant and often extensive disease, it is not the less deserving of notice when thus associated. It cannot be a matter of surprise, when we consider the relations subsisting between the different ab- dominal viscera, by means of the ganglial system of nerves distributed to them and influencing their functions, that disease of one of these will often change the sensibility and functions of the ali- mentary canal, with which it is more or less intimately connected in respect both of organi- zation and function. As it is useful to be aware of the various morbid associations of colic, I shall notice such as are most commonly met with in practice, with reference to the authorities who have considered them as distinct forms of the disease. 42. A. Sennert, Kindler, Walter, Df.tharding, Bonz, Tissot, Sauvages, and Schmidtmann, have noticed an inflamma- tory colic; which, however, in no respect differs from inflammation of the bowels either in an acute, sub-acute, or chronic form. Colic often rapidly passes into enteritis, and occasionally into dysentery ; and, chiefly from this circumstance, together with the more phlogistic nature of the attack, and the abdominal tenderness, Cullen and Good also have distinguished a variety of the disease by the term inflammatory. In many cases, also, of chronic, sub-acute, or septic pe- ritonitis, the muscular tunics of the intestines are paralysed, and their canal distended by flatus; the colicky symptoms predominating over and masking the inflammatory action. Hence chronic peritonitis has been often confounded with colic, as I demonstrated in a memoir on that disease published many years ago ; but, in such cases, the colic is merely a symptom. 43. B. Hoffmann and Schmidtmann have distinguished a species of colic by the term pleth- orica or sanguinea, comprising under it the varieties arising—a. from pregnancy ; b. from difficult or suppressed menstruation (the Colica Menstrualis of various writers) ; c. from sup- pression of the lochia ; d. from congestion or inflammation of the uterus (C. Uterina, Auct, var.); and e. from haemorrhoids (C. hamor- rhoidalis of Alberti, Hoffmann, Nezel, RanoS, and Rave.) That colic is often asso- ciated with these affections, or is occasioned by them, there can be no doubt; but it is unneces- sary to dignify these varied states of disorder, by arranging them as distinct forms of this disease. It is sufficient to notice them, so as to inform the inexperienced practitioner as to their occasional occurrence, and the importance of attending to the connection in practice , more particularly as they require a modified treatment for their removal. 44. C. Colic also frequently is an attendant upon acute, sub-acute, and chronic diseases of the liver, gall-bladder, and ducts; and, more es- pecially, upon the passage of gall-stones through the common duct. In such cases, the colic is not infrequently associated with jaundice. This connection of the complaint has been fully illus- trated by Baillou, Vogel, Lieutaud, Pro- chaska, Soemmerring, Wandeler, Wit- ting, Conradi, &c. and should not be over- looked. (See art. Concretions—Biliary.) In such cases, the fixed pain in the right epigastrium and hypochondrium, extending to the back, and right shoulder-blade or shoulder, in addition to the abdominal colicky pains, vomiting, and cos- tiveness, with or without jaundice, will assist the diagnosis. Some authors have likewise noticed the connection between colic and disease ofthe pancreas. That the latter will sometimes occasion the former cannot be doubted : but the difficulty of ascertaining the connection during life is great; more particularly as functional disorder of the duodenum, so generally present in almost all cases of colic, is readily mistaken for disease of the pancreas. (See aits. Duodenum, and Pa n- creas.) 45. D. The occasional dependence of colicky affections upon inflammation or other morbid states ofthe kidney, and upon the irritation of calculi in this organ, its pelvis, or meter, has been long known. Such complications have oc- curred to every practitioner, and have been par- ticularly noticed by Horstius, Martius, Piso, Freytag, and Cruchet: they are most fre^ quently met with in gouty and dyspeptic subjects, and persons advanced in life. 46. E. a. The frequent and obvious connection of colicky affections with worms, particularly in children and young persons, requires no further remark than that, although the former is merely a symptom of the latter, both obviously originate in debility of the digestive functions, b. The occurrence of colic in the gouty and rheumatic diathesis, during the more erratic and irregular forms of these affections, and after the disappear- ance or retrocession of them from an external part, has been so often observed, that many systematic writers have particularised a Colica Arthritica (Hoffmann, Musgrave, Stoll, Bang, Br andis, Reich, Schmidtm an n,&c), and a C. Rheumatica (Haller, Stoll, Eyer- el, Lentin, RanoS, Thorn, &c). c. The frequent appearance, also, of this affection in hysterical females, or associated with hysteria, is well known, and chiefly deserving of notice as respects the treatment : the intimate connection of both disorders with morbid sensibility of the organic nerves, and increased mobility of muscular 370 COLIC AND ILEUS —Remarks on their Patholoot. parts influenced by them, and the not infrequent dependence of them both on congestion of the Uterine organs, are too obvious to require illus- tration, d. Flatulent colic is often consequent upon, and complicated with, asthma and bron- chorrhoea ; owing to the impeded function of respiration in these diseases, and the discharge of gaseous fluids from the blood by the digestive mucous surface ; and, when it occurs in such cases, it aggravates the original complaint, e. The only other complication of colic, which may be mentioned, is its occurrence with, or even after the disappearance of, eruptive complaints, and in connection with scorbutic and chronic affections of the skin. This association has been noticed by Haller, Sigaud la Fond, Schmidtmann, and others; and has been term- ed by some writers, Colica Metastatica. It is probable that, in such cases, a sub-acute or chronic inflammation of some part of the intestines takes place consecutively of the primary affection, the colic being merely a symptom of the inflamma- tory state. But we should recollect that, in all afiections of the skin, the digestive mucous sur- face is more or less irritated or otherwise affected, and the allied functions disordered; and that an increase of such disorders may both change the state of the cutaneous eruption, and give rise to severe colic. 47. General Remarks on the Pathol- ogy of Colic and Ileus.—A. The remote causes of colic. Many of these have been par- ticularised when describing the different forms of the disease; a few only require to be enumerated. The more common of these are cold applied to the abdomen, loins, or feet; exposing the back to the strong heat of a fire; acrid, cold, indigestible esculents; cold fluids taken when the body is overheated; solid bodies accidentallyorotherwi.se taken, that admit not of solution or change by the juices in the prima via; irritating or poisonous sub- stances, and the injudicious use of acrid or drastic purgatives, particularly hellebore, scammony, and colocynth: the violent passions and emotions of the mind, as terror, anger, &c. (See § 12. et cet.) 48. B. Remarks as to diagnosis and prognosis. —An important point connected with the nature of the disease, and one which Dr. Abercrombie appears to have fully made out, is the fact of its sometimes being fatal with no other morbid ap- pearance than great and uniform distension of the bowels, a. There can be no doubt that this state will of itself—without any inflammatory action—give rise to tenderness and tension of the abdomen, and thus simulate inflammation, with which, however, it is very often accompanied ; and into which sudden distension of the bowels is very apt to terminate, b. Although ileus is generally the result of obstruction of the canal of the bowels, it is not necessarily so : for in fatal cases of both Madrid and lead colic, as well as in several of ileus itself recorded by Dr. Aber- crombie and other authors already referred to, no obstruction was found on dissection. The cases recorded by Barthez and Maxwell also show the propriety of not losing sight of this fact in the treatment of the disease, c. Sudden cessation of pain, and sinking of the vital energies, are not necessarily evidence ofthe accession of gangrene; for they have occurred in fatal cases of colic and ileus, where no inflammatory action and no gan- grene were detected; and, in some few instances, recovery has followed; and, on the other hand, as Dr. Abercrombie has remarked, extensive gangrene has been observed in cases where the pain was violent to the last. These facts con- firm an opinion which I bad given many years since, that the symptoms often referred to internal o-angrene do not prove its accession, but the ex- haustion of vital power, and of the sensibility of the organic nervous system ; and that a great proportion of the instances of sphacelation found upon dissection did not exist previous to dissolu- tion, but .accompanied or followed the fatal issue. d. The pulse is often a most fallacious guide in every form of colic and ileus; fatal cases some- times occur, in which the pulse, till within a few hours of dissolution, does not rise above the natural frequency; and in some cases in which there is no inflammatory action, the pulse is frequent throughout, e. Although ftrculent evac- uations are amongst the most favorable indications in the disease, they are not to be implicitly relied upon; for, when the disease is in the small in- testines, much faeculent matter may have ac- cumulated in the caecum and colon, which may be brought away by injections without the af- fected part being benefited. The subsidence of the more urgent symptoms after the discharge of faeculent motions is the only sure ground of a favourable prognosis, f. Though the organic changes I have enumerated (§ 37.), often pro- duce colic or ileus, they do not necessarily do so; for gradual exhaustion of the organic functions, and of life itself, without colic, may be the result They may also exist for a long time without sensibly interrupting the functions of the bowels, until some concurrent or determining cause occurs, and suddenly developes the disease in its worst forms, g. The existence of spasm in some part of the intestines, so much insisted upon .by writers as the cause of various states of simple, Madrid, and lead colic, as well as of volvulus, is evidently of less frequent occurrence than is supposed. Although I would by no means disallow its ex- istence, and cannot admit, with Dr. Aber- crombie, that the cord-like constriction of a portion of intestines frequently observed is its natural state, as in the case ofthe urinary bladder, yet it must be admitted that several symptoms, which have usually been referred to spasm, are actually owing to flatulent dilatation. Spasmodic constriction, however, evidently exists; for, in- dependently of the occasional detection, after death, of a more constricted state of a part of a bowel than can be considered natural, we cannot explain various phenomena connected with colic and volvulus without its aid. Besides, its existence is supported by analogical evidence; for it is a principle in the human economy, that all membranous, and, a fortiori, all muscular, canals contract spasmodically or inordinately upon irritation of their internal surfaces, h. In lead colic, the last or more dangerous symp- toms, whether of the complete form of ileus or not, are certainly more unequivocally at- tended with inordinate distension, particularly of the colon, than with constriction, even although the sphincter ani may be at the time spasmodi- cally contracted. »'. From the foregoing facts, the reader may infer that the diagnosis between colic and inflammation cannot be stated with COLIC—Treatment of its Simple States. 371 precision, as there is no one symptom that can be relied upon, — for inflammation with its conse- quences may exist, and yet the abdomen may not be painful on pressure. But it is from the man- ner of their association, and, still more, upon numerous minute circumstances, — some not ad- mitting of satisfactory description, others of only casual occurrence, — and upon the age, employ- ment, constitution, and habits of the patient, as well as from the operation of remedies, that we are to form our inferences both as to the diagno- sis, and as to the result. 49. Treatment of the different Spe- cies and Varieties of Colic—I. Of the Colic depending chiefly on functional Disorder. As soon as a practitioner sees a pa- tient in colic, his first object is to ascertain whether or not there be strangulated or incarcerated hernia, or either tension, tumefaction, or retraction, of the abdomen, or circumscribed tumour or hardness in any put of it, or in its immediate vicinity. By the knowledge thus acquired, as well as by the information he may derive as to the cause and history of the complaint, he will be much assisted in devising an appropriate mode of cure. 50. i. Treatment of the simple forms of colic. (§ 5.).—We have seen that these states of colic chiefly depend upon debility, or deficient vital energy of the alimentary canal, giving rise to altered sensibility of the organic nerves supplying it, to imperfect or irregular action of its muscular coat, and to interrupted or morbid secretion from its mucous surface and associated viscera. These states of disorder are to be removed, 1st, by anodynes combined with stimulants and cordials, which will generally calm the more urgent symp- toms; 2d, by purgatives and enemata directed so as to excite the secretions, and evacuate retained excretions; and, 3d, by gentle tonics and cordials, in order to remove debility and promote the di- gestive actions; all the causes likely to reproduce the disease being carefully avoided. 51. A. Such stimulants as are most anti- spasmodic, and carminative in their action, judi- ciously combined with anodynes, and assisted in their operation by frictions of the abdomen with suitable sedative liniments, or by fomentations, may be first employed. Formula? 178. 187. 2 If. 377. S35. in the Appendix, or the following, will generally remove the painful symptoms : — No. 133. R Aq. Menth. Virid. 7, x.; Spirit. Pimento (vel Sp. Anisi) ?, j.: Tinct. Hyoscyami 7, ss.; Confect. Opii gr. x. M. Fiat Haustus statim suinendus. Or, No. 134. R Aq. Pimento ", x. -, Tinct. Camphor. Comp. f, jss.; Spirit. Myrysiic-*, Spir. Carui, ai ' ss.; Confect. Aromat. gr. x. Fiat Haustus statim capiendus, et pro re nala repeteudus. No. 135. R Camphorn? rasae 7, j. -. tere cum 01. Amvg- dal. ^ ss., et adde 01. Lini £ j.; Tinct. Opii 5 ij ; 01. Rosmarini ^ ss. M. Fiat Linimentum, cum quo illinatur abdomen assidue urgenle flatu aul dolore. If the simple colic evince nervous or hysterical characters, the preparations of valerian, the spirit. ammon. foetid., &c. may be given or added to the above. If these afford not immediate relief, it will be more judicious to have recourse to laxative, oleaginous, and antispasmodic enemata, than to persist in their exhibition. Any of the formulae in the Appendix suitable to the circumstances of the case may be directed; or the warm balsams, assaftptida, the terebinthinates, the oil or extract of rue, and infusion of valerian, may be employed in this manner, along with the oleum olivae, or oleum lini, or any demulcent decoction. When the complaint assumes the flatulent form, the warm spices, or their oils, triturated with magne- sia or sugar, may be prescribed, or added to the above formulae. 52. B. Having relieved the more urgent symp- toms in this way,—an indication the more requi- site in the spasmodic state (§ 9.) of simple colic, and often requiring a freer use of the narcotics and antispasmodics than is specified above,—it will be necessary to act upon the bowels by pur- gatives given by the mouth. In most cases, a full dose of calomel, or of blue pill, is least likely to offend the stomach, whilst it is the most bene- ficial in its operation upon the suspended secre- tions : it will be advantageously followed in a few hours by a dose of castor oil, with a few drops of tinct. opii. or tinct. hyoscyami; or by. the decoc- tum aloes comp. with the subcarbonate of soda, the tinct. of hyoscyamus and compound tincture of cardamoms, either of which may be repeated, if necessary, and its operation promoted by the enemata already particularised. 53. C. Having evacuated the bowels, the next object is to restore the energy of the digestive organs, and to promote the abdominal secretions. This may be done by a course of mineral waters, as the Harrogate, the Tunbridge, the Bath, the chalybeate Cheltenham waters, or the artificial waters of Pyrmont, Carlsbad, Ems, &c, and by a judicious combination of gentle tonics with laxa- tives and the alkaline carbonates, according to the peculiarities of the case; the blue pill, or Plum- mer's pill, with soap, being also occasionally given at bed-time. Sydenham recommended the Peruvian balsam, to restore the digestive func- tions, and prevent a return of the disorder; and certainly there are few substances better suited for the purpose than it, when judiciously exhibited, or combined with other medicines. 54. If we find the foregoing means fail of af- fording very marked relief, we should suspect either some degree of latent inflammatory action or a disposition of the complaint to puss into this state; and unfortunately inflammation ofthe bowels may proceed to a dangerous extent, without either the state ofthe skin, or of the pulse — without any febrile symptom — indicating its existence. This topic should not be overlooked by the young practitioner. Morgagni, Rivf.rius, Simso.n, De Haen, Burseri, Schmidtmann, and Abercrombie, have demonstrated — and my experience has frequently confirmed their observa- tions — not only that enteritis will often assume, during the greater part of its progress, all the symptoms of simple colic, but that the complaint may run its course, until the sudden cessation of the painful symptoms, without any evident cause, furnishes the first evidence both of pre-existing inflammation and of incipient gangrene. On this and other accounts, therefore, we should endea- vour, in all the states of this variety of colic, to ascertain the existence or non-existence of in- flammatory action, or even vascular erithism in some part of the alimentary canal. If this dis- order exist, the tongue will generally be red at its point or sides, and furred or loaded in the middle; the urine will be small in quantity, or high colored; cardialgia will sometimes be com- plained of; and if tenderness on pressure be felt, 372 COLIC—Treatment of Bilious, &c. it will either be independent of any marked dis- tension of the abdomen, or it will be attended with tension and fulness, anxiety, a dark or dusky appearance about the eyes and mouth, and with thirst. Under these circumstances especially, and in the more severe attacks, particularly in the spasmodic, occurring in persons previously in health, blood-letting should not be omitted; and even in doubtful cases, blood may be taken either from the arm, or from the abdomen by cupping or leeches, followed by fomentations and poultices,—if there be tumefaction, by the warm turpentine fomentation and injection. Heating carminatives and antispasmodics will be injurious in all such -cases, whether vomiting be present or not; and too active endeavours to procure alvine evacuations by means of purga- tives given by the mouth may increase the dis- order. I have derived more advantage in these cases from small and repeated doses of the sub- carbonate of soda, or the sub-borate of soda, with nitre, in camphor mixture or some aromatic water —from the use of enemata and gentle frictions of the suiface of the abdomen with a rubefacient lini- ment (F. 311. 313.)—than from purgatives. In a few cases I have given the hydrocyanic acid, either in full doses of the oleum ricini, or in the oleum amygdal. dulcis. When judiciously prescribed, this powerful sedative has a most beneficial effect in restoring the digestive functions after the attack is removed. The hydrargyrum cum creta, or the blue pill, with taraxacum, hyoscyamus, or extract of hop, may also be given after the action of the bowels is restored. 55. ii. Treatment of colic from injurious in- gesta, fyc. (§ 10.)—a. The state of disorder proceeding from cold acid beverages will gene- rally be soon removed by antacids, combined with narcotics, as ammonia, soda, magnesia, &c. given' with opium, or hyoscyamus, and with cordials or carminatives (F. 179. 347, 348.); enemata and frictions of the abdomen, as already recommended (§ 51.) may be also employed, according to the circumstances of the case. b. When the affec- tion is occasioned by cold, acerb, or indigestible fruit or food, it will generally be necessary to commence the treatment by an active warm emetic; and afterwards cordials, cardiacs, and enemata (§ 51, 52.), may be prescribed, c. If the complaint be produced by fish, Cayenne pep- per is an almost unfailing antidote, d. If it be occasioned by smoked or tainted meat, or other esculents that have disagreed with the digestive organs, emetics, and afterwards cordials, warm aromatics, and stimulating clysters, with frictions of the abdomen, are among the most successful means, e. Colic sometimes is a consequence of indigestion, and of acidity or sordes in the digestive tube, often occasioned by too much or indigestible food; it then requires a combination of antacids with aperients or purgatives, as the compound de- coction of aloes, or the compound infusions of gentian and senna, with soda and ammonia. Af- ter the urgent symptoms are removed, the digest- ive functions should be strengthened and promot- ed by gentle tonics and deobstruent laxatives (F. 214. 218. 362. 872.). Richter recommends for this purpose equal parts of assafoetida and the fel tauri inspissatum, especially in the form of the complaint proceeding from acidity. 56. The colic of infants has been stated to proceed chiefly from acidity of the prima via occasioned by the quality or quantity of the in- gesta (§ 15.). The sub-carbonates of the alka- lies, magnesia, and the preparations of chalk or lime, with carminatives and cordials, are there- fore required. (See F. 616, 633.) A combi- nation of magnesia with the oxide of zinc is pre- scribed by Richter. Magnesia, soda, or am- monia, in the aqua fceniculi dulcis or aq. anisi, and afterwards a dose of fresh castor oil ; the semicupium, and, if it be requisite, an emollient or oleaginous enema, to which a little extractum rutse, olei anisi, or tincture of assafcetida, has been added, will generally remove all disorder. If, however, these do not soon give relief, the enema should be repeated, and the abdomen nibbed with an antispasmodic liniment (§ 51, R 135.). If the complaint occur about the period of dentition, the gums ought to be examined, and scarified, if any fulness or redness be remarked in them. If these means fail, those recommended in the sec- tion on volvulus (§ 77. el seq.) must be put in practice. 57. iii. Treatment of colic from morbid secre- tion, fyc.—A. The colic occurring in new-born infants, from retention of the meconium, is gene- rally soon removed by a dose of castor oil; and, if it fail, by an oleaginous clyster, or by one con- taining a tea-spoonful of honey and another of common salt, assisted by the semicupium, and the means stated above (§ 56.). B. Colic from ac- cumulation of facal matters, (§ 19.), or from constipation of the bowels, obviously requires purgatives and oleaginous or saponaceous injec- tions. Stoll prescribed emetics in this form of the complaint, and was followed in the practice by Sims and Hosack; Riverius gave rhu- barb and the turpentines ; and Baglivi and Sydenham advised cathartics and anodynes in oleaginous emulsions. The preparations of sul- phur, in doses sufficient to act on the bowels, have been praised by Agricola and Rave; and frictions and bandages of the abdomen have been recommended by many eminent writers. In this form of the disease, more advantage will be ob- tained from the repeated exhibition of medicines of a simply relaxing operation (sec F. 82. 96. 430.), assisted by large oleaginous and sapona- ceous injections m the manner recommended by Dr. Maxwell (see § 77.), than by cathartics, which may irritate or inflame the upper parts of the digestive canal, before they can reach or affect the parts where obstruction exists. Spirits of turpentine, with olive or castor oil, when per- fectly diffused and suspended in a suitable ve- hicle, are extremely efficacious in this state of disorder. An ounce of the spirits, with two or three of either of these oils, in about sixteen or twenty-four ounces of a mucilaginous decoction, should "be slowly but steadily thrown up by means of the enema apparatus, the pipe of which may be provided with a guard, to prevent the regurgitation of the fluid. In order to facili- tate the passage of this enema along the colon, the patient may be placed in bed, with the pelvis considerably elevated, and friction of the abdo- men may be employed during and after the in- jection of it. If there be no nausea, the following may be taken, and repeated in six or eight hours, if it be requisite : — No. 136. R Potassae Supertart. in pulv. 3 jss.— 7 ij. COLIC FROM LEAD —Treatment or. 373 Magnrs. Calcinat. 5 ss. ; Confect. Senna- et Svrup. Zingi- heris aa 5 ij.; Olei Anisi TT) iij. M. Fiat Electuarium. If nausea be complained of, a full dose of calomel only may be exhibited ; and, after a few hours, the above electuary given, and the injection re- peated; or the treatment recommended in the article Constipation may be adopted. If ten- derness and tension of the abdomen, with hard, constricted, oppressed, or quick pulse, be present, inflammation should be suspected, particularly if vomiting also exist. In this case blood-letting must be practised, and the disease treated in all respects as stated in the articles on Inflammation ofthe Intestines and Peritoneum. 58. C. The West Indian and Madrid colics (§ 20.).—a. Dr. Musgrave, whose experience of West India colic has been extensive, recom- mends ten or fifteen grains of calomel to be exhibited immediately, and afterwards five grains combined with a cathartic. He likewise advises a dose of a purgative mixture to be given in the intervals, if the stomach will retain it. The in- tentions this physician proposes are to evacuate the bowels, and to affect the system with mer- cury. As soon as the mouth becomes affected, the calomel should be omitted, and alvine dis- charges promoted. When the spasmodic action of the bowels is severe, and signs of vascular ex- citement appear, blood-letting ought to be prac- tised ; this evacuation tending both to relax the bowels, and to promote the absorption of the calo- mel. In addition to these means, the warm bath, and terebinthinate enemata, should be employed. 5.0. b. The Madrid colic (§ 20.).— M. Mar- quand states that an emetic given at the very commencement ofthe attack is sometimes of use, by evacuating retained bile ; but that it may be prejudicial, particularly if exhibited in an ad- vanced period of the complaint. He recom- mends, as the safest and most successful practice, 1st, to calm existing irritation by opiates; and, 2d, to restore alvine evacuations. He prescribes a grain of opium every three hours till relief is obtained, which is usually the case after the third or fourth dose. He afterwards exhibits purgatives, and promotes their operation by glysters, which generally bring away copious blackish and offen- sive stools. The Spanish physicians have com- monly recourse to the oleum ricini as a purgative in this complaint, but M. Marquand prefers scammony and jalap, as being, in his judgment, more certain and quick in their operation. This treatment is the same as that long since recom- mended by Mr. Quier, in the dry belly-ache of the West Indies. 60. iv. Treatment of lead colic (§ 25.).—In this variety of the complaint, as well as in those forms which have received the denomination of Madrid, West Indian, or hepatic colic, the hepatic ducts and gall-bladder are obviously obstructed or loaded by morbid bile ; the irritation caused by which most probably occasions spasm of the common duct, duodenum, and parts in the vi- cinity, in the early stages of the disease. Very different, and even opposite, modes of treatment have been recommended in lead colic, a. Blood- letting has been directed by Calmette, As- truc, Christison, and Gregory ; whilst other writers, as Dubois and Do fr esse, have considered it either unnecessary or injurious. I have prescribed it in some cases with manifest advantage, the state of vascular action evidently indicating the propriety of resorting to it; but, in others that I have seen, it obviously would have been injurious. When the face is flushed, the skin hot, and the pulse full or accelerated, it is both safe and requisite, b. The use of opium has the support of the ablest writers on the disease— of Grashuis, Riedlin, Stoll, Schlegel, Reynolds, Baker, Adair, Eyerf.l, War- ren, Wolff, De Haen, and Gf.ndron; but they are not agreed as to the period of exhibiting it. Sir G. Baker commenced with purgatives, whilst De Haen, Darwin, Warren, and Bateman began with opium, and gave purga- tives afterwards. Dr. Pemberton advised a combination of both—of laudanum with castor oil. It appears to me preferable to combine the first dose or two of opium with calomel, as recommended by Burger, particularly if the functions of the liver be obviously affected, as they often are, and if the stomach be irritable, as it generally is in the advanced state of the disease. But the dose of calomel should be large (from 10 to 20 grains), and not repeated oftener than once or twice. This combination will frequently of itself open the bowels; but whether it does so or not, purgatives ought to be exhibited, and their operation promoted. 61. c. As to the propriety of having recourse to this class of medicines, there is no difference of opinion, however much sentiments may vary as to the choice which should be made of them. Grashuis, Mosely, Fischer, Friese, and Odier, prefer the oleum ricini. Burger ad- vises it to be given with manna; Eyerf.l, after blood-letting, with emollients and opium ; and Tissot in clysters. Several writers prefer the combination of anti-spasmodics and sedatives with purgatives, on the supposition that the obstruction of the bowels attendant on the disease arises from spasm in some part of them. But, as Dr. Cheyne and Dr. Abercrombie have justly contended, it is quite as much owing to distension, from a paralytic state of the muscular coat, that the obstruction occurs, as to spasmodic constric- tion. According to this view, little benefit ean result, as respects the operation of cathartics, from combining them with antispasmodic ano- dynes, unless with such as may stimulate the intestinal canal ; and, in fact, such seems to be the result of observation. Some writer*, con- ceiving that lead colic may arise from the presence of the acetate or the oxide of lead in the prima via, have recommended the sulphate of magnesia with the view of forming an insoluble sulphate of lead. The experiments and views of Orfila, Good, and Dr. Paris, seem to favour the em- ployment of this sulphate as well as the sulphate of alumina, exhibited with an excess of acid, or in the compound infusion of roses ; and certainly unequivocal benefit results from the practice. But whether that benefit arises from reducing the lead to an insoluble salt, or from the operation of the sulphates in exciting the action of the partially paralysed muscular coat ofthe bowels, and there- by enabling them to expel retained matters of a morbid or noxious description, cannot readily be determined. We have no evidence of the exist- ence of lead in the prima via to an extent that admits of detection, nor has the formation of a sulphate of lead been demonstrated. I am there- 374 COLIC FROM LEAD—Treatment of. fore inclined to adopt the other mode of explain- ing the operation of these salts. I have found the croton oil an excellent purgative in this disease, particularly when it is added to either castor oil or the oil of turpentine, or to both. 1 have in one or two cases caused the croton oil to be rubbed over the abdomen in this species of colic, with the hopes that it might act upon the bowels; but I did not obtain this effect. The quick irritation of the skin, however, that it pro- duced, evidently proved salutary. Sulphur and its preparations, as well as sulphureous waters, have been prescribed by Luzuriaga in the Madrid colic, in which they are obviously bene- ficial ; and subsequent writers, particularly Ga r- nett and Hahnemann, proceeding on the erroneous opinion that the Madrid colic is identi- cal with lead colic, have recommended them also in the latter; but, as Orfila has expressly stated, they are most dangerous remedies in true lead colic. A case demonstrative of this fact occurred in my practice many years ago, and was pub- lished in the London Medical Repository for October 1822. The deleterious effects are there ascribed to the absorption of sulphur, which was taken by the patient, contrary to my advice, in order to counteract the habitually costive state of his bowels. 62. d. The sulphate of alumina has been given by some modern physicians, with the view already stated (§ 61.) ; but with many its exhi- bition has been altogether empirical. Grashu- is, Quarin, Adair, Fischer, Schlegel, Lindt, Percival, Michaelis, Gebel, and Summer favour the use of it, either alone or with mucilaginous and narcotic medicines. I believe that its efficacy is much enhanced by giving it with camphor, opium, and demulcents. Schmidt- mann details a case, in which the exhibition of two or three doses of alum produced a most co- pious operation on the bowels, after the most active purgatives had been given by the mouth and per anum without any effect. When re- siding on the Continent in 1818 and 1819, I saw many cases treated by this substance, given in doSes of from a scruple to two drachms in gum- water, or with camphor and opium. M. Kape- j.er, in his hospital, into which many cases of the disease are admitted, employed scarcely any other medicine than alum dissolved in mucilaginous decoctions, assisting its action by oleaginous clys- ters. The worst cases,—those with paralysis, loss of sight and hearing, violent cephalalgia, tre- mors of the muscles and limbs, &c. were restored in a much shorter time by this than by any other treatment, and with much less disposition to re- lapse, or to pass into a paralytic state. I have employed alum with uniform success in several cases, and combined it with camphor, Cayenne pepper, and occasionally with opium ; and have always found that, when given in sufficient quan- tity,—from two to four or five drachms in the twenty-four hours, and assisted by oleaginous clysters,—it will open the bowels more certain- ly than any other medicine. M. Gendrin has recently given alum in fifty-eight cases of this disease, all of which recovered in from three to five days. He has also found that a drachm, or a drachm and a half, of sulphuric acid in the twenty-four hours, taken in three or four pints of water, is equally prompt and efficacious. The ! sulphate of zinc was recommended by Dr. Mosely, seemingly from considering its opera- tion .analogous to that of alum; and the sulphate of copper was mentioned by Harrison. 63. e. Mercury has been very generally pre- scribed in this complaint, particularly by Clark, Hunter, Warrkn, Biss, Burger, Clut- terbuck, and others; but with very different views. Some have given it simply as a cbolo- gogue purgative; and others with the intention of preventing the accession of paralytic symptoms ; although it is by no means obvious how it can have this latter effect, since these symptoms sel- dom originate in structural change in any part of the cerebro-spinal axis, when they occur during or after lead colic. Those who have prescribed the preparations of mercury with this latter view, | as Clark, Warren, and Biss, have pushed it to the production of salivation ; but, although I admit that salivation will speedily alleviate the abdominal symptoms, yet I am of opinion that it will rather favour than prevent the accession of paralysis, the more especially as I have observed this affection to follow, notwithstanding the sali- vation which had been produced with the hopes of preventing it. 64. /. Besides the foregoing means, various others have been recommended by writers on the disease. Dr. Roberts has detailed two cases in which the nitrate of silver was internally ex- hibited with apparent benefit. Tobacco in vari- ous forms has also been prescribed. Bartho- lin us was the first to employ this plant in the treatment of colic, by directing its smoke to be thrown up the rectum—one ofthe safest and most beneficial modes of using tobacco internally. Dr. Graves has derived much benefit from com- presses, moistened with a strong decoction of it, applied over the abdomen; and from croton oil internally, assisted by clysters. Emetics have been recommended by some writers; but they are required only after lead has been taken in poisonous doses, or at the commencement of the attack, when the biliary organs are loaded by vitiated bile. They, however, form a principal part of the treatment usually adopted in the Pa- risian hospitals. Cold and warm baths have both been mentioned by writers as being sometimes of service; but I consider the former attended by some risk, and the latter seldom required, although occasionally palliating the more painful symptoms. The propriety of having recourse to external irritation in this disease has been admitted by many of the writers already referred to, and blisters and various other means of a similar kind have been adopted. In several cases I have, however, found more advantage from one of the liniments above recommended; or, if an irritating effect was desired in a short time, I have obtained it from either increasing the more irritating ingredients contained in these liniments, or applying a cloth moistened with one of them closely to the abdomen. The hot turpentine fomentation, or a few drops of croton oil rubbed on the surface of the belly, will have a similar effect; but the former of these, accompanied with suitable internal medicine, is the most rapidly efficacious. 65. g-. The great number of cases of this dis- ease admitted into the hospitals " La Charite " at Paris, and " Hotel Dieu " at Orleans, naturally COLIC FROM LEAD—Treatment of. 375 attracts attention to the plans of cure which are there adopted ; but at neither of them is the treat- ment so simple or so quickly beneficial as that adopted by M. Kapeler, and already stated. At La Charite the treatment consists chiefly of emetics, purgatives, sudorifics, and opiates ; and at several of the French hospitals large local de- pletions are also employed. But the whole plan of cure is generally complex and distressing to the patient. M. It a n o. u e , of the " Hbtel-Dieu'' at Orleans, states, that of about 150 cases he treated, he did not lose one. He commences with the semicupium ; and afterwards applies on the abdomen and loins a large plaster, consisting chiefly of diachylon, conium plaster, camphor, and tartarised antimony. This is allowed to re- main until pustules come out, and the pained parts are rubbed with a liniment, the active in- gredient in which is the extract of belladonna dis- solved in sulphuric ether. He next administers, once or twice daily, an enema with four ounces of olive or almond oil, and twenty drops of the aetherial tincture of belladonna in the linseed de- coction ; and prescribes, when the sufferings are se- vere, small doses of the same tincture to be taken at the same time in a demulcent mixture. This treatment is persisted in for three or four days ; and if considerable relief has not been obtained at the end of this time, castor oil is given in small and repeated doses, the anodyne liniment is as- siduously employed, and the plaster on the loins and abdomen is renewed, with an increased quan- tity of camphor and tartarised antimony. Although this plan of cure appears to be very successful, yet relapses are very frequent after it. 66. A. The treatment adopted by the Author in lead colic is directed with the views, 1st, of relieving the sufferings of the patient; 2d, of evacuating the retained secretions, which are always remarkably morbid, and apparently the cause of the phenomena constituting the fully de- veloped disease ; and, 3d, of imparting energy to the weakened nerves, and parts that they supply. In fulfilling these intentions, the practitioner is often placed in a practical dilemma, from the cir- cumstance of the medicine, which is most to be depended upon in relieving some of the most urgent symptoms, and enabling the liver to throw off the load of morbid secretions which oppress it J having the effect, in some constitutions especially, of increasing the exhaustion of nervous power, and the tremors and paralysis attendant on the worst forms of the complaint. Calomel, in a large dose, either alone or with opium, has an ex- cellent effect in allaying the distressing irritability of stomach, and carrying the biliary and other morbid secretions downwards: but if it be re- peated in such quantity oftener than once, or if free evacuations be not procured soon after its administration, it is apt to affect the mouth, and to prolong the period of convalescence. I have, therefore, endeavoured to procure from it a soothing effect on the stomach, along with its chologogue operation, guarding against its second- ary action on the system ; and have prescribed from ten to twenty grains in a bolus, with about ten graius of camphor, and sometimes with two of opium. This will generally allay the retchings, and enable the stomach to retain the medicine next to be given. About three or four hours after the above has been taken, a draught, consisting of half an ounce each of castor oil and oil of tur- pentine, with one or two drops of croton oil, on the surface of aqua pimentae, is administered, and its operation on the bowels promoted by a clyster composed of about four ounces of olive oil, or two of castor oil, one of turpentine, half an ounce of sulphate of magnesia, and from ten to twenty ounces of the decoction of linseed, or of marsh- mallows. This enema should be steadily thrown up by the improved apparatus. Whilst this treat- ment is proceeding, a liniment may be assiduous- ly rubbed on the abdomen, and on the limbs, if much pain be felt in them ; or a piece of flannel charged with one of these liniments (F. 297. 307., &c.) may be closely applied over the belly. If these means procure evacuations, recovery will soon follow ; but if the draught be tlirown off the stomach, or the injection be returned without effect, they should nevertheless be repeated. If the abdomen be much distended, and painful on pressure, the hot turpentine fomentation ought to be applied, as long as the patient can endure it, instead of the liniment. These measures will sel- dom fail of procuring most copious evacuations, which should be promoted by sulphate of mag- nesia, and spiritus aether, sulph. comp. in the com-' pound infusion of roses ; and by oleaginous clys- ters with camphor or assafcetida, and oil of linseed. After two or three doses of sulphate of magnesia have been given, the following draught may be exhibited, and repeated frequently ; the action of the bowels being promoted by the enema. No. 137. R Cnmphora; rasas gr. iij—vj.; tcre cum Mu- cilag. Acacia; J ss., et Aq. Pimento 3 j.; Sulph. Alumin. pulver. 5"-> Spirit. Anisi Jj.'- Syrup. Croci 5SS- Misce. Fiat Haustus, quarta vel quintet quaque hora sumendus, prius agitata phiala. No. 138. 11 Terebinth. Venet. vel Commun. 3vj.—5j.; Tinct. Assafmtida; ^ ss. (vel. 01 Anisi 5j.); Olei Olivae J iij.; tere cum Vitel. Ovi, et adde Decocti Malva; J xvj., in quo prius soluta erat sulphatis Magnesia; J ss.— 3 j., et "a' Enema. 67. i. The treatment of convalescence from lead colic is of much importance, particularly when at- tended with tremors, epilepsy, severe cephalalgia, or paralysis. At first the alum and camphor should be given for two or three days; and the action of the bowels promoted by oleaginous enemata ; the loins and abdomen being rubbed, night and morn- ing, with one of the liniments already recom- mended. As there is a great tendency of the dis- ease to return, particularly when the patient fol- lows the occupation which occasioned it, the strictest attention should always be paid to the state of the bowels, and the sulphates of mag- nesia and alumina, with compound infusion of roses, and some aromatic spirit, be taken fre- quently ; and, upon the first indication of obstruc- tion, recourse should be had to oleaginous clysters. 68. k. In order to remove the sequela of the dis- ease, particularly the paralysis, the patient should be allowed a generous diet, with exercise in the open air ; and strychnine, or the extract of nux vomica, with the aloes and myrrh pill, or F, 541. 565. may be taken twice or thrice daily. The palsy arising from the poison of lead is much benefited by this active medicine, as well as by frictions with stimulating substances, by electrici- ty, and the use of splints along the fore-arm and hand, as recommended by Dr. Pemberton. The Bath waters are very serviceable in pro- moting perfect recovery, and preventing a re- lapse : with these views, the balsams, particularly 376 COLIC AND ILEUS—Treatment of. the Canadian and Peruvian, may also be taken, with the sulphates of alumina and quinine, or with tonic extracts, camphor, &c. ; and, under every circumstance, the digestive organs should be strengthened and the action of the bowels pro- moted by tonics combined with aperients and antispasmodics. I have obtained marked advan- tage from strychnine thus combined, as well as from several of the gum resins, as ammoniacum, myrrh, assafcetida, and galbanum, particularly when, besides the reduced nervous and muscular power, the digestive functions still continued to suffer. (For the prophylactic treatment of this disease, see the article Arts and Employ- ments, § 17—30.) 69. II. Treatment of Colic caused CHIEFLY BY CHANGE OF STRUCTURE OR Position.—i. Of colic from constriction of the bowels. This state of disease will not be bene- fited by purgatives or carminatives ; but a judi- cious choice and combination of aperients will often be of service. In all cases of this descrip- tion, due examination per anum should be in- stituted ; and as stricture frequently occurs at the upper part of the rectum and lower part of the sigmoid flexure of the colon, a very long flexible bougie should be carefully introduced, as recom- mended by Dr. Willan. When we have reason to suspect the existence of stricture in any part of the colon, the use of mucilaginous, saponaceous, or oleaginous enemata should be long persisted in ; but the patient ought to be very careful not to employ any oil that is not perfectly sweet. At the same time, the action of the bowels may be promoted by an electuary composed of equal parts of the supertartrate of potash and sub-borate of soda, with confection of senna and common treacle, or either the inspissated juice of the sam- bucus, or simple syrup. I have seen advantage derived from a plaster, consisting of the emplas- trum picis comp., the emplast. ammoniaci cum hydrargyro, and either the extract, belladonna? or the extr. conii, kept long applied over the abdo- men. When the stricture appears to be low in the colon, and yet beyond the reach of a bougie, suppositories, with either of these extracts and the lead plaster, will be productive of some re- lief; and when it can be reached by a bougie, the occasional introduction of one will often per- manently remedy the disease. 70. Most of the cases of this complaint that I have seen, have occurred in persons who had long been in the habit of having recourse to purga- tives, consisting chiefly of calomel andcolocynth, or the compound extract of the latter—substances which have a remarkable effect in irritating the internal surface ofthe colon and rectum, and con- stricting their muscular tunics. It, is obvious that a frequent repetition of these medicines, unless their effects be counteracted by emollient clysters, will at last give rise to inflammatory thickening of the parietes ofthe bowel, and constriction of its canal. In most of these cases, also, there exists inflammatory action of the internal surface of the constricted part, and of its vicinity. Hence the advantage usually derived from a cooling regi- men, a spare or farinaceous diet, and cooling gentle laxatives, assisted by soothing aud de- mulcent clysters, as the following :— No. 139. U Semin. Fwnicul dulc. Semin. Anisi, 55 con- tus. Jss.; Fol. Malva; et l'lor. Anthem, aa 3vj.; Aqu-e 0 jss. Coque ad O j. ; dein exprime, et adde liq. expretio Olei Olivae, vel 01. Lini, ' iij. Potass* Tartar, et Sub-hcratia Sodie aa 3j-—3'j- Misce et fiat Enema, pro re nala inji- ciendum. No. 140. R Extr. Iivoscvami "^ij.: Camphoraerasft-rr. vj. —x. Soda; Sub-carbon, vel Sub-horatis 7 jss.— " ijss.; Potas- sae Nitratis ",ss.; lere cum Mucilag. Acacia- " vj., et adde Decoct. Papaveris Jx.—xx. Misce et fiat Enema. No. 111. R Extr. Belladonin- gr. iij.—vj.; lere cum De coct. Cydonia; (vel Decoct. Althaea", vel Dec. Hordei Comp.) ^ xij.—xvj.; et adde Potass*- Sub-carbon. 3j., Potassae Ni- tratis '•-)]. Misce pro Encmate. 71. ii. Treatment of Ileus.—The importance of ascertaining, previously to the adoption of a plan of treatment in this state of the disease, the exist- ence of hernia, has been already noticed; but the young practitioner should be aware that hernia may exist without the patient being aware of it; and the real state of the case may be mistaken, owing to the absence of any tumour, so very small a portion of the side of the bowel being strangulated as not even to obstruct its canal. I have twice or thrice—once in one of my ser- vants—met with such cases, in consultation with eminent surgeons, where the exact state of parts was inferred, and a successful treatment pursued. There are certain forms of the disease which may be briefly characterised, as they require a very different treatment:—1st, Great'distension ofthe abdomen, with diffuse, but not acute teuderness ; obstinate costiveness ; retchings, particularly when substances are taken into the stomach ; anxietv, and general uneasiness ; 2d, The above symp- toms, with fixed and severe pain, and great ten- derness, felt in a defined part of the abdomen, often about the region ofthe cajcuiii: 3d, Violent attacks of tormina, occurring in paroxysms, like the strong impulse downwards from the action of a drastic purge,—the action proceeding to a cer- tain point—there stopping, and becoming invert- ed,—followed by vomiting, which soon becomes feculent (Abercrombie): and, 4th, Where the symptoms of the third state are accompanied with tenesmus, and the discharge of a small quantity of bloody water or mucus, sometimes with indistinct or elongated tumour, and the other signs already described (§ 40.) as indicating invagination of the bowels. 72. In the first of these the bowels are evident- ly distended and inactive ;—in the second, they are probably in a similar state, owing to obstruc- tion, stricture, or strangulation, with inflamma- tion, most frequently in the vicinity ofthe ca?cum and its appendix ;—in the third, there are more evident signs of stricture or strangulation ; but this may also be an advanced stage of the second ;__ and in the/ourf/i, the symptoms are more strictly referrible to invagination ; although this may also exist in the third of these states. 73. A. It is evident that the first of these states will very frequently be much benefited by pur- gatives, particularly by a large dose of calomel (from 10 to 20 grains), which will, either alone or with camphor and hyoscyamus, allay the mor- bid action of the stomach, and move the bowels, particularly if it be assisted by the hot turpentine fomentation or epithem (§54.), and by enemata (§ 57. 66. 70.). In cases where a full dose of calomel only has been given, a dose of castor oil, with teii or fifteen drops of laudanum, may follow it in one or two hours ; and an injection with three tin.es the quantity of the same medicines ! may afterwards be thrown up. In some instances COLIC AND ILEUS —Treatment of. 377 equal quantities of castor oil and turpentine may be given soon after the calomel. After the irrita- bility of the stomach has subsided, the action of the bowels may be promoted by small doses, frequently repeated, of the purified extract of aloes, with hyoscyamus, and a small quantity of extract of gentian, which will promote its action. Gallesky states that he has found recently ex- pressed linseed oil, in the dose of a large spoon- ful, with a few drops of the oil of aniseed, given every hour or two hours, extremely beneficial. If the first dose of calomel neither opens the bowels nor allays the action of the stomach, it may be combined with from one and a half to three grains of pure opium. This will, in most instances, settle the stomach and open the bow- els, particularly if it be soon followed by the fo- mentation and enema already advised. 74. B. The tendency of colic to lapse into a latent or obscure state of inflammation has already been noticed (§ 54.); and this tendency is the greater, the more nearly the disease approaches to ileus from its commencement. As colic in every form is more especially an affection of the muscular coats of the bowel, and as inflamma- tion, when it supervenes, as it so frequently does, upon colic, seems to attack this part especially, and to terminate then more rapidly in gangrene than when it originates in either the mucous or peritoneal coats, so it becomes necessary to have a prompt recourse to blood-letting, particularly when rigors have opcurred, and the pulse is op- pressed or constricted, and the habit of body plethoric or muscular. In such cases, blood- letting should be full and decided, and, if neces- sary, repeated; but it ought not to be trusted to alone, or even mainly; for if carried too far, or employed too largely, or even at all in some cases and states of constitution, or too late in the disease, it may hasten a fatal termination. It is beneficial chiefly in the second and third states of the mal- ady, especially when resorted to early, and fol- lowed by local depletion, by calomel and opium, the warm turpentine fomentation on the abdomen, and subsequently by clysters (F. 144. 146, 147.). I believe, however, that in many cases, particu- larly those commencing as flatulent colic, blood- letting carried to the utmost extent will not of it- self prevent either gangrene from taking place, or faeculent vomiting from coming on. For in these, and in the first state above specified, the muscular and other coats seem to lose their vitality, with- out almost any other mark of pre-existing inflam- mation, that I could observe in some cases on dissection, than change of colour. And yet, when duly employed, particularly early in the other states of the disease, blood-letting will often give decided and immediate relief, and be quickly followed by free evacuations and speedy recovery. 75. C. Opiates and other anodynes are most important remedies in nearly all the states of the disease, but especially in the second and third particularised. The propriety of premising gen- eral or local blood-letting, or both, when it is clearly indicated, and the advantages of combin- ing opium or hyoscyamus, at first with a large dose of calomel, or camphor, or both, have been adverted to. These remedies will often of them- selves produce free evacuations; but in the states of ileus now mentioned, purgatives given by the | 32* mouth, unless of the mildest kind, or combined as above (§ 52.), and exhibited subsequently to the above remedies, are seldom of service. Appropriate enemata, however, should not be omitted. 76. D. The tobacco injection is one of the most generally adopted remedies in this disease, and one which has received the warm sanction of Dr. Abercrombie. This able physician re- commends it with judicious caution, and directs at first only fifteen grains of the tobacco to be in- fused for ten minutes in six ounces of boiling water; the quantity to be increased to twenty grains, and repeated after an hour, if no effect be produced. I believe that, when thus employed, early in the disease, and in persons previously of sound vital power, this will often be of service, or at least not detrimental. But I have seen several cases wherein this powerful substance, even when no more than half a drachm had been infused for fifteen minutes in a pint of water, produced the most distressing effects; and in one case, where it was given in opposition to my opinion, which was in favour of a terebinthinate injection, death followed its administration before three minutes had expired, — evidently from its sedative opera- tion in an advanced state of disease. I have seen many cases in which it had been administered, and, unless under the circumstances in which I have stated it to be admissible, or when stimuli are given at the same time by the mouth, I be- lieve that it favours a fatal termination, by ex- hausting the vital power of the alimentary canal, and disposing inflammatory action to terminate in gangrene. The introduction of tobacco smoke into the large bowels appears a much safer and more efficacious practice, and to be appropriate to a greater number of the many morbid states of which ileus is an effect. . 77. E. Various other kinds of injection have been recommended; and some of them are more deserving of confidence in the treatment of ileus than almost any other remedy. I have already mentioned several (§ 66. 70.), and referred to others in the Appendix (F. 140, 141. 150.), on which very considerable reliance may be placed. Dr. Maxwell has found large injections of warm linseed oil—from two to four pints—steadily and slowly thrown up, regurgitation being prevented by pressing the guard of the pipe against the anus, remarkably successful, after fteculent vomiting had come on, and the usual means had failed. He recommends, in such cases, the patient to be placed on the right side, with the pelvis elevated above the rest of the body, the premature return of the injection being prevented by firmly press- ing a ball of linen against the anus. He directs this clyster to be repeated every three or four hours, until relief is obtained; and, when much exhaustion is present, with the addition of lauda- num. This physician likewise advises, in cases where the existence of intus-susception is suspect- ed, the inflation of the intestines by air, and ad- duces cases in which it was followed by copious evacuations; but it seems doubtful whether or not invagination existed in any of them. This prac- tice, first recommended by Hippocrates, after- wards insisted on by Alexander ofTRAi.LEs, Zacutus Lusitanus, and Riverius, and men- tioned bySAGAR, and some other systematic wri- ters, is certainly deserving of trial where we have 378 COLIC AND ILEUS —Treatment or. reason to suspect invagination or internal strangu- latiou. In most cases, however, inflation with to- bacco smdke appears preferable; but, as Quarin remarks, it should be frequently repeated, and its effects carefully watched. Although the infusion of tobacco has been chosen for injection by Vic at, Fowler, Campet, Conradi, Hufeland, and Abercrombie, yet I agree with Syden- ham, De Haen, Sagar, Quarin, and many others, in considering the smoke superior to the infusion; the former being adopted by some mere- ly on account of the greater facility of conveying it into the bowels, and without reference to the very different operation of these two modes of employing this powerful medicine. But in cases where inflation by air or tobacco smoke is adopt- ed, purgative injections should speedily follow, as directed by Hippocrates, if evacuations have not taken place; for the smoke may even pass out by the mouth, and yet copious motions may not otherwise be procured. Besides these means, yeast has been administered as an injection in warm small beer, with the intention of evolving its fixed air in the bowels, and thereby extricating any unnatural convolution or slight invagination that may have been formed. Sulphuric ather has likewise been thrown into the large bowels, with the expectation that its fumes would operate in a similar manner. Antimonial wine, and the powder or infusion of ipecacuanha have been prescribed in enemata, with the view of relaxing spasm, in cases where it is presumed to be the chief cause of obstruction; whilst the infusion of poppies and of chamomile flowers, various ano- dyne, saponaceous, laxative, and oleaginous injec- tions (§ 57. 66.), have also been directed with the yiews already stated. 78. F. Baths, fyc.—Tepid or warm baths are sometimes useful adjuvants in the early stages of the disease, and are generally recommended. Cold fluids taken into the stomach, and thrown in- to the large bowels, in considerable quantities, and cold epithems constantly applied on the abdomen, have been prescribed by Bureau,* Maret, Ra- p,oe, Steidele, Darwin, Conradi, Bald- in ger, Smith, and Abercrombie. The dash- ing of cold water over the lower extremities and abdomen of the patient, whilst he is kept in a standing posture, has likewise been directed by several physicians; but this practice, although oc- casionally of service, seems less successful than the judicious application of cold to the surface of the abdomen itself. When this cavity is distend- ed, tense, painful on pressure, particularly in a circumscribed portion, with increased temperature of its surface, the cold douche, or the application of cloths moistened with vinegar and water, will often prove of advantage. Dr. Bran dis. of Copenhagen, states that he has employed iced drinks, and cloths wetted with iced water to the abdomen, in ten cases with success; and that in some instances the practice requires to be perse- vered in for a long time, and assisted by antispas- modic and laxative enemata, and by opiates with stimulants and tonics taken internally. 79. 67. When signs of depression of the vital * Mr. BUREAU recommends thv use, and gives a plate de- nrriplive, of a simple hydraulic apparatus for injections, the same in all respects as one lately introduced inlo thLs coun- try from France, under the name of clysmaduct, but which is suited only to the injection of water. energy manifest themselves in the advanced stage of the disease, stimulants are required, and, if judiciouslv selected and combined, their exhibition will sometimes be rapidly followed by amend- ment. Wherever the lowering measures already noticed are followed by increase ofthe symptoms, particularly vomiting and restlessness, or by sink- in" of the nervous power or of animal heat on the surface ofthe trunk, antispasmodic stimulants and tonics should be conjoined, according to circum- stances, with certain of the measures described above. Purgative tinctures are sometimes of ser- vice in this state, particularly the tinctures of aloes, with liquor potassae, and tinct. hyoscyami; and the tincture of senna, with spirit, ammon. succinati and spirit, anisi, in large or often repeated doses. Notwithstanding constant or even faeculent vom- iting in this stage, advantage will sometimes be derived from a full dose of unrectified oil of tur- pentine (from - iv.—x.), taken on the surface of aqua pimenta;, to which either spirit, anisi, tinct. cardamom, co., or tinct. capsici, has been added. I have seen the vomiting cease, and the disten- sion ofthe abdomen rapidly subside, immediately after this draught, which "should be repeated if the former has been thrown oft". A full dose of common oil of turpentine, taken by the mouth, has a singular effect in constricting, and, as it were, drawing the small intestines close to the root of the mesentery; so that, in cases where I have given it, and in which hernia had chanced to exist, the hernial sac has become quite empty soon after its exhibition. May not the advantage obtained by it occasionally arise from the disen- tanglement of a constricted or imprisoned portion of intestine by this mode of operation, as well as from its influence in restoring the action of the paralysed and dilated coats of the bowel in other cases? In many states of inflammatory action, particularly those attended with exhausted tone of the capillaries and depressed vital power, it is one of the most active means we possess of pre- venting gangrene or effusion, and of restoring the natural action ofthe vessels. 80. H. In some cases, after depletions have been carried far, or in nervous and irritable habits, the inverted action of the stomach and upper part of the alimentary canal appears to continue in consequence of the vital exhaustion and irritability of parts; but, if these states were put a stop to for awhile, and the powers of life supported, the natural action of the bowels — respecting the immediate restoration of which the patient is often injuriously harassed — would generally at last return. Under such circumstan- ces, pills consisting ofthe oxide of bismuth, cam- phor, and opium, frequently repeated; or of the first of these, and extract of hop, or of henbane, or the hydrocyanic acid, in the recent oleum aruyg- dal. dulcis, or oleum oliva?, in moderate but rath- er frequent doses, and occasionally with an aro- matic spirit or distilled water; will often prove of service, particularly when aided by the ex- ternal means about to be recommended. When thus exhibited, the prussic acid has a restorative effect; and it is still further beneficial when as- sociated with suitable stimulants, as camphor, a>ther, &c. In a few instances I have inferred, from the situation of the pain, and other symp- toms, that the disorder originated in the duodenum, or jejunum; and in these especially, the oxide of COLIC AND ILEUS—Treatment of, from Intus-susoeptios*. 379 bismuth and the prussic acid have been of con- siderable benefit. The ammoniated tincture of guaiacum, with paregoric elixir, in full doses, and given in milk, or in the recent oil of almonds or of olives, or in linseed oil, has also occasion- ally proved of advantage. The acetate of mor- phine is sometimes of service in allaying the dis- tress, anxiety, and irritability of the stomach and diaphragm ; but it should be prescribed in an aromatic spirit, and in a dose which will secure its anodyne effect without sinking the vital ener- gies. I have used the following with marked advantage, repeating the dose every two hours until an effect was produced :— No. 1 !2. ft Acetatis Morphinx ^r. iv. -, Spirit. Myris- tica; et Spir t. Pimenta; aa 5 j.; Spirit. Camphora; et Tinct. Benzoini Comp. ih\ ss. Solve. Capiat-; j. ad3 'j- in Saccharum, vel Syrupum, vel Olea supra memorata. 81. /. The ingestion of crude mercury, or of globules of lead, to the extent of one or two pounds, has been recommended in ileus by seve- ral authors, particularly in that state of the malady which presents the symptoms indicating invagi- nation of a portion of intestine. Sydenham, Schenck, Belloste,Paro,Panzani,Hoff- mann, Sag ar, Quarin, Ne vinson, Darwin, Abercrombie, and many others, have noticed this practice; some of them, as Sydenham and Quarin, in doubtful terms—others more favour- ably. M. Roll and has detailed the history of a case, wherein, other means having failed, he gave about 10 ounces of crude mercury, which, after a short time, occasioned a sensation of change in the position of some part within the abdomen, instantly followed by relief. Similar instances have been recorded by Dr. Uwins and Dr. Bel- luci. I have never tried this metal; but, many years ago, I saw a patient—a female between twenty and thirty,—relieved from all the charac- teristic symptoms of this state of the disease by the ingestion of about two pounds of common shot, which also has been recommended in volvulus, by many ofthe best medical writers ofthe three last centuries, and by some of them in preference to quicksilver. Large blood-lettings, the tepid bath, und various other means (§ 54. 77.), should gen- erally precede the ingestion of lead or quicksilver. 82. K. Various external means besides those already noticed, have been recommended in ileus. Sagar* states, that he was cured of volvulus, by having the abdomen, at the commencement of the attack, kneaded like dough, with oiled hands, —a plan instituted evidently with the view of disentangling a displaced portion of bowel. Ar- ktjevs, and Paul of .'Eg in a, directed cupping on the abdomen. Celsus advised dry cupping on both the loins and abdomen; but little advan- tage can be expected from this latter measure, unless it be performed by one capacious vessel, as is, I believe, occasionally done in some north- ern continental countries. Quarin states, that in an extreme case, all oilier means having failed, and the pulse being small and irregular, the ex- tremities cold, the countenance sunk, with hiccup, &c, he had recourse to dry cupping, using for the purpose porcelain bowls. Relief soon followed, * " Olim Crisii incidi in hunc morbum fvolvulimi) ego; Ilungarus Sarlor accitus me restituit intrayfres horas methodo leouenti: impositum me supinuin prato, inunctisve oleo olivarum manihus suis depsabat prout pislores paslam panis subliliter incipiens successive semper fortius totum abdomen mc-uui." (p- 320.) and the bowels were copiously evacuated, their action having been assisted by enemata of infusion of chamomile flowers and tartarised soda. 83. L. Dr. Abercrombie expresses himself in favour of large blisters on the abdomen ; but much more certain and immediate relief—often within ten minutes after its application—is derived from the hot spirit of turpentine fomentation, placed over the whole abdomen. Where there is little or no tenderness of this cavity, I have, however, preferred inunction of its surface with one of the liniments above directed (§ 51.) ; keeping subsequently a cold turpentine epithem applied. Forbes, Wilmer, and Balding er also advocate the use of blisters on the abdomen; but Meier prefers placing them on the insides of the thighs. The recommendation of Syden- ham, to keep a young dog constantly applied to the abdomen, will appear to many a singular remedy; but the views with which he prescribed it are by no means devoid of reason. 84. M. Numerous writers antecedent to the time of Quarin, and subsequently, have recom- mended an incision to be made through the parietes ofthe abdomen, and the internally stran- gulated, or the invaginated, portion of bowel extricated through it. Nuck has recorded a case where this operation was performed with success. Van Swieten objects to it, the uncertainty of the existence of volvulus or internal strangulation. But, in several cases of invagination which I have seen, and in a great many I have perused— almost all those, the history of which has been fully detailed—the symptoms described (§ 40.) as characterising this state were present, par- ticularly the tormina, followed by desire of evacuation, and tenesmus, with the discharge of a little bloody mucus or water; the oblong tu- mour, in a part of the abdomen, admitting of being recognised at some period ofthe disease; have been superadded to the other symptoms of ileus, and pointed out its precise nature. In two cases I felt inclined to have had the operation performed ; and, indeed, suggested it. The di- agnosis was found correct on examination after death. A case is given by Dr. Fuschius, in Hufeland's Journal for February, 1825, al- most identical with one of these, and characterised by the above diagnostic symptoms, in which he resorted to this operation over the place to which the patient referred the sensation of obstruction, and where an obscure oblong tumour, in the situation of the ascending colon, was detected. An invagination of the colon was removed, and the patient perfectly recovered. The reader need not be informed that ileus very commonly pro- ceeds from strangulated hernia, and sometimes persists from adhesions, &c. after the displaced bowel has been returned. The propriety of hav- ing an early recourse to the operation after we fail in returning the protruded intestine is here very obvious. 85. N. During, and subsequent to, conva- lescence from ileus, the patient should wear flannel next the skm, and promote the functions of the stomach and bowels by vegetable bitters com- bined with gentle aperients, and the sub-carbon- ates of the alkalies. The bulky and flatulent vegetables ought to be avoided, and the extremi- ties and surface of the abdomen and loins kept equably warm. The utmost attention should be 380 COLIC — Treatment of its Sympathetic States. paid to diet; all indigestible substances, and acid or acerb beverages, carefully avoided. 86. III. Treatment of Symptomatic or Complicated Colic—A. The means of cure in most cases of this description should be directed to the diseased viscus, by which the functions of the alimentary canal are affected, a. Those colicky symptoms which are produced by irri- tation, or the passage of gall-stones through the common bile-duct, and by the obstruction occa- sioned by concretions in the intestines, will gene- rally be relieved by nearly the same treatment as that recommended in this article ; but whatever difference should exist, is detailed in the article on Concretions. 6. The colic which is symp- tomatic of worms in the intestines requires, if the attack be severe, the internal and external means already recommended to allay the urgent symp- toms; but after this is accomplished, the remedies resorted to for the cure of verminous disorders should be employed. (See art. Worms.) 87. B. The occurrence of colic from affections of the kidneys, particularly from calculi in their pelvis or ureters, should not be overlooked by the practitioner; nor should he forget that it is some- times consequent upon aneurism of the abdominal aorta, and of tumours formed in the mesentery, or in the omentum, a. In the first of these pa- thological states, much relief will be afforded by the alkaline sub-carbonates, with opiates or se- datives, and followed by oleaginous purgatives and enemata, in addition to whatever depletory or other measures the circumstances of the case will point out. The use of liniments with cam- phor, soap, and opium, rubbed on the abdomen and loins, will also give much relief. 6. In colic depending upon the latter organic changes, little beyond palliating the urgent symptoms by the remedies now mentioned, can be expected. 88. C. Flatulent colic, generally of a pro- longed description, and often not easily removed, at least in a permanent manner, sometimes occurs in the course of asthma and bronchorrhrea, owin<» apparently to the interrupted functions of the mucous surface of the lungs; the evolution of gaseous fluids, from the blood being impeded on this surface, but supervening vicariously on that of the alimentary canal. In such cases, after the bowels have been freely evacuated, carminatives combined with ipecacuanha and hyoscyamus ; the infusion of valerian, with prussic acid, and spirit, anisi; powders of magnesia, oxide of bis- muth or of zinc, and ipecacuanha; sulphate of zinc, with myrrh, camphor, and opium or hyos- cyamus; and camphor mixture, with extract of belladonna, spiritus anheris sulphur, comp. and spirit, menthm; are among the means which will afford the greatest relief. 89. D. There are few more common compli- cations than hysteria and colic; but the treatment varies not materially from that now stated, a. In such cases, the functions of the uterus require strict attention; for morbid sensibility, and even vascular excitement, both of this viscus and of the ovaria, are often present. The treatment too commonly adopted m this state of complication although it may give immediate but temporary- relief, not infrequently perpetuates the patholo- gical state, of which both hysteria and colic are merely symptoms. Instead of enploving medi- cines which excite both the digestive mucous surface and the generative organs, in these cases, cooling and soothing remedies are much more appropriate to them, such as those above enu- merated (§ 87.) ; local depletions, nitrate of potash, sub-carbonate of soda, extract of hop, cooling aperients, vegetable tonics, exercise in the open air, &c. B. When the complaint is symptomatic of difficult menstruation (§ 43.), general or local blood-letting may be resorted to in the plethoric subject: but in the weak or hys- terical, camphor, ammonia, soda, &c. with hyos- cyamus; or the acetate of morphine or laudanum given in some aromatic spirit, the ammoniated tincture of guaiacum in linseed tea, the prepara- tions of rue and of juniper, and the treatment de- tailed in the article on the Disorders of Men- struation, will generally give speedy relief. c. Colicky pains sometimes occur during preg- nancy : in such cases, cooling aperients, with antispasmodics and opiates or other anodynes, and preceded by sanguineous depletion, if con- gestion or plethora exist, will remove all disorder. d. Severe attacks of colic are not uncommon upon suppression ofthe menses or of the lochia. If a tendency to inflammatory action manifests itself, and especially if the patient be plethoric or robust, general or local depletion should be prac- tised ; a dose of a mixture composed of a decoction of the radix rubia?, tincture and syrup of saffron, and as much borax as it will dissolve, should be given every two hours; the volatile liniment with camphor and opium ought to be rubbed on the abdomen ; and, afterwards, a fomentation with the decoction of poppy-heads, &c. applied to the same situation. Schmidtmann advises a cata- plasm, consisting of marshmallows, henbane, bruised linseed, and poppy-heads, to be placed warm on the abdomen; and the steam of hot water to be conveyed to the pudenda, e. If colic proceed from congestion, or inflammatory irri- tation of the uterus or ovaria, local depletions ; diaphoretics, and refrigerants, combined with se- datives ; aperients, with cooling emollient ene- mata, and low diet, are the most appropriate remedies. 90. E. Colicky complaints are not infrequently referrible to congestion and irregular vuscular action in the liver, pancreas, or spleen; or, if not arising from such disorders, are associated with them, owing to deficient energy of the or- ganic nervous system; and, consequently, to im- perfect performance of the abdominal functions generally, a. In cases of this kind, local deple- tions, followed by purgatives, exerting a chola- gogue and deobstruent action, external irritation, and, subsequently, by vegetable tonics, laxatives, regular exercise, and a course ofthe Leamington, Harrogate, Buxton, or Cheltenham, mineral wa- ters, or the artificial waters of Carlsbad, Spa, Ems, &c, according to the circumstances of the case, will generally remove all disorder. Im- peded circulation through the portal system, is more or less concerned in the causation of colic pains in these cases; the return of blood through the mesenteric and hremorrhoidal veins deranging the contractile actions of the intestines, and giving rise, in many cases, particularly those in which this pathological state obtains, to the additional association of hemorrhoidal affections, which if neglected, may terminate in anal fistula'. 6. It is not uncommon to find a severe attack of colic COLIC — Treatment of its Sympathetic States. 381 usher in hamorrhoidal discharges: the impeded circulation through the portal vessels, and the consequent fits of colic, being both relieved by the consecutive hamiorrhage from the haemor- rhoidal veins and mucous surface of the rectum. In almost all such cases, in addition to the con- gestion and associated disorder of the' assistant chylopoietic viscera, there are more or less vas- cular plethora, impeded secretion generally, and deficient energy ofthe organic nervous system,— a complicated state of disorder evidently requiring local depletions from the region of the liver, or, as Continental practitioners very reasonably pre- fer, from the vicinity of the anus, with the reme- dies above stated, and assisted by regular exer- cise, gentle tonics, aperients, and a regulated diet and regimen. From this it will not appear singu- lar that very dangerous attacks of colic, or even of ileus, will sometimes occur after the operation for haemorrhoids or anal fistula?, or other morbid states of the rectum, when performed, as they sometimes are, without previous medical treat- ment of a kind appropriate to the state of internal disease, c. The complication of colic with either acute or chronic jaundice is evidently referrible, either to the passage of gall-stones (§ 86.), or to the pathological state of the liver now noticed, or to inflammatory action in the duodenum or biliary ducts, or, lastly, to congestion of bile in the hepatic ducts, or in the gall-bladder. When symptoms of local plethora or congestion can be detected, cupping, and the rest of the treatment now directed, will be serviceable. (See Jaun- dice—Treatment of.) 91. F. When the colic arises from atonic, mis- placed, or erratic gout, large doses of the sub- carbonates of the alkalies, or magnesia, with camphor or ammonia, are required, followed by blood-letting, if the pulse, habit of body, and strength of the patient admit of it; by calomel, with camphor and hyoscyamus, or opium, at bed-time ; by active cathartics, conjoined with stimulants and restoratives, as long as the alvine evacuations indicate the propriety of their ex- hibition ; by purgative and antispasmodic injec- tions, and by rubefacients and sinapisms to the lower extremities. After morbid secretions and retained faeces are evacuated, colchicum may then be given with ammonia, or with camphor and magnesia. But arthritic colic occurs most frequently in aged persons, or in those with ex- hausted constitutions, in whom, instead of evacu- ations, beyond the expulsion of morbid secretions, active stimulants,—as large doses of camphor and ammonia, or of guaiacum and ammonia,— with warm spices, Cayenne pepper, and some- times combined with opium or aconitum, and assisted by sinapisms, are indispensably requisite. 92. G. If colic supervene on the disappearance or suppression of rheumatism from the joints or aponeurosis, or the repulsion of chronic eruptions, local depletions, followed by camphorated lini- ments and fomentations ; warm turpentine epi- thems applied on the abdomen ; calomel, with antimonial preparations, or with ipecacuanha and opium ; warm vapour and fumigating baths ; the sub-carbonates of the alkalies, sulphur, the com- pound decoction of sarsaparilla, or the decoction of dulcamara ; blisters, tartarised antimonial plas- ters or ointments, saponaceous and oleaginous ene- mata ; and sinapisms to the extremities or parts primarily affected ; constitute the chief means of cure. The frequency, und, in two of the forms ofthe disease especially, the danger, of the com- plaint now discussed have induced me to be more circumstantial in the account of its pathology and treatment than may appear requisite to many : but I am convinced that the experienced prac- titioner will not be of the number ; but will find cause to regret, with myself, upon reviewing his knowledge, that his information on the subject is not greater than his means of observation have yet afforded him, or my labours can possibly assist him in obtaining. Bibliog. and Refer.—A. Common Forms ofColic —Pliny, Hist. Nat. 1. xxvi. cap. i.—Celsus, De Medicina, I. iv. sect. 13, 14.—Alexander Trallianus 1. iii. ch. 41 — Baillou, Consult, v 1. i. p. 5.—Schenck, I. iii. pp. 173. 179. and 274.—Willis, Opera Omnia, d • Anim. Brut., par. ii. cap. IS. p. 202.—Bonet, Sepulchretum, &c. 1. iii. sect. xiv. obser. 1. 5.; et Mercuiius Compitalitius, p. 115. et seq.— Riverius, Observ. cent. i. ob. 12,13. 59, 4ic.; cenl. ii. ob. 12. 38, &c.; cent. iii. ob. 22. 48.—Roljfink, De Dolore Colico. Jen*, 1660.—Alberti, De Colica Haemorihoidali Hala;, 1718.—Hoffmann, De Intestinoium Doloribus, Opera, vol. ii. p. 294.; et Consult, cent. ii. n. 16.—Huxham, in Philos. Tra.is. No. 422.—Harris, De Morb. Inf. p. Sl.—Kampfer% Amcen. Exot. p. 588.—Juncker, De Morbis Colicam conse- quentibus, 4lo. Halae, 1749—Agricola, Comment, in Pop- pium, De Sulphure, p. 416. 462.—Sauvages, Nosologic Melhodique, &.c. t. ii. p. 510.—Stoll, Ratio Med. par. ii. p. 135. 138., par. iii. p. 65.—Rosen, De Dolor. Spasiico-flatu- lentis Prim. Viar. Svo. Lond. 1771.—Burseri, Institut. Med. Pract. vol. iv. ed. Lips. p. 358. et seq.—Bang, in Act. Reg. Soc. Med. Hann. vol. i. p. 285. et seq., et vol. iii. p. 115. et 141. et seq.—Ranoe, in Ibid. p. 349., et vol. iv. p. 113.— Kbnig, De Reined. Indigenis.—Tode, Biblioth. i. 3. 148.— Tournuy, Ergo Colico Dolori Opium, 4to. Nanceii, 1784.— Buudry, Sur la Colique Nervo-gastrique. Paris, 1805.—. Eber/e, De Colica Infantum. Arq. 1784.—Barker, in N. Y. Med. Repository, vol. v. No. iii. art. 3.—Conrudi, in Hufe- land's Journ. der Pract. Arzneyk. vi. b. p. 414.—Rave, in Ibid. vii. b. p. 168.—i, I lie down). Cams, Sauva- ges, Good. Cataphora, J. Frank. Lethargie, Assoupissement, Fr. die Schlafsucht, Schlaf- fieber, Ger. Sopore, Somnolenza, Ital. Classif. 2. Class, Nervous Diseases; and 1. Order of this Class (Cullen). 4. Class, 4. Order (Good). IV. Class, III. Or- der (Author, in Preface). 1. Defin. Preternatural sleep, with physical torpitude, and suppression ofthe mental poioers. 2. I. Varieties and Symptoms.—There are various modifications of coma, each of which have received different appellations, as Lethargus, Cataphora, Agrypnia, Carus, &c.; these names being also used generically by some authors, but more frequently specifically, as I shall apply them ou this occasion. They are all most commonly symptomatic of pre-existing disease; but they are also occasionally primary affections. I shall, therefore, after describing very succinctly each variety of coma, and its more constant symptoms, notice it first as a primary affection, and next as an important phenomenon in other acute diseases, particularly of their severe forms or advanced sta-„ ges: afterwards the different pathological states causing this affection, the signs which distinguish them, and, lastly, the means best adapted to re- lieve them, will be briefly stated. 3. i. Covia Vigil—Agrypnia, Kwua, ayov- jiiSvdec, (Hippocrates), Typhomania, Sopor cum Agrypnia—is characterised by a constant disposition to sleep, without falling into quiet, sound, or natural sleep; by low muttering deliri- um, or unconnected talk; unnatural action of the hands and fingers, sometimes also of the feet; pale sunk countenance; a natural or but slightly increased temperature ofthe head; by the patient opening the eyes and staring about upon the slightest disturbance, or starting up as if frighten- ed by strange sights, and again attempting to lie down; and sometimes by difficulty of speech and of swallowing liquids. 4. ii. Lethargy — Lethargus* (from Xi'^v, * I have, conformably with the received acceptation of lethargy in this country, made it the slightest form of soporose coma; although the ancients, our countryman Willis who has written ably on this affection, the greater number of wri- ters of the sixteenth and seventeenth centuries, and many modern German authors, have defined it nearly as follows:— 11 profound sopor, or preternatural sleep, with fever and de- Lethe, et aoyog, celer), Veternus, Lat.—is cha- racterised by slight but constant somnolency, or mental and corporeal torpor, evidently depending upon a morbid condition of the brain; when ad- dressed, the patient answers forgetfully, and after- wards sinks into the same state as before. This is a slighter grade of the following varieties, and may pass into them. 5. iii. Coma Somnalentum—Cataphora—is characterised by sopor or profound sleep, without the power of wakening spontaneously; the pa- tient, when roused, slowly opening the eyelids, and answering either rationally, forgetfully, or incoherently, but immediately afterwards falling into the same state of profound sopor; and fre- quently by relaxation of the muscles of the lower jaw, it thereby differing from apoplexy and carus. 6. iv. Coma profundum—Carus, Kuqoc — is characterised by its more or less sudden inva- sion; by the profound sopor, the eyes being shut as in a deep sleep, and the patient being generally deprived of motion and sensation. Sometimes, however, upon being called to loudly, he opens his eyes, but immediately shuts them, without answering any question; and occasionally when pinched he draws away the part, indicating re- maining sensibility; the breathing is undisturbed or irregular, sometimes laboured, but without stertor: there is seldom much febrile heat, and the evacuations are passed without consciousness. 7. A. Review ofthe chief symptoms.—a. The pulse varies greatly in each ofthe above states of coma. It is generally slow, full, and soft; but it is also often small and quick in coma vigil, or in any of the varieties, when accompanying the last stages of fever; and small, hard, and some- times irregular, in the coma attendant upon, in- flammatory action ofthe brain or its membranes. It is also frequently unequal, intermittent, and generally slow, but sometimes also quick, in the coma produced by injury of the brain, and by haemorrhage or effusion of fluid within it. b. The respiration is often natural, as in coma vigil; sometimes accompanied by sighs, or laboured, as in coma profundum; frequently slow, and very seldom stertorous, unless in the coma of apo- plexy, c. The pupils of the eyes are generally more or less dilated, and sluggish in their mo- tions, or altogether insensible to light; but they are sometimes, in the most unfavourable cases, much contracted, or one contracted and the other dilated, d. The countenance is usually tumid, and without expression; sometimes pale or bloat- ed, or red or injected; the eyes are prominent or suffused, and the head somewhat warmer than natural, or of the healthy temperature, the beat of the carotids being full or strong: in the coma consequent upon fever, and in coma vigil, the features are commonly pale, sunk, and cool; the action of the carotids being weak and soft in some cases, and hard and oppressed in others. e. The mental powers are commonly suppressed; but upon being momentarily excited, they some- times appear more or less disordered, particularly in any of the states of coma supervening upon fever, or inflammation of the brain or its mem- branes; low delirium and febrile heat then being also present. /. The surface of the body is often natural, sometimes cold or clammy; but when lirium " thus applying the term to the more profound state of febrile coma. 388 COMA AND LETHARGY —Idiopathic—Symptomatic. the affection is caused by fever or inflammation, the temperature may be somewhat elevated, and the skin dry. g. The extremities are fre- quently natural at first, but they are also often cold or clammy, or become so. h. The posi- tion is commonly supine, without attempts at motion, in profound coma; and, in the worst cases, the patient slips down in bed. i. The tongue is natural, or merely much loaded, in some instances; but in coma symptomatic of in- flammation or fever, it is usually furred, dry, and brown, hard, and constricted. A:. The alvine excretions are either retained, or passed without consciousness. 8. B. Duration and termination.—a. Any one of the forms of coma may be sudden in its attack, and terminate speedily in death; or it may come on gradually, and be of short duration, sense and voluntary motion as slowly returning. The seizure may be repeated frequently, or it may be periodic, particularly when attendant upon epi- lepsy, or remittent fever of a bad form. When its accession is slow, it often commences with drowsiness or headach. b. Its duration is very various; the lethargic and slighter varieties being occasionally of long continuance — sometimes lasting many weeks, and spontaneously passing off; the more profound states of coma frequently terminating fatally in a few hours, and seldom continuing longer than a very few days. c. It may terminate in either recovery or death, or in some other disease with which it is more or less closely related, as apoplexy, paralysis, insanity, or melancholia, epilepsy, and epileptic or other forms of convulsions with which it occasionally alternates; and in inflammation of the brain or its membranes. 9. C. Diagnostic remarks.—The states or grades of disease described above may pass one into the other, or into some other malady, wheth- er they appear primarily or consecutively. They are often very nearly allied to, or rather are less degrees of, apoplexy; and apparently consist of a somewhat similar condition of the organic ner- vous power and vascular action within the brain, to that which obtains in a great proportion of the attacks of that disease (§ 62. et seq.), particularly those which do not immediately depend upon liamiorrhage. a. The close resemblance of many cases of coma vigil to ecstasy, and of the other states of coma to catalepsy, not only as to the grouping of the sensible phenomena which re- spectively constitute them, but also as to their pre- sumed proximate causes, indicate that catalepsy and cataleptic ecstasy are merely unusual modifi- cations ofthe state of cerebral disease now under consideration, b. The absence of stertor consti- tutes the chief difference between the most pro- found state of coma, carus, and apoplexy, c. The fulness and strength of the pulse, particularly in the carotids, and the natural or strong state ofthe respiration, are sufficient to distinguish coma from syncope, in which latter the action of the heart is greatly diminished primarily, the functions of the brain failing consecutively, d. Coma differs from asphyxy m the circumstance of the respiratory functions being first suppressed, and subsequently the action of the heart in the latter; the conse- quent coma arising from congestion of venous blood in the brain, produced by the abolished re- spiration, and obstructed circulation through the lungs and cavities of the heart. 10. II. Of Primary or Idiopathic Coma. — F.ither of the varieties described above may occur as a primary affection arising from states of the organic nervous power and circulation with- in the brain, which will be noticed in the sequel (§ 13.), and which are commonly produced by the following agents :— Causes.—The continued or intense action of cold upon the nervous system and circulation; the influence of narcotics, par- ticularly in some constitutions; indulgence in spirituous or intoxicating liquors, either carried too far or continued too long; venereal excesses; insolation; fatigue or prolonged watching; the in- fluence of particular odours, condiments, or kinds of food, in some temperaments; inanition or ex- haustion of vital power, by whatever cause, es- pecially in the aged ofthe male sex; immoderate evacuations or discharges; mephitic or carbona- ceous fumes or gases; sadness, anxiety, fright, terror, anger, and other violent mental affections; the inappropriate use of either warm or cold baths; the exhaustion of vital or nervous power by ex- cessive or long continued pain; concussions and injuries of the brain; erratic, atonic, or retrocedent gout; pregnancy or child-bearing; and suppression of the menses or lochia; are the causes which produce, in a primary form, any of the states of coma described above. 11. III. Symptomatic Coma.—Either of the varieties of coma may supervene in the advanced course, more rarely on the invasion, of intermit- tent, remittent, or continued fevers, particularly typhus; of inflammations of the brain and its membranes; and of insanity and melancholia. Simple determinations of blood to, or congestion of, the encephalon will frequently be sufficient to induce the slighter states of coma; whilst its more severe or profound conditions are common conse- quences of effusions of blood or serum, and of numerous organic changes occurring within the head. (See Brain—Organic Lesions of its Mem- branes and Substance, § 21—84.). It is one of the most important symptoms that appear in the course of erysipelas of the face or head, and of exanthematous fevers; it may likewise supervene, •particularly coma vigil, in the advanced stages of several acute maladies evincing exhaustion of the vital energy ofthe brain and nervous system, and in those in which the circulating fluid and secre- tions become vitiated or contaminated. The co- ma which is usually consecutive of epileptic or convulsive attacks consists ofthe slighter varieties denominated lethargic and somnolent, forming a part or consequence of these diseases. Coma is sometimes, also, a symptom of severe hysteria, particularly in plethoric persons with interrupted catanienial discharge; and, in rare instances, of worms, but by no means so frequently as stated by some writers. The occasional occurrence of any of the varieties of coma from suppression or retention of urine, from metastasis of gout and rheumatism, from the suppression of accustomed discharges, and more rarely from the retrocession of eruptions, and the drying up of old ulcers, should not be overlooked, particularly as such morbid relations require a peculiar and appropri- ate treatment. 12. IV. The Prognosis in most cases of coma is unfavourable; for, although many will recover —even the great majority—the slighter cases will often present sudden changes. A much more COMA AND LETHARGY —Pathology of. 389 favourable opinion may be entertained of coma when it is produced by narcotics and spirituous liquors, than when it comes on in the course of febrile or malignant diseases, particularly after the absorption of morbid matters into the blood. The occurrence of epistaxis, of swellings of the parotids ; the accession of the catamenia, or the haemorrhoids ; a feculent diarrhoea ; copious gen- eral perspiration ; abundant discharge of urine depositing a sediment; erysipelas, eruptions, boils, gout, or rheumatism, appearing in external parts, particularly the lower extremities; and the re- turn of sound natural sleep during a state of coma vigil, or typhomania; are very favourable— indeed, critical symptoms. The persistence of the affection; scanty secretion or retention of urine; subsultus; spastic contractions of one or more limbs; loss of speech, and total insensibil- ity; distortion of the eyes; vomiting or retching; a previous breaking up of the constitution; pre- existing cachexy, and old age; bleeding from the ear, when it has been caused by external injury, as in concussion; constant supine posture, and slipping low down in the bed ; coldness of the head, with sunk countenance, and cold clammy surface ; loss of the faculty of deglutition, or re- turn of matters put in the mouth; are very un- favourable signs. 13. V. Pathology.—A. Primary and symp- tomatic coma may be resolved into the following pathological states, either of which may exist singly, or in conjunction with one another:— 1st, Exhaustion of the organic nervous influence sup- plying the brain, or torpor or suppression of it, inducing a state which may be called paralytic — a paralysis of all the cerebral functions : this con- dition is produced chiefly by directly or indirect- ly sedative causes, and by whatever depresses or exhausts the vital energy generally, or the nervous power in particular : it may be attended by anaemia ofthe brain ; and then the coma will be preceded by, or accompanied with, convul- sions, or alternate with them ; but it is more frequently productive of some one of the states about to be noticed, especially congestion, and occasionally effusion within the head : it may go on to dissolution, or it may be followed by re- action and active congestion or acute inflamma- tion ; the comatose states sometimes observed at the invasion of dangerous forms of fever, and of certain apoplectic seizures, and the coma of the early stage of concussion of the brain, being of this description. 2d, Congestion of the capil- laries, veins, or sinuses of the brain, is, perhaps, the most common morbid condition that obtains in coma, as respects the vascular system : but this state can scarcely arise, unless the organic nervous influence with which these vessels are supplied has been exhausted or depressed, excepting in those cases where the congestion proceeds from obstructed return of blood by the sinuses, or by the large veins coming from the head : in many cases, therefore, the existence of this state pre- supposes that first described, at least to some ex- tent; and whether thus originating, or proceeding from impeded or obstructed return of blood, will equally occasion pressure of the organic nervous and cerebral tissues, and suppression of their functions : congestion of the blood-vessels within the head may, moreover, be associated with some other morbid states, as with contamination of the 33* circulating fluid; as in the coma that occurs in the advanced stage of typhus, and when morbid se- cretions are absorbed into the blood. 3d, Active determination of blood to the head will seldom occasion more than lethargy or coma vigil, — states which are frequently produced in this way in the advanced stages of various acute diseases, and sometimes by the use of anodynes, which, in some constitutions, disorder the nervous functions and excite the cerebral circulation. 4th, Inflammation of the brain or membranes, owing to the tume- faction consequent on it, &c, will often be ac- companied with coma; and still more frequently terminate in it, as shown in the article on that disease: and, as we have seen that coma will thus proceed from very different or even opposite states of organic nervous power, and of vascular action, it becomes a matter of the utmost practi- cal importance to distinguish them with accuracy : but not only may those pathological conditions exist in different cases, they may obtain at differ- ent stages of the same case : thus the coma of concussion, in which the first of those conditions i exists, may successively pass into congestion and inflammatory action, formisg the three stages : which Mr. Abernethy has very accurately pointed out in concussion of the brain ; coma, accompanied with very different symptoms, and modified in degree, being present throughout. 5th, The circulating fluid itself may be more or less changed ; it either being of a darker colour, and in a less decarbonised state, than in health; or i having entirely lost the power of coagulating, or presenting a coagulum of a weak or dissolved I texture. (See Blood, § 94.) In addition to [ this state of the circulating fluid, congestion of the cerebral vessels and increased action of the | heart may exist, as in the advanced stages of | malignant, exanthematous, and febrile diseases ; these associated lesions may be also preceded by, or coexistent with, depressed vital or organic nervous energy of the encephalon. 6th, Effusion of blood or serous fluid within the brain will give rise to profound coma, generally as a conse- quence of either the first, second, third, or fourth preceding states, occurring either primarily, or in the advanced progress of febrile diseases. 14. B. It must be evident, that a successful treatment of coma, under the numerous circum- stances and diversified forms in which it presents itself in practice, must be based upon a recogni- tion of the pathological states that occasion it. But how are these states to be ascertained ? The difficulty even of an approximation to this know- ledge is doubtless great; but the practical results, to which the information leads, are of the utmost importance, as respects both the issue, and the reputation of the physician. I shall therefore offer a few remarks, with the view of facilitating the investigation of this subject, and placing our intentions of cure upon a rational basis, a. In the first of the above pathological states, the pulse is weak, soft, unequal, or intermitting ; the pulsation of the carotids is smaller, weaker, and softer than natural ; the breathing is soft, slow, or laboured, but without stertor ; tlie limbs and muscles are relaxed, and deprived of sensibility; the surface is pale, cool, moist or clammy, par- ticularly the extremities ; the head is cool, or at least not above, frequently below, the natural temperature; the countenance is pale or sunk; 330 COMA AND LETHARGY — Treatment of. the eyes open, without suffusion, and the pupils dilated; the tongue is soft, flabby, and broad, unless in the last stages of fever, when it is covered by a brown or dark fur ; and the skin is dry or harsh. The feebleness and intermissions of the pulse, the depression of animal heat, and the loss of sensibility and voluntary motion, are generally in proportion to the exhaustion of vital power in the brain, and therefore important guides in the treat- ment of coma, b. The second pathological con- dition, or that of congestion, will vary in diflerent cases, or even in different stages of the same case, from the depressed state of vascular action and animal heat, described above, to that now to be noticed. The pulse is oppressed, or full, slow, irregular, occasionally nearly natural, — in the carotids somewhat fuller, stronger, or more labour- ing, than in health, or in other parts where it can be felt ; the respiration is either natural or slow, laborious or irregular ; the countenance is slightly tumid, bloated, or livid; the eyes are somewhat suffused and prominent, the pupils dilated and in- sensible ; the temperature of the head is occa- sionally natural, but more frequently slightly increased, and the face and scalp moist; the ap- pearance of the tongue, as in the foregoing state, varies according as the coma is a primary or con- secutive state of disease ; the evacuations are either retained or passed insensibly ; and sensi- bility, voluntary motion, and mental manifest- ation, are abolished in proportion to the extent of depression of the organic nervous influence of the brain, and of vascular congestion. This state may supervene on the former with more or less rapidity, and terminate either in a return to healthy action, or in the third and fourth states referred to. c. The third and fourth patho- logical states are different grades of vascular action, often arising out of the preceding : that consisting of active congestion or increased deter- mination of blood through the cerebral vessels may present nearly the same symptoms as those characterising congestion, but in a much slighter degree ; sensation and voluntary motion not being quite abolished ; the coma being in its slighter grades, — as lethargy and coma vigil, very rarely coma somnalentum. The pulse and respiration may not be materially affected, or it may be merely accelerated ; the temperature, even ofthe head, may also be natural, or but slightly in- creased, that ofthe extremities being depressed; the countenance may not be materially changed ; in some cases it may be even sunk or depressed; but the carotids generally beat more fully and I strongly than in health ; and the mental mani- festations are not merely more or less suppressed, but sometimes also disordered. The state of in- flammatory action, and its consequences, give rise j to phenomena of greater intensity than those now I noticed, and which have been very fully de- scribed in another place. (See Brain, § ISO.) d. The fifth state which I have referred to, as ! obtaining in 6ome cases of coma, seldom occurs alone, but is associated with one or two of the j preceding, particularly the first, second, or even J the third conditions. It is characterised chiefly by a lurid, foul, dirty, or cachectic appearance of I the suiface ; a sunk or sallow countenance ; a j frequent, soft, small, or broad and open pulse : by ( low delirium or typhomanui ; starting of the ten- dons, and picking of the bed-clothes ; preceding and associated febrile, exanthematous, or malig- nant diseases ; and by fetor of the secretions and excretions. In some cases, when this state has come on rapidly, the tongue is merely broad, flabby, marked by the teeth at the edges, and covered by a creamy sordes ; but in the last stage of acute diseases, it is deeply furred, or coat- ed with a thick mucous sordes of a dark brown colour, often extending to the gums, and even to the lips. e. The sixth and last state, that of effu- sion, may be consequent upon any of the preced- ing, and be caused by one or more of them. If the effusion be sanguineous, the attack is often sudden ; the respiration is generally stertorous, irregular, &c; and signs of local paralysis may often be detected. (See Apoplexy.) If se- rum be effused, the coma is as profound as that caused by sanguineous effusion ; but slower in its accession, and less frequently attended by sterto- rous breathing, and local paralysis; it is also more commonly preceded by signs of inflammation, ac- tive determination, or congestion of blood, within the head. (See Dropsy of the Encephalon.) 15. VI. Trf.atment.—The foregoing patho- logical states will often insensibly lapse into one another, as in concussion and inflammation of the brain, giving rise to distinct stages of these dis- eases, and requiring a different treatment for each; and, according as they may thus vary, so will their symptoms be modified ; the principal pheno- mena connected with the cerebral functions, the pulse, the respiration, the animal temperature, the state of the head and carotids, &c. being the practitioner's guides in the direction and com- bination of his means of cure. These means will now require no further notice than a bare enumeration, as they are more fully discussed in the articles on the diseases in which coma, in one or other of its forms, most commonly pre- sents itself. 16. A. Thefirst pathological state (§ 13,14. a.) requires stimulants and counter-irritants; but these remedies must be exhibited with much caution ; as an excessive or inappropriate use of them might produce, even in the slighter cases of cere- bral exliaustion, determination of blood to the head, and convert congestion into inflammation,— consequences which will frequently supervene, at least in a slight degree, as in concussion, not- withstanding the utmost care to avoid them. The preparations of ammonia, musk, and cam- phor, internally and externally employed ; ene- mata, containing the same medicines, or the infu- sion of valerian, castor, assafcetida, or the tere- binthinates; wine and cordials, given frequently and in small quantity; irritating or vesicating em- brocations, cataplasms, sinapisms (Celsus, Are- tjeus, Paulls .Eginkta, to the head), and plasters, as well as moxas, and the cautery (Za- CUTUS LusiTANl'S,RH0DIUS,aildSEVERINUS) applied to various parts, or even to the head itself; blisters to the nape of the neck, behind the ears, or to the head (Bonet, Lan/.ani, Syden- ham); volatile substances held to the nostrils or applied to the temples; errhines (Cklius Aure- lianus, &c); urtication (Aretjeus, Selti); galvanism and electricity (Hufeland, &c); the affusion of warm, tepid, or, in some, cold water on the head; active and stimulating emetics (Riviere, IIigal, &c); purgatives "combined with stimulants, antispasmodics, and tonics • COMA AND LETHARGY—Treatment of. 391 cathartic clysters, conjoined with similar sub- stances ; the use of coffee and green tea, par- ticularly when this state of disease has followed the ingestion of sedative or narcotic poisons, and after the stomach has been evacuated by emetics and the stomach pump, and washed out by the injection of warm water; are severally of use in this state of coma, and may be resorted to in va- rious combinations, according to the circumstances and severity of the case. All these measures are, however, not equally applicable to every case where this pathological state may be presumed to exist; but the judgment and experience of the practitioner can alone enable him to employ them in an appropriate manner; the shades of differ- ence in particular cases requiring certain means, or peculiar combinations of them, scarcely ad- mitting of description, at least within the limits to which I am necessarily confined. 17. B. The second pathological state (§ 13, 14. b.), when closely verging, as it occasionally does, upon the first, will require several of the means enumerated with respect to it; whilst, when fully formed, and approaching that of active determination or congestion, but few of them are applicable. Much, however, will manifestly de- pend upon the habits and the constitution of the patient; upon the nature and duration of the dis- ease of which coma is an advanced phenomenon; and upon the state of the pulse, the temperature ofthe head, and the character ofthe countenance. The first state is injured by blood-letting in any form, it being even not an infrequent consequence of inanition, or even of anaemia ofthe brain; but this second state will generally be benefited by depletion, and in proportion to its approximation to the third and fourth states described above (§ 13, 14. c). The question chiefly is as to what extent it may be carried, and the manner in which it may be performed. In the majority of cases, local depletions, by cupping between the shoulders and nape of the neck, or by leeches applied behind the ears or on the neck and occi- put; by simple scarifications by a lancet in the last-named situation in some cases ; in others bleeding from the feet whilst they are placed in warm water, and cold or tepid water is being poured in a stream upon the head; and in certain instances the application of a number of leeches on the inside tops of the thighs, or about the anus; are the preferable modes of having recourse to depletion in this state of disease; but the extent to which the evacuation should be carried must entirely depend upon the symptoms and circum- stances of the case, and the effects-produced by it. In addition to this important means, purga- tives ought to be given by the mouth, and their action increased by cathartic clysters, in which either assafetida, valerian, camphor, the terebin- thinates, or other antispasmodics and stimulants, may be also exhibited. Counter-irritants and de- rivatives should be applied, but at a distance from the head; and, while a frequent operation of the bowels is procured, the functions of the skin and kidneys should be promoted by diaphoretics and diuretics, the extremities being kept warm, the head cool, its hair cut off, and the shoulders highly elevated. In many instances of this state, even local depletion should be cautiously employed; and in these, as well as in others, much advantage will often accrue from having recourse to restor- ative means. It is in this pathological condition of coma, and hi those about to be noticed, that oil of turpentine, in large doses, so as to act freely on the bowels, has proved so beneficial in my practice. This state very generally obtains in coma from narcotics and spirituous liquors; and is then, especially, very remarkably benefited by the cold affusion on the head, and the prepara- tions of ammonia. IS. C. The third and fourth states (§ 13, 14. c.) require nearly the same treatment as the second, but carried much further ; general and local depletion, cold affusion on the head, or the application of ice, or evaporating lotions ; the most active cathartics, clysters, and derivants or counter-irritants, and the other measures, as fully pointed out in the article on Inflammation of the Brain (§ 174.). When these states have gone on to effusion either of blood or of serum,—the sixth pathological condition adduced,—the treat- ment recommended in Apoplexy and in Dropsy of the Encephalon (see these articles) should be employed. 19. D. The fifth pathological state obviously requires stimulants, tonics, and antiseptics, par- ticularly camphor in considerable doses; the chlo- rides of soda, potash, &c.; wine, with cordials, spices, &c. ; bark, with camphor; purgatives conjoined wtth stimulants, so as to excite the eliminating or depuratory functions ; cathartic, tonic, and antiseptic clysters; calomel, combined with camphor and ammonia, or musk; the tur- pentines given by the mouth, and in enemata, with capsicum and aromatics; external derivation and counter-irritation; the various balsams, with the chlorides, &c. ; quinine, with the aromatic sulphuric acid; the preparations of cinchona or cascarilla with soda, or with the muriatic acid, or muriatic aether; Cayenne pepper internally, as well as externally in camphorated embrocations, &c. When coma is consequent upon the retro- cession of gout, rheumatism, erysipelas, or cuta- neous eruptions, the propriety of having recourse to sinapisms, rubefacient pediluvia, and other derivatives, in addition to such other means as the symptoms of the case may suggest, must be obvious. If it follow suppressed discharges, we should endeavor to restore these, or produce one supplemental of them. (See the treatment of the diseases of which coma is most frequently an important symptom.) Bibliog. and Refer.—Hippocrates, LTsqI rovawv, iii. Opp. p. 488.—Galen, Lib. de Comate, cap. ii. t. vii. p. 195.—Celsus, 1. iii. cap. 20.—Aretaus, Cur. Acut. 1. i. c. 2. —Paulus JEgineta, 1. iii. cap. 9. et 10.—Oribasius, Synop I. viii. c. i.—Avicenna, Canon. I. iii. fen. i. tract, iii. c. 7, &.c.—Zacutus Lusitunus, Pr. Hist. 1. vii. Obs. 4. {The actual cautery behind the ears.)—Rhodius, 1. i. obsJ 36. {The cautery to the neck.)—Severinus, De Efficac. Med. p. 213.—Ballonius, Consult. I. i. 45., 1. iii. 32.—Willis, De Aniin. Brut. Path. cap. 3, 4, 5.—Riverius, Prax. Med. t. i. cap. i.—Sydenham, Opera, p. 281.—Bonet, Sepulchretum, I. i. sect. iii. obs. 5. 13. 18.—Eisen, De Comate Somnalenlo. Basil 1674.—Heinz, De Affectibus Soporosis. Argent. 1677. —Morgagni, Kpist. v. art. 13. 23. 29—36.—Bellini, De Morbis Capitis, p. 455.—Hoffmann, De Affect. Soporosis, obs. 5. Opp. iii. p. 216.—Boerhaave, De Morbis Nervorum, p. 640.—Cartheusrr, De Typhomania. Francf. 1750.— Krugcr, De Somno, Morborum Matreet Filio. Helms. 1754. —Haller, Observat. Med. Pract. Goet. 1750.—Sauvages, v. iii. class vi.—xxix. 7.—Bang, in Acta Reg. Soc. Med. Hafn. vol. iii. p. 127__Vogel, Beobachtungen, No. 9.— Hinze, in Stark's Archiv. h. vi. p. 178.—Behrends, in Hufe- land's Journ. der Pr. Heilk. b. xi. 2 st. p. 1. ; Ibid. b. xx. 4lh st. p. 5. (Galvanism recommended in.)—Riga!, in Me : . de Toulouse, 1788.—Portal, Cours d'Anatomie Med. 392 CONCRETIONS, BILIARY — Pathology of. t- i. p. 21. (An instance of coma from narrowing of the carotid arteries.)—Selti, in Brugnatelli, Bibliolhcc* Fisica, v. u.—Brewster, Edin. Philos. Trans, for 1817. Udiopath. coma from congestion.)—Cooke, Treatise on Nervous Dis- eases v ,. ,>. 372. (Idiopath. lethargy.)-J. Frank, Prax- eos Med. l_ mv, praccepta, par. ii. vol. i. sect. i. p. 367.— Bahn, in hncyclopad. Wurterhuch der Med. Wissenschaf- ten, b. vim. p. l (vel Suh-carb. Soda>) * j. ; Vini Aloe's ", vj ; Extr. Taraxaci ' iij.; Spin'!. Piment* " ss. M. Capiat tertiam vel quartam pattern pro dose, et repetatur pro re nata. No. 148. Magnes. Sulphatis j. (vel Potass* Sulpha- tis 3 a.) Infus. ltosar. Comp., Infus. Gentinas Comp. aa CONSTIPATION £vj.; Acidi Sulphurici Arom. TT] x.; Tinct. Sennae (vel Tinct. Aurantii) jj. — 5 ij. M. Fiat Haustus, omni raeridie capiendus. In most instances of constipation depending upon torpor of the small intestines, and deficient biliary secretion, a full dose of blue pill or of calomel should be exhibited at bed-time, and a common black draught the following morning, at the commencement of the treatment, with the view of promoting the secreting functions of both the liver and the mucous follicles ofthe bowels; and a moderate action ought to be kept up for some time subsequently by the remedies now adduced. 17. b. In those cases in which the large bowels are chiefly in fault, the preparations of aloes va- riously combined, the means already mentioned, particularly R 146, 147., or those recommended in the articles on the Colon, and on Colic, will be generally found appropriate. In some instan- ces, however, it will be requisite to have recourse to more powerful cathartics than I have yet mentioned—particularly when irritability of the stomach, or of the system generally, does not exist — and to promote their action by enemata. The following, or F. 140, 141. in the Appendix may be employed. No. 149. R Pulv. Jalap, gr. xij.; Pulv. Scammoniae gr. v.; Potassae Sulphatis 3j., Olei Carvoph., et 01. Carui, aa TT] iij. Tere bens, simul, et fiat Pulvis in quovis vehiculo idoneo sumendus. No. 150. \\ Masnes. Sulphatis 3 Tj-j Infus. Sennae Comp. ' ij. ; Tinct. Jalap. 3j- ; Tinct. Opii TTf vj.—x. (vel Tinct. Hyoscyami"", ss.); Tinct. Castorei, Spirit. Pimentae, aa 3 j. St. Fiat Haustus. No. 151. R Extr. Colotynth. Comp. V) ij.; Saponis Castil. gr. xij.; Olei Crotonis gtt. iij. (vel Extr. Nucis Vo- micae gr. iij.). M. Fiant Pilulae xii. Capiat diias hora de- cubitus. No. 152. R Mannae " j.; Infus. Anthemidis % xij.; solve, et adde Olei Olivae 5 ijs3. ; Magnesia; Sulphatis § jss. Sit Enema. 18. c. In cases apparently depending upon deficient tone of the muscular coat of the large bowels, and imperfect propelling power of the upper part of the rectum, I have seen benefit derived from combining the spirituous extract of nux vomica, or strychnine with the pilula aloes cum mvrrha, or with the compound extract of colocynth, as directed above in 14 151., in place of the croton oil. When this state is connected with deficient secretion from the intestinal mucous surface (§7. 6.), small doses of the croton oil, from one sixth to one- half of a drop, combined with some other purgative, arid repeated daily, or on alternate days, will remove obstructions from, and restore the secretions of, the mucous follicles. In cases also where the internal surface of the intestines are loaded with a viscid mucous sordes (§7. g-.), it acts more efficiently than any other medicine, particularly when combined as above (R 151.), or with calomel or blue pill, and re- stores more permanently the functions of the in- testines. I have recently met with several cases of constipation, consequent upon attacks of pesti- lential cholera, and in nearly all of these I have inferred the existence of not only imperfect peri- staltic action of the bowels, but also an accumu- lation of viscid, mucous, or albuminous sordes on their internal surface, — an inference confirmed by the state of the evacuations. The combina- tion of purgatives now alluded to has proved more efficacious in removing this morbid condition, than any other I have employed. 19. d. In children and young fepiales, consti- pation is generally attended, even if it be not 35 — Treatment. 499 caused, by deficient secretion from the mucous follicles, and by an accumulation of mucous sordes (the Saburra intestinales of the older writers, and the Embarras Sabural and Embar- ras intestinal of French authors) on the internal surface of the bowels. In these cases, a dose of calomel, with either jalap or scammony, and tri- turated with sugar, and followed by castor oil, or the infusion of senna with salts, or by the decoc- tion of aloes, &c, according to the circumstances of the cases, will generally, procure full evacua- tions. But in many such cases, the repeated ex- hibition of these will be required before the col- lected sordes can be removed; and even when the evacuations have assumed a healthy appear- ance, it will be requisite to resort occasionally to purgatives combined with tonics and resolvents— such as senna, aloes, or rhubarb, with gentian, cascarilla, cinchona, or calumba; and with potass, soda, &c, before the functions ofthe bowels will be altogether restored. 20. e. When the fcecal retention assumes the form of obstipation, and is attended with difficult or imperfect evacuation; or with frequent desire, and tenesmus; and with hard, rounded, scybalous discharges; we may infer the existence of rigidity of the longitudinal bands of the colon (§ 7. e.); and should combine anodynes and antispasmodics with purgatives. I have commonly derived most advantage from small doses of castor or olive oil, exhibited frequently, in some carminative or aro- matic water, with a little tincture of hyoscyamus and ipecacuanha wine; and from demulcent, anodyne, and oleaginous clysters (F. 143, 144. 795.) Electuaries, also, consisting of the con- fection of senna, with cream of tartar, magnesia, extract of hyoscyamus, &c. (see F. 96. 98.), will generally prove more serviceable, in these cases, than very active medicines. When the retained scybalous faeces produce irritation of the colon, the frequent calls to stool, and the scanty, mu- cous, and watery evacuations, may lead the prac- titioner to suppose, if he rely upon the account of the patient only, that diarrhoea, instead of consti- pation, actually exists, and hence to adopt an im- proper treatment. In these cases, the warm or tepid bath, the addition of ipecacuanha, or hyos- cyamus, or both, to the purgatives given by the mouth, and the use of clysters with infusions of ipecacuanha and linseed, and with olive, linseed, or almond oil, will generally procure the evacua- tion of scybalous faeces. When the bowels are distended by flatus, the operation of aperients will be most assisted by gentle friction of the abdo- men ; and confidence to persist in the use of it will be given by directing the friction to be employed with some liniment (F- 298. 306.), or with R 157. subjoined. No. 153. R Olei Ricini recentis3j— 3 ij. i tere cum Vitelli Ovi unius, et adde terendo, Vini Ipecacuanha; TT) x.; Tinct. Hyoscyami IT] xv.; Tinct. Castorei TT] xx.; Aquae Pimentae 3 xj. M. Fiat Haustus, 4ta vel 5ta quaque hora sumendus. No. 154. R Potassae Supertart. in pulv. " j.; Sodae Sub- carbon, exsic. (vel Magnes. Calcinat.) 3 iij., Confectionis Sennae % jss.; Confectionis Rutae T, ijss. ; Extr. Hyoscyami gr. xij.; Pulv. Ipecacuanhae gr. ij. — iij.; Tinct. Capsici 3 ss.; Syrup. Zingiheris q. s. ut fiat Electuarium, cujus ca- piat partem quartam 4tis vel 5tis horis donee plene" dejecerit alvus. No. 155. R Soda; Sulphatis, Mannae Opt., aa % j., solve leni cum calore in Aqua? Menth. Virid. J vjss., et adde Tinct. Sennae \ i.; Vini Ipecacuanhae 3 j.: Tinct. Capsici 3ss.; Spirit. Carui 3 ij. M. Capiat Coch. larga quatuor tertiis vel quartis horis. 410 CONSTIPATION —Treatment. No. 156. R Olei Amygdala-, Olei Ricini, Manna; Opt., aa3Jss.; Aq. Pimentae 3*j. M. Fiat Haustus, 4tis, 5tis, vei b'tis horis sumendus. , No. 157. R Unguenti Cetacei % jai.; Olei Carui et Tinct. Opii aa ^ jss. Misce, et fiat Linimentum, cum quo illinatur abdomen, urgente flatu. 21. J?, a. In the more obstinate or prolonged cases of constipation, which have resisted the above, or any other means usually employed to procure evacuations, we should endeavour to ascertain, by enquiring into the previous state of the patient's digestive and intestinal functions, and by examining the abdomen, rectum, and parts in the"vicinity, the probable cause of obstruction. The account which may be furnished of the appearance of the evacuations heretofore, and of the facility with which they had been evacuated, as well as of the sensations felt before or at the time of evacuation, will very materially guide the judgment of the practitioner in concluding respecting the existence of organic disease of the colon or rectum, or in the vicinity of the latter. Frequent attacks of diarrhoea, tenesmus, or dysentery, previously to the occurrence of con- stipation, or of pain in the course ofthe colon, or along the sacrum, should always lead us to sus- pect narrowing, or thickening, or both, in some part of the colon or rectum (§ 9. d.). In such cases, we should endeavour to solicit fecal dis- charges by oleaginous and saponaceous clysters, and frictions of the abdomen, rather than by purgatives taken by the mouth; and we ought not to be too officious in the use of these ; but should so study the feelings of the patient, as to prevent irritation and febrile disturbance — the harbingers of inflammation—from coming on. In those cases particularly, examination of the state of the rectum, and the lower part of the colon, by the introduction of the long flexible bougie, as recommended by Dr. Willan, should not be omitted; and if any stricture exist within the reach of this instrument, its gradual dilatation should be attempted. If a stricture be reached, it may be of service to use a hollow bougie, along which enemata may be thrown up so as to pass beyond the seat of obstruction, which might otherwise not be overcome by them. Instances have been met with, in which stricture and or- ganic disease of the colon have apparently existed for some time without constipation having been complained of; and yet the exhibition, when con- stipation did take place, of acrid purgatives in large and repeated doses, has been soon followed by an unfavourable issue, which, however, might not have been much longer deferred by any treat- ment whatever. Cases illustrative of this occur- rence have been recorded by Home, Sterry, Annesley, &c. (See references.) 22. 6. In almost every instance in which the bowels still remain obstinately costive after two or three doses of purgative medicine have been given, but without any urgent symptom being complained of, it will be more advantageous to use gentle means, to trust chiefly to enemata, and to wait patiently the result, than to prescribe medicines which will irritate, and invert the action of the upper part of the digestive tube without reaching the seat of obstruction. If, notwith- standing, symptoms of inflammatory action begin to appear; or if the stomach become irritable; or if the pulse be oppressed, hard, or constricted; ©r if the patient be plethoric and of a sanguine or irritable temperament; venaesection, or the appli- cation of leeches to the abdomen, or both, should be resorted to, and hot poultices and fomentations, or the warm turpentine epithem, or a blister, be afterwards placed upon the belly. The patient may then be left quiet-for several hours, in expec- tation of the action of the purgatives previously given; or, if the stomach be irritable, soothing and anti-emetic remedies (F. 178, 179. 357.) only, or a full dose of calomel with opium or hy- oscyamus, should be taken, and after a few hours the enema may be repeated. In cases of obsti- nate constipation, unconnected with contraction of the colon or rectum, a large dose of calomel, either alone, or with opium or hyoscyamus, may be exhibited, and repeated once or twice, at dis- tant intervals; each dose being followed either by castor oil, or by the common black draught, or by half an ounce of turpentine with an equal quantity of castor oil in any suitable vehicle. But where inflammatory disease, or lesions con- sequent upon inflammation, are suspected to exist in either the colon or rectum, calomel, or even a full dose of blue pill, will often aggravate the mischief, unless emollient enemata be frequently thrown up. Indeed, I believe, from the experi- ments and observations I have made respecting the action of calomel on the alimentary canal— from remarking its effects in irritating and inflam- ing the inner surface of the colon and rectum when taken in large doses — and from the history of the previous ailments, and treatment of many of those who have had stricture of the rectum or colon—that a very large proportion of such cases has been brought on by the frequent use of calo- mel as a purgative. 23. c. When we believe that constipation is owing to a torpid or paralysed state of the mus- cular coats of the large bowels, and the accu- mulation of hardened feces consequent thereon (§ 9. a.), oleaginous purgatives given by the mouth; in some cases, a full dose of calomel, followed by a turpentine and castor oil draught; and, subsequently, oleaginous, saponaceous, and terebinthinate enemata; are generally the most appropriate means. If, however, these fail, then small but repeated doses of castor, olive, or al- mond oil; frequent demulcent enemata; the as- persion of cold water over the abdomen or lower extremities; or injections of cold water, may be tried. (See § 26.). If there be great inflation or fecal distension of the colon, friction, with the carminative liniment prescribed above (R 157.), may also be employed, with various other internal and external means recommended in the articles on Colic and Colon. In aged females especi- ally, hardened feces sometimes collect to such an extent, and are lodged so firmly in the rectum and lower part ofthe colon, as to require removal by mechanical means. Cases of this kind have been detailed by Schu rig, Pet it, Bis hoprick, Secheverel, White, &c, and have occurred in my own practice, as well as in that of many others. They require the careful introduction of a marrow-spoon, or some similar instrument, into the rectum, to break down the feces; and subsequently the means just stated, particularly oleaginous and terebinthinate injections thrown up by the pump apparatus now in general use, which should be provided with a large and very long pipe, or with a long, hollow, and flexible CONSTIPATION —Treatment. 411 bougie, which ought to be passed as far as possible up the rectum. 24. d. If alvine obstruction be apparently ow- ing to organic, malignant, or other diseases about the uterus, its appendages, the vagina, or rec- tum (§ 10); or to spasmodic constriction of the sphincter ani excited by inflammatory irritation j in its vicinity, or by haemorrhoids, the warm- bath, semicupium, or the hip-bath ; the vapour of j hot water and narcotic decoctions directed to the anus ; anodyne and relaxing injections ; and the extract of conium or hyoscyamus, made into either a suppository or an ointment, with the addition of a little of the extract of belladonna ; may be prescribed, along with such other meas- ures as the circumstances of the case may require. 25. e. When constipation is dependent upon, or associated with, disease of the spine, or in- flammatory irritation of the membranes and en- velopes of the cord, leeches should be applied near the place where pain is complained of; or the patient may be cupped in the vicinity, kept quiet, and in the horizontal position ; and the ac- tion of the bowels promoted by the means stated above (§ 16, 17.), and by terebinthinate injec- tions. If inflation of the bowels exist, the car- minative liniment may be employed ; and if ten- derness, tension, or pain ofthe abdomen be com- plained of, leeches, followed by fomentations, &c. as already advised (§ 22.), should be resorted to. 26. C. Besides the above, other means have been recommended by authors in various states of the disease, and found of much service when appropriately prescribed. Joerdens advises the frequent administration of assafcetida in enemata, and, in cases of deficient secretion and healthy action of the colon, it is certainly of essential use, either alone or in conjunction with purgative medicines. Starke recommends the inspissated ox-gall, both in the form of pills and in clysters. In the latter form, it is calculated to prove an ex- cellent adjuvant of other means ; and when com- bined with aloes, taraxacum, soap, extract of gen- tian, &c. (F. 559. 562.), it is very serviceable in restoring the healthy functions of the bowels, and digestive organs generally. Wendt directs re- peated clysters of the decoction of gratiola to be thrown up. Numerous writers have advocated the application of cold, in cases of obstinate con- stipation. Schenk, A. Fonseca, Blankard, and Laison advise the patient to walk or stand upon a marble pavement or slab ; and Brassa- volus states that Savanarola cured the Duke of Ferrara, by making him walk bare-footed over a cold wet marble floor. Stevenson, Fal- coner, Percival, and Spence direct the affusion of cold water over the lower and upper extremities, and adduce cases wherein the prac- tice had been successful after other measures had failed. Kite, Bartram, Sancassini, and Schmidtmann recommend cold epithems, and the affusion or aspersion of cold water, over the abdomen ; and Kaehler, Korb, and Bran- dis advocate the administration of cold clysmata, in addition to the employment of cold externally. The cold and tepid shower bath, the cold plunge bath, and warm and tepid bathing, have severally been resorted to in aid of other measures, and are frequently of use,—the former particularly in ha- bitual constipation, the latter in cases attended by difficult and imperfect evacuation, and seemingly dependent upon rigidity of the longitudinal bands of the colon. Electricity and galvanism have been employed successfully by Kite, Sigauc la Fond, Grapengiesser, and Clarkson ; and the injection of tobacco smoke, and of a weak infusion ofthe leaves of tobacco, has been advised by Von Mertens, Vogel, and other authors referred to, when discussing the treatment of Colic and Ileus (which see). The decoction of berbery; powdered charcoal (Mitchell and Daniel), in the dose of one, two, or three table-spoonsful given every hour in milk or lime- water ; frictions of the abdomen (Quelmalz); inunction of it with linseed or olive oil (Riedlin, &c); fomentations consisting of senna leaves made hot and moist by boiling water, and placed oyer the abdomen (Petit); purgative extracts; tinctures, and infusions, applied to this situation, either in the form of ointment or fomentation (Schenck, Alibert, &c); and enemata con- taining tartarised antimony (Elias), have also been employed. The exhibition of emetics was advised by Hippocrates, Praxagorus, Me- lius Aurelianus, and Alexander Tral- les ; and of ipecacuanha or antimonial emetics by Stoll, Sims, Sumeire, Deplace, and Hosack. I have seen benefit derived from in- unction ofthe abdomen with an admixture of cas- tor and linseed oils, to which three or four drops of croton oil had been added. In a great propor- tion of the cases of constipation which have oc- curred to me since 1817, when I first adopted the practice, very certain and immediate advantage has been derived from a full dose of calomel (either with or without opium or hyoscyamus,) followed in a few hours by half an ounce of oil of turpentine, and an equal or somewhat larger quantity of castor oil, taken either in a cup of milk, or in a glass of some aromatic water. The action of these has usually been promoted by an injection containing castor, olive, or almond oil ; and, if the operation has not been sufficiently co- pious, another dose of castor oil has been given, and the enema repeated.* * The following synopsis exhibits a succinct view of the treatment:—!. It the pulse be hard or constricted, and if there be pain, increased on pressure, bleed generally or locally or both—apply blisters or hot fomentations, or the cold affusion, or cold epithems, kc, on the abdomen; after- wards exhibit purgatives, enemata, kc 2. If constipation seems to arise from diminished secretion and exhalation, give calomel or blue pill, carbonates of the alkalies, jalap, the purgative oils, senna, camboge, elaterium, croton oil, &c. ac- cording to circumstances. 3. If it depend upon a rigid fibre and habit of body, combine purgatives with relaxants and nauseants—with ipecacuanha, antimony, colchicum, soda hyoscvamus, &c: prescribe emollient and relaxant medicines in preference to those that are acrid ; and give them with an- tispasmodics and sedatives. 4. When it arises from torpid peristaltic action and lessened secretion, conjoin tonics gum resins, and bitters, with purgatives and aperients; myrrh as- safcetida, galbanum, &c, with aloes; sulphate of quinine or extract of gentian with aloes; the alkaline solutions, with tonic infusions; use friction with stimulating liniments to the abdomen or along the spine; resort to the cold salt-water bath or shower bath, and the tonic and aperient mineral waters of Cheltenham, Leamington, Vichy, and Carlsbad. 5. When it is attended by accumulations of hardened faxes in the co- on, have recourse to copious soapv or oily clysters—to the introduction of a marrow-spoon to break down'the fa>ces—to the injections of cold water. &c. by the valve-apparatus, with a long bougie attached to the pipe—to the aspersion of cold water on the abdomen, or the application of cold to the lower extremities, kc 6. If it proceed from organic change of the large bowels, or of parts affecting them, solicit evacuation by emollient and relaxant enemata, and suppositories; soothe lo- cal and constitutional irritation, preserve the functions of the stomach, and give the alkaline solutions with conium, bella- 412 CONVULSIONS —Pathology of. 27. ii. The prevention of a recurrence of the disease should be strictly guarded against, particu- larly after active cathartics have been given to re- move it. Purgatives, aperients, or laxatives, com- bined with stomachic bitters and tonics (F. 187. 266. 872.), ought to be taken dai'y, and after- Wards on alternate days, until the functions ofthe bowels are fully restored. The patient's diet should be light and nutritious ; all astringent and indigestible substances avoided ; and, if the abdo- minal secretions be deficient, an occasional dose of blue pill, or hydrarg. cum creta, and a course of taraxacum, with deobstruent laxatives and ton- ics (F. 390. 510. 873.), prescribed. Subsequently a course of Leamington or Cheltenham mineral waters, or the artificial Seidschutz, Marienbad, and Carlsbad waters, and in some cases the Pyrmont and Spa waters, will prove of much benefit. The shower-bath, upon getting out of bed, or the cold salt-water bath, will further tend to promote the digestive and defecating processes. Costive per- sons, with a large or pendulous abdomen, should wear a broad belt or bandage around it, which will serve to promote the functions of the bowels. The patient should carefully avoid the remote causes of constipation, attend daily to the first in- timations to stool, and have an early recourse to medicine when such intimations are delayed be- yond the usual time. When the bowels require the assistance of medicine to preserve them in a regular state, aloes may be combined with mas- tich and Cayenne pepper, or with a bitter extract, myrrh, and assafoetida, and taken daily about two hours before dinner. Bibliog. and Refer.—Hippocrates, TIcqI vovcfvn, iii. Opp. v. p. 491.—Calius Aurelianus, Opp. p. 243. 529. —Alexander Trallcs, lib. ii. cap. 44.-—Bullonius, Opp. i. p. 40.—Sthenic, Observat. 1. iii. n. 285.—Sa/muth, cent. i. obs. 24., cent. ii. obs. 65. 98., cent. iii. obs. 26. 45.—Blankard, Collect. Med. et Phys. cent. vi. No. 68.—Panarolus, Ja- trolog. Pentecost, i. "obs. 1.—Smetius, Miscellan. p. 561__ Bonet, Sepulchret. 1. iii. s. xiii. obs. 11. p. 589.—Trian, Observ. Med. p. 25. and 56.—Morgagni, Epist. xxxii. de Alvi Adstriclione.—Callisen, in Act. Soc. Med. Havn. i. and ii. p. 329.—Aaskow, in Ibid. ii. p. 9.—Brendel, Observ. Anat. Med. dec. i. n. 20.—X F. Walther, De Intest. An- gustia. Lips. 1731.—Quelmulz, De Frictione Abdominis, &.c. Lips. 1749.—Lieutaud, Hist. Anat. Med. 1. i. obs. 292, 293. 301.—A. Fonseca, De Tuenda Valelud.—Suncassani, in Haller, Bibl. Med. Pract. vol. iii. p. 601.—C. G. Ludwig, De Causis Obstructiouis Alvinae, 4lo. Lips. 1770.—Petit, Traite de Malad. Chirurg. t. ii. p. 101., et t. iii. p. 47. 103., et. Mem. de 1'Acad. de Chirurg. i. p. 239.—Sauvages, t. ii. p. 363.—Dcvilliers, in Journ. de Med. t. iv. p. 257.—Mar- teau de Grundvilliers, in Ibid. t. xiii. p. 226.—Laison, in Ibid. t. Ixxxvii. p. 354.—Cullen, Materia Medica, vol. ii. p. 496.—Roeschlaub, Magazin. b. iv. No. l.—Erhard, De Prae- ternat. et rara Obstipat."Alvi Causa, ice. Erf. 1790.—Stoerck, Annus Med. vol. i. p. 125.—Block, Med. Bemerkuns, p. 124.—Stoll, Rat. Med. par. ii. p. 135., vol. vii. p. 151.— Weikard, Vermischte Scriften, b. ii. p. 52.—Starke, Klin. Iustit. p. 174.—Baillie, in Trans, of Soc. for the Improve- ment of Med. and Chirurg. Knowledge, vol. ii. No. 14. p. 174.—Meckel, N. Archiv. b. i. No. 3., et Acad, de Berlin, kc. 1759, p. 39.—Stevenson, Edin. Med. Essays, kc vol. v p 893.—Lorry, Hist, de Soc. de Med. vol. ii.—Burggrave Medicin. I alle, p. 232.—Cruickshanks, Anat. of Absorb! Vessels, p. 119.—Reil, Memorab. Clin. vol. i. fasc. 1. No 3. —Theden,X. Bemerkung. b. iii. p. 76.—Ford, in Lond. Med. and Physic. Journ. vol. iv. p. 390.—Kite, in Ibid vol viii. p. 164.—Leske, Auserl. Abhandl. b. i. p. 61.—Wedel Stark's Archiv. b. vi. p. 613,—Riedlin, Millenarius, No 301 et 536.—Sims, Observ. p. 20.—Sumeire, Journ. dc Med t Ixi. p. 369.—Odier, Manuel de Med. Pratique, p. 207 — Moeller, in Baldmger, N. Magazin. b. xx. p. 178. —Oiion- der, N. Denkwiirdigkeilcn, b. i. st. 2. p. 130.—Falconer in Mem. of Med. Soc. ol London, vol. ii. p. 72.—Shei-uien, in donna, &c.—(From the Author's short Ifotes of his Lectures delivered from 1824 to 1829.) J Ibid. vol. ii. p. 9.—Kaehler, in Stark's Archiv. b. ii. tt 2. No. 2.—Grapengeisser, Versuche, kc. p. 100.—Alibert, in Mtm. de la Soc. Med. d'Emulation, t. i. p. 182. 443.—Wil- lan, Miscel. Works by A. Smith, i.c. Lond. 1821, p. 446.— Daniels, in Philad. Med. Journ. vol. v. p. 119.—Wendt, in Annalen des Klin. Inslilut. 1 heft.— Secheverel, in Journ. (itner. dc Med. &c. t. xix. p. 6.—Huf.land, in his and Himly's Journ. der Pract. Heilk. Nov. ie09, p. 130.—Par tal, in Mem. de I'Institul. Nat. de France, 1807.—Pomma, in Journ. de Med. Contin. July, 1810, p. 74.—Spenre, Med. Trans, of Coll. of Phvs. vol iii. p. 99.—Gerard, in Duncan's Edin. Med. Comment, vol. x. p. 44.—Warren, in Ibid. p. 255.—Helsham, in Ibid. vol. xiii. p. 282.—Bishoprick, in Ibid. vol. xx. p. 340.—Hosack, in Duncan's Ann. of Med. 1796, p. 310., and Lond. .Vied. Hep. t. xvii. p. 77.—Mossmun, in Ibid. 1797, p. 307.—Clarke, Trans, of Irish Acad. vol. vi. p. 3.—E. Home, Tran*. of Soc. for Med. and Chirurg. Im provement, vol. ii. p. 182.—Bader, Observ. 39.—horb, in Richter's Chir. Bibl. b. viii. p. 120.—Mursinna, Beobach. b. i. p. 141.—Bateman, Art. Constipation und Costiveness, in Rees's Cyc\opadi».—Joerdens, in Hufeland's Journ. der Pract. Heilk. b. xvii. st. 2. p. Bl.—E/ius, in Ibid. b. x. st. 1. p. 140.—Mitchel, N. Y. Med. Repos. 1800.—Sterry, in Lond. Med. Repos. May, 1823.—Crampton, Dublin Hosp. Reports, vol. iv. p. 305^—Howship, On Dis. of the lower Intestines, and Costiveness, Aic. 8vo. Lond. 1820.—Reece, On Regulating the Stomach and Bowels, kc 8vo. 2d edit. 1827.—Green, Edin. Med. and Surg. Journ. vol. ix. p. 166. —Oudnay, vol. xvi. p. 383.—Clarkson, in Ibid. vol. xvi. p. 475.—Annesley, and Author, in Researches on Diseases of India, 4ic. vol. ii. p. 50. et seq.—Vulentin. in Bull, des Ann. des. Scien. Med. t. x. p. 74.—Bompard. Traite des Malad. des Voies Digestives, kc 8vo. Paris, 1829, p. 280.—Stani land, Lond. Med. Gazette, vol. xi. p. 245. CONSUMPTION. See Pulmonary Consump- tion, and Mesenteric Consumption. CONTAGION. See Infection. CONVULSIONS.—Syn. Z.iuoulc, Gr. Spasmi Clontci, Motus Convulsivi, Distensiones Ner- vorum, Conductiones, Auct. Var. Convulsion, Spasme, Fr. Zuckungen, Ger. Convulsioni, Ital. Convulsion Fits. Classif. 4. Class, Nervous Diseases ; 3. Order, Spasmodic Affections (Cullen). 4. Class, Affecting the Nervous Function ; 4. Order, Affecting the Sensorial Powers (Good). II. Class, III. Order (Au- thor, in Preface). 1. Defin. Violent and involuntary contrac- tions of apart, or of the whole of the body, sometimes with rigidity and tension (tonic con- vulsions) ; but more frequently with tumultuous agitations, consisting of alternating shocks (clo- nic convulsions) ; that come on suddenly either in recurring or in distant paroxysms, and after ir- regular and uncertain intervals. 2. Convulsions have attracted a due share of attention from the medical writers of all ages. Hippocrates states, that "convulsions arise either from repletion or evacuation," (Aphor. sect. vi. § 39.); and Galen, whilst he admitted the propriety of referring them to these two mor- bid states, argued for a third, namely, irritation occasioned by a morbid humour. ALtivs ad- hered to a similar arrangement, but considered that the thii-d of these pathological conditions per- formed the principal part. Subsequent writers, chiefly copiers or commentators on Galen, adopted his views. Zacutus Lusitanus im- puted much importance to the second morbid state of Galen, viz. excessive evacuation; and considered that a positive or relative dryness of the nervous and muscular system was occasioned by it. The writings of Willis and Sylvius DKLFBoe made some alterations in the received doctrine ofthe origin of convulsions, by referring more than their predecessors had done to the nervous system and animal spirits, and less to CONVULSIONS —Forms of. 413 the influence of morbid humours. It was not, however, until the appearance of the writings of F. Hoffmann, that a spirit of accurate in- vestigation was manifested in this department of medical enquiry. This writer, to whom our science still continues under great obligations, regarded convulsions as a consequence chiefly of a morbid state of the spinal cord and its mem- branes,—an opinion which has been adopted by many, and which numerous facts seem to sup- port, in respect of several manifestations of these complaints, although it cannot so frequently be shown that this part of the voluntary nervous system is that primarily affected. 3. The opinions respecting the nature and re- lations of convulsions, entertained during the last century, and what has past of the present, have been so numerous and vague, that the advan- tages resulting from a review of them could by no means compensate for the limits they would occupy. Such of them as deserve notice will be referred to hereafter. It may, however, be remarked respecting them, generally, that no two writers of reputation agree as to either the import of the word, the diseases coming within this denomination, or the manner of arranging and considering them. Under such circumstan- ces, the systematic and eclectic writer might be placed in much difficulty, if he had not ex- tensive and diversified experience to guide him. Upon this, however, my chief reliance is placed, even while I endeavour to profit by the labours of my predecessors,—some of them my followers in the adoption of important curative means in these affections. 4. If, in defining convulsion, we state it to be "an anormal action of muscular or fibrous parts," we at once make it synonymous with spasm, and embrace a most numerous class of diseases, viz., those forming Dr. Cullen's order, Spasmodic Diseases, as well as many of those in which spasm is merely a part of the morbid state. If we define it to be " an irregular or anormal action of voluntary muscles," we shall comprise all those maladies, which usually put on nearly a regular form or type, owing to certain pecu- liarities of the spasmodic action and concomitant phenomena; as tetanus, epilepsy, &c. But if we adopt the more confined and precise definition given above, those disorders only which assume no regular type; but which, whilst they approach, on the one hand, those of a regular form, often pursue, on the other, very eccentric courses, and even anomalous states. It is impossible to con- sider the diseases of the frame in a way true to nature, and at the same time as abstract entities —as species perfect and distinct of themselves. They are individually, in truth, merely certain morbid states, lapsing on the one side insensibly into.others, to which, although most intimately allied in every respect, different names have been but too arbitrarily assigned; and passing on the other side into affections otherwise denominated, although not materially differing in their natures. Thus, if we make spasm the essential character of one great family of diseases, we may divide it into subordinate orders, genera, and species, ac- cording to the parts affected, and the functions concomitantly disordered, and the permanency, the rigidity, the relaxations, and the frequency of recurrence of the spastic action. But still the 35* essence of disorder will be very generally the same; and each of these subdivisions—each of the manifestations of the particular morbid states made the basis of distinction—will so insensibly glide into each other, as to defy the possibility of drawing lines of demarcation between them. The practitioner will be unable, on many occasions, to detect in practice the specific differences as- sumed; and will continually meet, as I have in many hundreds of instances, with cases which he cannot refer to one species more than to another, and which are as much eclampsia as epilepsy, or as much what are usually called convulsions as either the one or the other. If we take the cha- racter of the spasm, in respect of permanency, rigidity, relaxation, and recurrence, as a basis of arrangement of all the diseases attended by anor- mal action of voluntary muscles, we shall have every grade, passing imperceptibly from the most acute form of tetanus through cramp, epilepsy, eclampsia, convulsions, &c, down to the most atonic states of chorea and tremor. Also, if we consider the affections called convulsions, and which are usually irregular in their forms, with reference to the character of the anormal contraction of the muscles, we shall perceive it in some cases of the most violent and spas- tic nature, frequently of some continuance, the relaxations being of brief duration, or scarcely observable ; and in others nearly or altogether approaching to tetanic. These constitute the more tonic form of convulsions, from which there is every possible grade, down to the atonic or most clonic observed in chorea or tremor. Thus, then, anormal actions of muscular parts, like all other morbid actions, may, in respect of grade, be either above or below the healthy standard — tonic and clonic marking each res- pectively ; but between which there exists every possible degree; these terms being therefore en- tirely relative, and conveying no definite and unchanging meaning. But, besides varying re- markably as to grade, the anormal actions of voluntary muscles may be attended by numerous phenomena giving them specific characters. Thus, when accompanied with complete insensibility, or any other superadded morbid condition, they have been denominated epileptic, hysterical, &c; and, from this circumstance, they assume certain types, but of no very constant or immutable kind. When, however, they are not so associa- ted, they constitute a simpler state of disease, and put on less regular forms, affecting either the whole of the voluntary muscles, or a greater or less number of them. 5. I. Forms.—From this, therefore, it is to be inferred that, although Dr. Cullen, and ma- ny others, have considered convulsions as cha- racterised by the clonic nature of the spasms— by the alternation of contraction and relaxa- tion without the control of the will — yet this does not universally obtain, they sometimes as- suming states approaching to tetanic, and every degree of violence, as well as length of duration. The more regular and specific forms of convul- sion, as epilepsy, hysteric fits, raphania, hiccup, tetanus, rabidity, &c, are discussed in separate articles; I shall, therefore, consider at this place only those simple and irregular states of convul- sion which do not fall within its more specific manifestations. 414 CONVULSIONS—Local. 6. Simple convulsions present great diversity of character. They have been already shown to differ widely in violence and degree; and they vary as greatly in duration, modes of accession, and recurrence, as well as in the number of parts affected by them. Hence they may be acute or chronic—most frequently the former; partial or general; continued, recurrent, or intermittent; uncertain in their accession, or periodic; and they may, moreover, attack a number of parts in succession. The circumstances and causes which originate them will also impart to them certain characters, which, although frequently difficult of detection, should not be overlooked. Thus, they are either idiopathic or symptomatic, most frequently the latter, even when the primary lesion illudes observation. But these diversities of form, although most deserving of attention, can only partially serve as a basis for the practi- cal consideration of convulsions. I shall there- fore view them—1st, in respect of their partial or local occurrence; 2d, as to their general mani- festations; 3d, as they affect infants and children; and, 4th, as we observe them in connection with the puerperal states: I shall also notice them as associated with, or consequent upon, other acute diseases. 7. i. Partial or Local Convulsions.— Many of the disorders which have been imputed a convulsion of individual parts, fall more ap- propriately under the denomination of spasm. I shall therefore briefly notice only such as, from the alternation of relaxation and contraction, appear to approximate to the convulsive state. A. Involuntary contractile parts are more sub- ject to spasmodic action, than to that which may be said to be really convulsive. Whether or not certain of the phenomena presented in various diseases of the alimentary canal, as gas- trodynia, pyrosis, rumination, retchings, colic, borborygmi, ileus, the tormina of dysentery, &c, are more properly convulsive or spasmodic, must be entirely a matter of opinion, to which but little practical importance should be attached, as they are both modifications merely ofthe same proximate condition. This remark applies equal- ly to the anormal actions sometimes presented by the urinary bladder and uterus; and it is proba- ble that palpitations of the heart, and angina pectoris, are chiefly manifestations of convulsive contractions of this viscus. (See Angina Pecto- ris, and Heart—Palpitations of.) That hiccup is altogether owing to convulsive actions of the diaphragm, cannot be doubted. (See Hiccup.) 8. B. Voluntary muscles and parts present the most unequivocal appearance of partial or local convulsion; although several local affections, de- nominated convulsive by some writers, are, more strictly speaking, spasm or cramp of particular muscles, a. The muscles of the eye-lids, owing either to the contraction of an ill habit, or to irritation of the ophthalmic branch of the fifth pair of nerves, are sometimes clonically con- vulsed— forming the nictitatio of authors, b. The muscles of the eye-balls are also not infre- quently similarly affected, particularly in infants and children — occasioning, particularly during sleep, rolling of the eyes. Ihis state of local convulsion is common during dentition, and dis- orders of the stomach and bowels. Either a more severe state of convulsion of these muscles, ap- proaching to spasmodic contraction of one or more of them, or a paralysis of their antagonists, will occasion distortion ofthe eyes, or strabismus, with or without irregular oscillations of the iris, dilated pupil, &c; as in inflammatory and organic 1 affections within the cranium, and in verminous disorders c. Twitching convulsions of the mus- cles of the face, or those inserted into the lips; retraction of the angles of the mouth, giving rise to what has been called the risus sardonicus; are often observed, but generally as a symptom of | the invasion or actual existence of most danger- I ous diseases; as inflammation of the encephalon, or ofthe diaphragm, and various organic changes I affecting the substance of the brain. Twitchings of the muscles of the face, however, sometimes occur in persons of a nervous and irritable tem- perament, or with an excited brain, without any apparent disease, d. Convulsive movements of the tongue are seldom observed unconnected with irregular movements of other parts, unless in the diseases now named, and in apoplexy, e. Slight convulsive actions ofthe muscles of the lower jaw, giving rise to grinding of the teeth in sleep, are very common occurrences in persons with worms, or other diseases of the alimentary canal; or ex- cited circulation of the encephalon. /. Trismus, or spasmodic contraction of these muscles, in in- fants, arises from disorders of the prima via, the impression of cold, or irritation of the umbilicus, but does not strictly fall under the head of con- vulsions, g. A clonically convulsed state of the muscles of the neck are sometimes, but rarely, observed, producing convulsive tremor, or shak- ing palsy of the head, which is aggravated on certain occasions of mental perturbation, and nervous or vascular excitement. (See Palsy, Shaking, and Tremor.) h. The abnormal actions which approximate more closely to the permanent or spastic contractions, and affect one or more of the cervical and adjoining mus- cles, are much more common, and are often induced by a current of cold air, by over- straining, or by inflammatory irritation about the bodies, or intervertebral substance of the upper cervical vertebra;; or from disease about the medulla oblongata or base of the brain; or from irritation of remote parts — as of the genital organs of the uterus or ovaria; or from strangulated hernia, — an instance of which last has been observed by myself. In all such ca- ses, the head is drawn more or less to one side, or backwards, or forwards; but similar flexures of the neck often are occasioned by the paralysis of muscles on the side from which the head is bent, the tonic or natural action of the unaffected muscles drawing the head from the paralysed side. In the one case, however, the muscles" are rigid and strung like a cord on the contracted | side, and more or less pain is complained of either in them or in the vicinity, particularly on attempts to bend or turn the head or neck in an opposite direction; whilst, iu the other case, these symptoms are wanting. These are more pro- perly cases of spasm than of local convulsion, as the contraction seldom alternates with relaxa- tion, but is commonly more or less permanent. However, cases sometimes occur, which are in- termediate between permanent spasm and con- vulsion, especially as a symptom of the diseases last referred to. i. Convulsive movements in the CONVULSIONS — General. 415 pharynx and (esophagus, impeding or preventing deglutition, are frequent in hysteria, and in the last stage of several fatal diseases, k. They also affect the muscles ofthe larynx, the diaphragm, and other respiratory muscles, either separately, in rapid succession, or nearly simultaneously. Some of these affections are transient, and the result of slight causes ; as in sneezing, coughing, sighing, sobbing, &c.; others are extremely dan- gerous, owing to the nature of the parts affected, the severity and continuance of the convulsive movements, and the circumstances in which they supervene ; as in spasip of the glottis, spasmodic croup, certain states of asthma, with severe fits of coughing, singultus, &c. /. Convulsive ac- tions also occur in the muscles of the abdomen ; as in hysteria, common and lead colic, and in consequence of intestinal worms. The most re- markable instances of true convulsion of the abdominal muscles merely, that I have observed, have occurred in adult persons infested by the large round worm. m. The muscles of the spine sometimes experience convulsive actions, but more frequently spastic contractions, occasioned by hysteria, disease of the bodies of the vertebrae or membranes of the spinal cord, injuries of adjoining parts, strangulated hernia, acute rheu- matism, the passage of biliary or renal calculi along the ducts, and inflammatory irritation of the uterus or ovaria. n. Either one or both of the upper extremities are occasionally affected by convulsions, more commonly both. The fingers are generally clenched around the thumb, which is drawn upon the palm; the arm being either extended forcibly, and the hand turned as in pronation, or the fore-arm bent upon the arm, or both these occurring in rapid alternation. Such are the more tonic convulsions of the upper ex- tremities; but their muscles also experience slight and extremely clonic contractions; as the subsul- tus tendinum often observed towards the close of fevers and diseases of the brain ; the more tonic or spastic convulsions, particularly when affecting one arm only, also arising from lesions of some part of the encephalon, or of the upper portion of the spinal cord. o. Convulsions of" the lower extremities are characterised by analogous move- ments, and chiefly affect the flexor and extensor muscles. The toes are bent downwards, and the legs and thighs either drawn upwards or extend- ed, or both the one and the other alternately. 9. Convulsions of voluntary muscles may oc- cur as now described, or in two or more situa- tions, or even in different or opposite parts, either simultaneously or in succession. They may af- fect one side ofthe body only, the other being in its natural state, or paralysed. They much less frequently attack either half transversely. 10. ii. General Convulsions.—General convulsions observe no certain mode of accession. On some occasions they attack suddenly ; but they are much more frequently preceded by pre- monitory signs, especially in children and chronic cases,—a knowledge of, and attention to, which may be made available in preventing their oc- currence. They are also sometimes recurrent, or succeed each other, with more or less rapidity. 11. A. The premonitory signs are vertigo and dizziness, irritability of temper; flushings, or alter- nate flushing and paleness of the face; luminous or other spectra floating before the eyes; various noises in the ears; partial loss of sight or hearing ; restless or unsound sleep, or uncommon weight or drowsiness; fulness or prominence, and rolling of the eyes; clenching, or grinding of the teeth", clenching ofthe hands, &c. during sleep; a tumid appearance of the countenance and hands ; cold- ness or cramps ofthe extremities; slight tremors, shivering, horripilation, shudderings or horrors ; nausea, retching or vomiting; or pain and dis- tension of stomach and left hypochondrium ; un- usual flatulence of the stomach and bowels, or other dyspeptic symptoms; pains in the loins or back; frequent sighing or sobbing; numbness of various parts ; stammering or impeded utterance, loss of memory, and absence of mind; palpita- tions, or slowness and irregularity of pulse; slow, laborious, or irregular respiration; and, sometimes, a copious discharge of limpid urine. In some instances, leipothymia, or threatened syncope, precedes the general convulsions. 12. B. a. The more tonic seizure.—The convulsive movements constituting the paroxysm generally follow rapidly upon one or more of the above signs, and vary remarkably as to violence and duration. During their continuance, the countenance is very much distorted ; the eye- balls are prominent, full, wild, staring, and rolled in all directions; the eye-lids are either open, or rapidly shut and opened ; the patient grinds and gnashes his teeth, and sometimes foams at the mouth, or protrudes the tongue. The alternate contractions and relaxations of the whole volun- tary muscles, and contractions and extensions of all the limbs, are performed with the utmost irregularity, rapidity, and with so great force, as often to require the united strength of several persons to preserve the patient from injuring himself. In these struggles, the teeth, or even the bones of the extremities, have been, in some instances, broken. The respiration is laborious, interrupted, and sometimes accompanied by a hissing noise. The countenance, and indeed the whole scalp, are sometimes tumid, bloated, or red, and often leaden or livid towards the close of the fit, particularly in plethoric persons, when the respiratory actions are much impeded, and the affection originates in cerebral disease. In other cases, the face is pale, and the pulse weak, or small and constricted. The urine and faeces are occasionally voided with violence during the paroxysm : occasionally large quantities of limpid urine are passed. In these, the pulse is generally full, strong, and commonly slow or irregular. In many instances, the general sensibility and con- sciousness are but very slightly impaired, par- ticularly in the more simple cases, and when the proximate cause is not seated in the encephalon; but in proportion as this part is affected, primarily or consecutively, and the neck and face tumid and livid, the cerebral functions are obscured, and the convulsions attended by stupor, delirium, &c, or rapidly pass into, or are followed by, these states. 13. b. The more clonic convulsions.—Such are the common manifestations of convulsions, when they are not occasioned by inanition ; the paroxysms, however, varying greatly in violence, duration, and frequency of recurrence, according to the degree of vital energy, and numerous other 416 CONVULSIONS — Ge ne ral. circumstances. But when they arise from, or are associated with, exhaustion, excessive discharges, and evacuations of the vascular system, they as- sume a somewhat modified character. They are then not attended by sopor; the general sensibility and cerebral functions being but little, or not at all, affected. The pulse is frequent, small, weak, broad, or open ; the features are but slightly dis- torted ; the countenance is pale and collapsed ; and the limbs and extremities cold, and much less rigidly convulsed than in the tonic or more spastic seizures. In many cases, the convulsive movements resemble a succession of general shocks, succussions, or shudderings, sometimes of great violence, and often of considerable con- tinuance, occasioning the bed or room to shake, and terminating the life ofthe patient: in others, they consist of constant tossings of the limbs and trunk. 14. C. Duration and recurrence.—The pa- roxysm may cease in a few moments or minutes, or continue for some, or even many, hours. It generally subsides rapidly, the patient experi- encing, at its termination, fatigue, headach, or stupor; but he is usually restored in a short time to the same state as before the seizure, which is liable to recur in a person once affected, but at uncertain intervals. After repeated attacks, the fits sometimes become periodic (the convulsio recurrent of authors). In adult females, they commonly accompany the menstrual periods. When they arise from organic disease within the cranium, each successive interval is generally shortened, until their recurrence is so frequent that the patient is scarcely recovered from the languor, or other symptoms, consequent on one seizure, until he has another, which at last either ends in profound coma, or terminates life. 15. D. The modifications of convulsions are extremely numerous. In some cases, the respir- atory muscles are much affected, and the fit is accompanied with yelling and shrieks, evidently not proceeding from pain (the convulsio ejulans, or shrieking convulsion). In other instances, the abnormal movements shift from one part to another, or attack .various muscles in succession. In these, the seizure is comparatively slight, and the cerebral functions not remarkably disturbed ; the convulsio erratica of Dr. Goon. In rarer cases, the seizure assumes the form of convulsive tremor, as remarked by Dr. Prichard ; is at- tended with a hot perspiring state of the head, vertigo, and slight stupor ; and continues one, two, or three hours. 16. a. Besides these, various other forms of convulsion occur, particularly in persons under the influence of a morbidly excited imagination, or religious enthusiasm; and in females endowed with the nervous and irritable temperaments, with great mobility of the muscular system, and who are affected by nervous or vascular excitement of the generative organs. On many occasions, these seizures have been propagated to a number of persons by sympathy. Ihe convulsions which became almost epidemic in the west of Scotland, in 1742, and were occasioned by religious enthu- siasm, are not only instances of* a peculiar form of this affection, but also among the most striking on record of the influence of imagination, and of sympathy, or of imitation, in disordering the func- tions of the body. A number of persons were attacked nearly at the same time, when hearing the addresses directed to the imaginations and passions of their hearers by the followers of Whitfield ; and always when impressed by the denunciations of vengeance, and hopes of salva- tion, which they set forth. The mental agony which was thereby induced, gave rise, in many, to the most violent tremblings and agitations of the bodv, which were frequently preceded by faintings, and followed by convulsions, and subse- quently by sobbing, weeping, and crying aloud. In some cases, the convulsions produced epistaxis, which generally terminated the seizure. Such appears to have been the usual course of the pa- roxysm, according to the meagre accounts which have been furnished of it. (See Edin. Med. and Surg. Journ. vol. iii. p. 442.). The con- vulsions described by Mr. Cornish as having been prevalent in Cornwall in 1813 and 1814, owing to the same causes, hardly differed in any respect from the above. 17. b. The convulsions which were prevalent in some of the Zetland Isles during the middle and towards the close of the last century, but which have seldom occurred there since that period, seem to have had some resemblance to the fore- going, as well as to hysteria. Dr. Whytt has referred to the frequency of convulsions in these islands ; and has adduced the extreme facility with which they were propagated among young women, as a proof of the existence of a wonder- ful sympathy between the nervous systems of different individuals. The convulsions now al- luded to, commonly attacked adult females when at church ; but men and young girls were not altogether exempted from them. They are de- scribed very nearly as follows, by gentlemen who had frequently witnessed them:—Persons affected, generally fall down in apparent fainting or swooning fits, and soon afterwards utter wild cries and shrieks, the sound of which puts all who are subject to the disorder in the same situation. Their limbs and bodies are tossed about, the most frightful screams being uttered by them all the while. Their heads are also thrown from one side to the other, and their eyes are fixed and staring. In this manner they roar and struggle for five or ten minutes, and then rise up without recollecting a single circumstance that happened to them, or being in the least fatigued by the exertions made in the fit. Females are most commonly attacked in a crowded church, and on occasions of public diversion and merriment. 18. Similar instances of the spread of con- vulsions, by the infection of sympathy or imi- tation have been recorded by writers, and cases of it have occurred within the observation of the author. Dr. Haygarth has adduced a remark- able occurrence of this description.—Twenty- three females, from 10 to 25 years of age, and one lad of 17, who bad all intercourse with each other, were seized, in 1796, in Anglesea, with slight pain of the head, or of the stomach and left side, followed by twitchings or convulsions of the upper extremities, continuing with little intermission, and with much violence, for a con- siderable time. The disorder was not so violent in bed; but it continued in some cases during sleep. The pulse was moderate, the bowels cos- tive, and the general health not much impaired. There was usually hiccup ; and, when the con- CONVULSIONS, INFANTILE —Symptoms and History of. 417 vulsions were most violent, giddiness, with loss of hearing and recollection. During convalescence, the least fright, or sudden alarm, brought on a slight paroxysm. (See Chorea and Related Affections, &c.) 19. iii. Infantile Convulsion';.—Convul- sions often attack infants of a delicate and irri- table frame, and those who are seized by severe internal or constitutional disease, or are suffering some concealed visceral irritation. They occur most frequently in children under four or five years of age, and particularly during dentition. They decline in frequency from this epoch to the commencement of the second dentition, or about the seventh year, when they again are often met with. Mr. North doubts that any increase takes place at the seventh year. The above is the result of my experience, which in great measure agrees with that of Beauhes,Tissot, and others. As infantile convulsions present various peculiarities in their causes, phenomena, complications, and consequences, and are besides among the most important morbid conditions which come before the practitioner, I shall con- sider them apart. 20. A. Premonitory signs often usher in the attack, but occasionally no such symptoms are observed. I suspect, however, that they are more commonly altogether overlooked, than en- tirely absent. They consist chiefly of manifest- ations of generally increased irritability. This is shown by the temper, if the child be a few months old or upwards; by want of sleep at night, ] and heaviness in the day, or by perfect insomnia; by a lighter and shorter sjeep than usual, the child starting up on the slightest noises, or as from a frightful dream, with fits of screaming without evident or sufficient cause ; by alter- nately flushed and pale countenance, or un- wonted animation of the face and eyes, followed by languor and heaviness ; by a half-closed or open state of the eyelids during slumber, with j startings and twitchings; by fixed, vacant, staring eyes, the pupils being either contracted or dilated, or frequent oscillations of the iris, without beino- influenced by the admission of light, or contrac- tion of one pupil while the other is dilated ; by stretchings or rigid extensions of the limbs; by hiccup, or irregularity of breathing, or short gasps, followed by long laborious inspirations ; by twitchings of the fingers, or clenching of the hands, or pressure of the thumb upon the palm, the fingers being extended and separated from each other, or frequently moved about; by the sudden relinquishing of the breast soon after having sought it eagerly, and the throwing back the head, with an expression of anxiety, and an appearance of dilficult deglutition; and by ful- ness of the upper lip, with a pinched nose and countenance, and slight bluen&ss below the eyes and about the mouth. Many of these symptoms, designated by the vulgar, " inward jits," may with justice be attributed to inflammatory irrita- tion of the arachnoid, as indeed contended for by Parent, Martinet, Lallemand, &c; and, in my opinion, especially of the arachnoid of the base and internal surfaces of the brain. Brachet and North have enumerated them as premoni- tory of convulsions, which they doubtless most frequently precede; but in a great many cases convulsions hold the same relation to inflamma- tory and febrile attacks in infants, as rigors do to the same diseases occurring in adults; and hence these signs must often be common to both, and also to some other infantile diseases. This is shown by their frequency in remittent fever, and other inflammatory irritations of the gastro-intes- tinal mucous surface of children. 21. B. The paroxysm of convulsions in chil- dren is similar to that occurring in adults. In the most severe cases, there is a violent, involuntary, and alternating or convulsive action of all the voluntary muscles extending to some internal or involuntary parts; in which, indeed, the affection often seems to originate, or which appear to be those first affected. In plethoric infants, the face and scalp are tumid, reddened, and subsequently livid; the eyes are distorted and staring, or turned up beneath the upper eyelid, leaving only the sclerotic visible; the respiration is impeded and laborious, but very rarely attended by foaming at the mouth and protrusion of the tongue, unless the paroxysm be epileptic. The whole surface often becomes slightly violet-coloured towards the close of the fit, and the hands tumid. In many instances, particularly in weak or exhaust- ed children, the seizure is much less violent, the countenance being pale and collapsed, and the convulsions more clonic. There are sometimes only twitchings of the muscles of the face, and alternate contractions and relaxations, or rapid shocks, of a few parts, or of only one half of the body, or of various parts in succession, with slight blueness about the eyes and mouth; but more frequently the whole body is convulsed, and the countenance distorted and haggard. The mental faculties, and general sensibility, in the slight or clonic convulsions, are generally not interrupted. They are also, however, frequently obscured, but only during the height of the paroxysm ; and sometimes even entirely abolished in the severe recurrent convulsions attending cerebral disease —the eclampsia of some authors (§ 24.). 22. C. The utmost diversity exists as to the du- ration and recurrence of the fit. In some cases it is only momentary, or of a very few minutes' du- ration. In other instances it continues for several hours, with frequent remissions. It may likewise cease, and shortly afterwards return, and thus sub- side and recur at short but irregular intervals for several times, and at last cease altogether, or ter- minate life. Or the first seizure may be so se- vere as to be fatal. These recurring fits are often at last attended by insensibility, which is not al- together, or even not at all, recovered from in the intervals. This form of the malady is more common in children than in adults, excepting as it occurs in the puerperal states, or towards the termination of tumours and abscesses in the brain. As the convulsive movements constituting the fit become less and less violent and constant, and respiration fuller and freer, the natural appear- ance of the surface returns, and the child is ena- bled to cry; it afterwards falls either into a re- freshing sleep, or, if the convulsions have a cerebral origin, into a stupid or lethargic state of various duration. 23. D. There is a species of spastic or tonic convulsion, which is but rarely met with, affect- ing chiefly the extremities. It seems more nearly allied to spasm than convulsion, into which, how- ever, it sometimes passes ; and occurs, chiefly, 418 CONVULSIONS, PUERPERAL —Description or. in very young children, and in those approaching to puberty, particularly those who are nervous and irritable. I have seen but few instances of it; but it has more frequently been seen by MM. Jadelot and Tonnei.le. It consists of rigid contraction of the upper and lower extremities, of the former only, but more frequently of both. The hands are slightlv bent on the forearm, and the feet are stretched in the same axis with the leg. The spastic action of the muscles contin- ues for several hours, or even days, then ceases, and returns, and often thus recurs frequently at short intervals. The intellectual faculties, the general sensibility, and the muscles of the trunk, are not affected; and the pulse and natur- al functions not materially disturbed. The cases of it which have occurred in my practice, have all been evidently owing to the irritation of worms, or morbid matters in the alimentary canal, or to dentition. 24. E. Another form of convulsions is much more frequently met with in children, to which the name of Eclampsia has been given by Ros e n , Sauvages, Brachet, and others, and which has been considered as infantile epilepsy by some, and, with more justice, by others, as convulsions occurring in the more robust children as a conse- quence of cerebral congestion of an active form. But it differs from epilepsy, in the absence of foaming at the mouth, by the irregular and fre- quent recurrence of the attack, by its longer du- ration in most cases, and by its uniform connec- tion with evident signs of fulness of blood, or acute disease in the brain. This form is seldom preceded by precursory symptoms of any con- tinuance. The child cries, its face and scalp be- come red and tumid, it loses consciousness, and is seized with violent convulsions, or with tremor and rigidity, or a succession of spnsLic shocks of the limbs. In a few seconds, or minutes, or even hours, the seizure subsides; but is generally re- newed at short intervals; the head remaining hot and pained after each return of the fit, which never terminates by a critical sleep of short continu- ance, and in restoration of the healthy functions, as in epilepsy, unless assisted by active treat- ment, but is frequently fol'owed by profound stupor or complete insensibility. From the fore- going it will be evident that eclampsia is merely a more severe form of convulsion, differing from others only in respect of the severity or tonicity of the muscular contractions, the more complete abolition of sensibility and of the cerebral func- tions, and its more uniform dependence upon congestion of the brain and its consequences (§ 21.). The eclampsia of children is in every respect similar to the convulsions of the puerperal states (§29.). 25. F. There are certain phenomena connected with the accession and the course of the convul- sive fit that require attentive observation, as they furnish indications of the pathological state oc- casioning the seizure, and, indeed, form the basis for rational indications of cure. These have in- timate relation to the origin of the paroxysm either in repletion or inanition—in congestion, or in anaemia of the cerebro-spinal masses; in which latter the convulsions of children not in- frequently originate, as shown by Dr. M. Hall, and subsequently by others, and as I have had fiequent opportunities of remarking for many years. When the convulsion is attended with a congested state of the circulation in the head, it will generally be readily recognised, both from the history of the case, and from the premonitory and concomitant symptoms. The warm, tumid scalp and face; the flushed countenance ; the con- tracted pupils and suffused conjunctiva ; quick, full, or hard pulse, particularly of the carotids; are evident signs of an excited circulation in the brain, not infrequently either accompanied with, or running into inflammatory action. When the countenance and scalp are swollen, full, dark, or livid; the fontanelle elevated and tense ; the eyes distorted, prominent, vacant, and stupid; the pupils dilated ; the veins of the head and neck large and dark; the pulse slow, irregular, or oppressed ; the respiration laborious; the ves- sels within the cranium are evidently congested. Dr. John Clarke, and many other writers, im- pute the convulsions of children to irritation or organic change, either directly or indirectly in- duced in the brain or its membranes, particularly in the arachnoid, according to M. Br a c h et. We shall see, when we come to treat of the proximate cause of convulsions, that, although this may be most frequently the case, it is by no means uni- versally so. For we occasionally meet with con- vulsions consequent upon exhaustion, and even ana?mia, as in the last stages of chronic diarrhoea or other diseases; and after large or repented depletions, where there is no evidence of irrita- tion of the arachnoid, or of organic change. In many such cases there may occur notwithstand- • ing, especially during the height of the parox- ysm, temporarv and sjight congestion of the head, as shown in the article Blood, (§ 54—61.); but, still, evidence of anamia of the brain, and, indeed, of the general system, will be furnished in the depressed and relaxed fontanelle; in the pale, collapsed, and pinched features ; in the re- tention of consciousness and unimpaired general sensibility; in the bloodless and dull appearance ofthe conjunctiva and cornea; in the state ofthe pulse in the carotids, and the low temperature of the head; and in the pale, shrunk, wasted, and often bloodless condition of the whole sur- face. 26. There is a disease to which infants are liable, that consists of a spasmodic contraction of the muscles ofthe larynx and of the extremities, and which has been confounded with convul- sions, or with spasmodic croup, and variously denominated. As the muscles ofthe larynx are chiefly affected, and as the disorder consists of spastic rather than convulsive action, it is treated of in a separate article. (See Larynx, Spasm of.) 27. iv. Puerperal Convulsions.—Convul- sions may come on (a) during the latter months of pregnancy; (b) during parturition; and (c) during the first fortnight after delivery. They may be partial or general, most commonly the latter; and they may assume various shades of tonicity, from a state of tetanic violence to the more clonic form, characterised by alternating contraction and relaxation ; but they usually present very nearly the same phenomena as eclampsia—being attended by loss of conscious- ness, and recurring paroxysms, between which sensation is not restored. | 28. A. Premonitory symptoms commonly usher CONVULSIONS —Complications of. 419 in the seizure; but, in some cases, they are either absent, or so brief in duration, or so slight, as to evade detection. Cahussier thinks that they are scarcely ever wanting altogether. The pa- tient usually complains shortly—sometimes for several days—before the attack, of lassitude, de- pression, and a feeling of indisposition which she cannot well describe; frequently of disorder of the stomach; often of weight or pain in the head, or of drowsiness, vertigo, and sparks, or various dark or bright objects, floating before the eyes. These symptoms are renewed at intervals during a day or two, and are occasionally attended by embarrassment of speech. To these usually are superadded, shortly or just before the seizure, a change in the expression of the countenance; partial or occasional failure of sight, or loss of sight; sometimes loss of hearing; haggard, va- cant, and fixed state of the eyes, with a dilated pupil; ringing or other noises in the ears; some- times most acute and splitting pains in the head, with a flushed neck and face; generally sick- ness, pain, oppression and anxiety at the stomach; thirst; a full and quick pulse; subsequently a slower pulse; and swelling of the neck and countenance; tetanic stiffness of the wrists; cramps in particular muscles or parts; twitch- ings of the muscles of the face; shocks or shud- derings through the frame; altered respiration; loss of consciousness; and all the phenomena constituting the developed seizure. Dr. J. F. Osiander states that he has seldom observed a i tumid state of the face and hands wanting as a premonitory symptom. If the convulsions occur during parturition, the pains often become feeble and frequent before the seizure. 29. B. The complete seizure.—To these suc- ceed involuntary contractions of the muscles of the face and jaw, instantly followed by spasmodic succussions, or general convulsions of a violent or tonic character; sometimes approaching to teta- nic, but commonly closely resembling eclampsia; or the universal convulsions of the epileptic or hysterical paroxysm. The respiration is laborious, imperfect, sonorous, and hissing,—frequently with foaming at the mouth,—and the tongue is often protruded; the eyes are injected,prominent,fixed, staring, or rolling; the countenance and head tumid, red, or livid; the limbs are strongly convulsed, and tossed about; the heart beats strongly; and sen- sibility and consciousness are entirely abolished. After a short time the convulsion subsides; respi- ration becomes less laborious, and the countenance less livid; but the comatose stupor continues, some- times with slightly stertorous breathing; when, after an indefinite, but generally a short, inter- val, the spasmodic succussions and general con- vulsions return as before, or with slightly modified severity or duration, and subside into stupor us before. Thus they may recur two or three times — more frequently, several or many times — when the patient either quickly awakes, uncon- scious of what has passed, as if from a slumber; or passes into a more comatose state; or recovers partially; sight and hearing, or speech, or both, being lost for a time. Or she may experience some one of the unfavourable terminations here- after to be noticed. 30. It may be generally remarked, that, upon the accession of puerperal convulsions, a flux of blood takes place to the head and superior ex- tremities; the veins of the lower limbs becoming proportionately empty, and the pulsation of their arteries being comparatively small and weak. The worst forms ofthe attack are often attended by a firm spasmodic constriction of the cervix uteri, preventing the expulsion of the foetus. M. Menard states, that, in the majority of cases of death by convulsions previous to delivery, the child has been found dead, the contraction of the features and extremities denoting that it had par- ticipated in the affection of the mother: this, however, wants confirmation. In some instances, the child has been unexpectedly born during the violence of the convulsions, as if expelled by them with unwonted celerity. 31. C. Modifications. In persons of a nervous temperament, local pain or irritation, or even ex- haustion alone, may induce that state of cerebral affection upon which convulsions are consequent, without the supervention of plethora, and active congestion of, or determination of blood to, the brain characterising the great majority of cases. In these persons, the seizure is sometimes preced- ed by sinking, leipothymia, or fainting; the coun- tenance is neither tumid nor livid; the eyes and face are unsuffused, but wild — often sparkling, staring, or rolled irregularly; the pulse is small, hard, or constricted; the urine is frequently copious and pale; and the agitations and tossings of the limbs greater, but less rigid or spastic, than in the mixed epileptic and apoplectic forms described above. In these cases, there is evident- ly cerebral irritation, or erithism; and, during the paroxysm, abolition of consciousness: but the patient generally either partially recovers her sensibility between its exacerbations or recur- rences; or awakens out of this state entirely restored, and without experiencing any of those sequela? which are left by the more congestive attacks. In other instances, seizures occur, pre- senting characters intermediate between these; but the first described state is by far the most common. From this it may be inferred that convulsions, in any of the three periods con- nected with child-bearing, will evince modified phenomena, according to the constitution, tem- perament, habit of body, predisposition, and pre- vious ailments of the patient. In the plethoric, epileptic, irritable, sanguine, and robust, it will present the characters of eclampsia or epilepsy — the most common—or of apoplexy or coma; and in the hysterical, the nervous, the delicate, &c, it will assume these now noticed, which ap- proach those of a severe hysterical attack. The convulsions which come on in the puerperal states from large losses of blood, are either of this kind, or of one closely resembling it, or intermediate between it and the epileptic. 32. v. Convulsions associated with oth- er Manifestations of Disease.—Convul- sions may occur on the invasion, during the course, and at the crisis or decline of a great number of acute diseases, particularly in children under eight years, about the period of* puberty, and in females of a nervous and susceptible constitution. Their connection with irritations, &c. in the prima via, and with organic diseases in, or affecting the large nervous masses, is considered at another part (§ 37. 44,45.); but their association with some other maladies require a more especial notice in a prac- tical point of view. a. The invasion of various 420 CONVULSIONS — Diagnosis of. acute distempers is ofteu attended. by convul- sions. Indeed, in some of the severe diseases to which young children are liable, particularly the exanthematous fevers and inflammations, convul- sions usurp the place of the cold stage or rigors which usher in these diseases in adults, and are generally preceded by coldness of the surface. When occurring in this manner, they should be regarded as indicating one of three things, viz. a morbid susceptibility of the nervous system, and predisposition to disease in the cerebro-spinal axis; or an approaching developement of febrile reaction and of eruption, if the patient be of a sound constitution; or else an imperfect evolution of both, with a disposition to visceral irritation, inflammation, or effusion, particularly ofthe brain or abdominal viscera, if the habit of body be in fault, or if there exist any hereditary disposition, or vice remaining after previous disease. 33. b. The course of various diseases some- times becomes associated with occasional or re- curring convulsive seizures; often of a partial, or of an irregular, peculiar, or anomalous character; but frequently, also, such as those described under genera] convulsions (§12, 13.). Children, and fe- males about the period of puberty, are most liable to these complications. We observe these seizures in hooping cough and croup; in the remitting fevers of infants; in mania, and febrile insanity; in inflammatory and numerous organic diseases of the brain (§ 37. 44. 45.) and spinal cord; in verminous complaints, and other disorders of the alimentary canal; in organic lesions and calculi of the kidneys and urinary bladder; and in states of nervous and vascular excite- ment or irritation of the female organs. In all these complications, either active congestion or determination of blood to the head, or irrita- tion of the cerebro-spinal axis and membranes, or both these states, may be presumed to exist; active congestion being occasioned by impeded return from, with increased impetus of the cir- culation to, the brain and medulla oblongata; irritation of these parts being generally propa- gated thither from some portion of the organic nervous circle, and through the medium of this circle, in which it had been primarily excited. We not infrequently observe convulsions at- tended or followed by mania and insanity, or even supervene in the course of these mental disorders. When this is the case, the convulsive seizure is commonly of a tonic and acute form, and approaches nearly to eclampsia and epilepsy, constituting the maniacal convulsions of authors. The convulsions which occasionally are observed in females, in connection with irritation of the sexual organs, are evidently owing to the propa- gation of disorder, through the medium of the or- ganic or ganglial, to the spinal nerves, or to the cord itself, or even to the brain; as well as to the extent to which these various parts of the cere- bro-spinal system are thereby influenced; and the various forms which the convulsions thus ori- ginating commonly assume, are to be imputed to the existing state of local or general plethora, or to the degree of determination of blood to the head with which the superinduced irritation is attend- ed. When we reflect upon the connection of the organic nerves with the spinal, and especially on the mode of that connection with the brain itself and the rest of the cerebro-spinal system, we shall not be surprised that irritation of the extremities of the organic nerves, either in some one of the female organs, or in some part of the prima via, excites in one person, according to peculiarity of temperament, hereditary predisposition, habit of body, or state of vascular plethora, convulsions of a spastic or tonic character in the limbs and trunk, the cerebral functions being undisturbed; in another person, convulsions either of a clonic or irreo-ular form, consciousness also being re- tained; or either of these forms, or both of them variously or singularly mixed, with partial or complete deprivation of sense and mental mani- festation, or with a comatose or maniacal deli- rium superadded. Nor should it be a matter of wonder that irritation thus originating gives rise to various other abnormal nervous and muscular phenomena, such as catalepsy, ecstasy, hysteria, &c. 34. c. Convulsions sometimes also usher in the crises of fevers and other acute diseases. This occurs most frequently in delicate or hyste- rical females, the abnormal contractions assum- ing a variety of forms, and often an hysterical character; but it also not infrequently is observed in the male sex, especially in young and delicate persons. This association of convulsions is ge- nerally dependent upon a severe affection of the brain in these fevers, and attended by either coma or delirium; and although they may indi- cate a favourable change, particularly when ac-1 companied with, or immediately followed by, other critical phenomena, or when they put on the true hysterical form, yet they may be the outward signs of an exasperation of the cerebral or cere- bro-spinal affection, particularly when the mental faculties and general sensibility are not soon after- wards restored. Other morbid associations, as with worms, diseases of the brain and spinal cord, &c, may be considered as causes of con- vulsions rather than complications. 35. IT. Diagnosis.—Simple convulsions may with difficulty be distinguished from epilepsy and hysteria. They cannot readily be mistaken for tetanus or rabidity. There are many cases, which the nature of the exciting cause, and the history ofthe case, show to be different from true epilepsy, and yet they cannot easily be distin- guished from it during the height of the pa- roxysm; and the remark applies equally to the hysteric fit. In fact, convulsions present so many and so slight grades of difierence, as to the spastic contraction of the muscles, and the fre- quency and rapidity of its alternation with relax- ation,—as to the presence of, or immunity from, cerebral disorder, as well as to the nature and extent of such disorder, — are so intimately allied in respect of their causes, of the particular system of the frame upon and by which these causes produce their sensible effects, and of the nature of these effects as far as they become symptoms or signs of the particular lesion which occasioned them, that the difficulty of diagnosis is very great in many instances, excepting to the acute and experienced observer, whilst it is suffi- ciently easy in others, a. Generally, however, simple convulsions will be readily distinguished from epilepsy, by the retention of consciousness and general sensibility in the former, excepting in the height of the paroxysm in the severer or more plethoric cases, as in eclampsia and puer- CONVULSIONS — Terminations — Prognosis. 421 peral convulsions, in which both are lost; by the general absence of the consecutive sleep or sopor of epilepsy; by the irregular and frequently recurring form of the seizure; by what is known of its origin and connection with obvious causes, and by the mode of its attack and of recovery from it. There are also various symptoms which, although common to eclampsia, puerperal con- vulsions, and epilepsy, are yet peculiarly charac- teristic of this last; and we find, in addition, other phenomena which simple convulsions sel- dom present, particularly the frightful scream on the accession of the epileptic fit, the ante- cedent aura or peculiar premonitory signs, the very sudden and unexpected seizure when the aura is wanting, the expulsion of the seminal and prostatic secretions, as well as of the alvine excretions; the more frequent occurrence of foaming at the mouth, and severer affection of the respiratory muscles; the more leaden appear- ance of the countenance, and the more common recurrence of the paroxysm at a stated time, than in convulsions, particularly after the first sleep, or when the patient awakens or is rising in the morning. (See Epilepsy—Diagnosis.) f} Con- vulsions are readily distinguished from hysteria, by the antecedent copious discharge of pale urine, the globus hystericus, and the borborygmi; and by the alternate crying and laughing attend- ing the seizure of the latter. Some instances of simple convulsion, arising from irritation of the female organs, will, however, very nearly ap- proach, if not altogether run into, the hysterical character; as we also see many cases of puer- peral convulsion differing but little from epi- lepsy, excepting in the frequent recurrence of the paroxysm in the former before the patient has recovered from the sopor consequent upon the antecedent fit, and in one or two of the diagnos- tic signs noticed above, y. The continued or permanent nature of the spasms in all the forms of tetanus, and the absence of any tendency to obscuration of the general sensibility and mental faculties, during the whole unremitting duration of this dreadful disease, are sufficient diagnostics between it and convulsions, ij. Rabidity can- not be mistaken for this affection, if the history of the case, the uncommonly increased sensi- bility ofthe whole frame, the dread of fluids, and unimpaired cerebral functions, characterising ra- bies, be attended to; for, although convulsive seizures occur frequently in it, they are produced by so slight external or mental causes — by every attempt at swallowing liquids — that their nature and origin cannot be for a moment doubted. (See Rabidity.) 36. III. Terminations or Conseo.uen- ces, and Prognosis.—A. Convulsions, in any of the forms now placed before the reader, may terminate, (a) in health; (b) in some other dis- ease; or, (c) in immediate dissolution, a. Their termination in health may be marked by no pe- culiar phenomenon, beyond the non-recurrence of the seizure. In other cases they are followed by critical evacuations, particularly haemorrhage from the nose, mouth, or ears, after which they may never recur, or which may produce an im- munity from them for a time. Vomiting and diarrhoea, or the accession ofthe catamenia, may likewise prove critical. 37. b. They often are followed by other dis- I 36 i eases; or rather the original disorder or change of structure, of which convulsions are merely a part of the sensible and outward signs, may, from its increase, or extension to adjoining parts, occa- sion other or additional phenomena more or less intimately allied to convulsion, as palsy, apoplexy, coma, loss of speech or of sight or hearing, cho- rea, or mania, delirium, idiotcy, &c, each of which may pass into the other, or be variously associated with one another. Thus loss of sight, hearing, speech, and idiotcy, may be the conse- quences in the same case. Also, either of these consecutive phenomena may arise from the cere- bral congestion, and its effects, produced by the frequent recurrence or by the severity of the fit, particularly when the respiratory functions are much impeded in it, and the system is plethoric and relaxed. My limits will not admit of illus- trations of these facts, either from my own expe- rience, or from the other sources which are re- ferred to at the end of the article; but they are of common occurrence, and may, after continu- ing for a longer or shorter time — in some cases for many years—in others for a very short pe- riod, either be recovered from, or terminate ex- istence. In some cases, convulsions are followed by a state of leipothymia, trance, or complete syncope, which, when profound and continued, may be mistaken for dissolution, and endanger premature interment. There is reason to sup- pose tHat, in some countries where interment usually follows death at a much shorter period than in Great Britain, this dreadful fate has over- taken the patient. In other instances, lethargy, or torpor, terminates the paroxysm, which, in rare instances, has been of long duration, and also may be mistaken for death. Whilst the convulsions of childhood more commonly give rise to, or terminate in, loss of one or more of the functions of sense, in chorea, in idiotcy, or in hydrocephalus; those attacking adults are more disposed to puss into either apoplexy, coma, pal- sy, or mania: and whilst the convulsions of the former class of subjects are more frequently the consequence of irritations affecting the abdominal viscera, those of the latter, excepting in females, are more generally the result of disease within the cranium or spinal column, often at a certain stage of its progress. 38. c. Their termination in death takes place either through the intervention of one or more of the diseases noticed above as their consequences, or, more directly, from the extension of convul- sion or spasm to the respiratory muscles, inducing asphyxy, or from an overwhelming congestion or effusion of blood in the brain. This sudden un- favourable change more commonly occurs in pu- erperal convulsions than in other forms, excepting when they proceed from abscesses or tumours within the cranium. Death may also occur from accidental suffocation during the paroxysm. 39. B. The Prognosis of convulsions depends chiefly on what is known of their causes, on the antecedent and consecutive phenomena, on the history of the case, and the degree in which the functions of the brain and nervous system are affected during and after the fit. a. If the convulsions occur in children, without fever or any primary or cerebral disturbance, and ap- parently from worms, disorder of the prima via, Sec, a favourable opinion may be entertained. 422 CONVULSIONS —Causes of. But when they are preceded by head-affection, by fever, followed by strabismus, stupor, or loss of one or more of the functions of sense; when they are prolonged or recurrent; or are followed by signs of any of the unfavourable terminations noticed above, much danger should be appre- hended. Indeed, all cases depending upon cere- bral disease are attended by more or less danger, which in some instances become most imminent, particularly when the symptoms of hydrocephalus are present, b. In adult persons the prognosis is equally unfavourable, when the affection is evidently the result of cerebral disease, or of or- ganic changes — and when the fits become more and more frequent, or severe, with more marked cerebral disturbance either attending upon or following them. On the other hand, when they are symptomatic of disorders of the prima via, or of the generative organs, a favourable opinion may be entertained, c. Puerperal convulsions, however, should never be considered devoid of danger, more especially when they occur after delivery; or in consequence of great ex- haustion of vital power, or of uterine hemorr- hage. When they are slight, are unattended by stertorous breathing, or by paralytic or apoplec- tic symptoms, and when parturition is so far ad- vanced as to readily admit of its completion by art, less danger may be feared. But the prog- nosis of convulsions generally must be inferred from a careful review of the diversified cMrcum- stances of individual cases, especially in respect of their remote and efficient causes, and of their disposition to terminate in either of the ways pointed out. 40. IV. Appearances on Dissection of fatal Cases. (See Brain, § 4 — 133.) Epi- lepsy, and Spinal Cord. 41. V. Remote and efficient Causes. —i. The remote causes of convulsioyis are nume- rous : but they often require a certain original or acquired predisposition of system to ensure their operation; and various influences which may only predispose to them in some persons, may even excite them in others. .d. Predisposing. There is every reason to suppose that the off- spring may derive constitutional predisposition to convulsions from the parents. Persons of a ner- vous and irritable temperament, — of a delicate frame, and largely developed head (Desf.s- sartz),—of a relaxed and soft fibre, and ple- thoric vascular system,—children whose fonta- nelles are very late in closing, — those who are naturally of a quick, sensitive, and unstable dis- position, and whose physical and moral constitu- tions are readily impressed,—are predisposed by original conformation. Those infants who have experienced injury of the cranium during partu- rition (Smellie); persons who have early, pre- maturely, or inordinately indulged in venereal pleasures—who have placed no restraint on their passions, particularly anger, — who have become debilitated by any cause (Autenreith),—who have had their cerebral organs unduly and too early excited, and before the process of develope- nient was sufficiently far advanced; the present state of civilisation and precocious mental im- provement; the greater irritability of the system accompanying the epochs of dentition; the irri- table and plethoric states attendant upon preg- nancy; habitual determination of blood to the head; previous attacks of convulsion, either be- fore or after puberty, or in a former pregnancy; attempts to conceal pregnancy, and the mental distress and shame attending it in unmarried women; exhaustion of nervous or vital power by increased discharges, long continued pain, or want of sleep; all luxurious indulgences; too much sleep; inanition and want; prolonged lac- tation; fluor albus, &c.; and certain electrical states of the air, by which the nervous system is influenced, and rendered more susceptible of im- pressions and excitement; are the chief causes which generate a predisposition in the frame. It has been remarked by Dr. Ramsbottom, and other writers, that puerperal convulsions were most frequently produced during warm electrical states of the atmosphere. 42. B. The exciting causes of the various forms of convulsion are very numerous; and they act in different ways in producing their effects. I have already stated, that irritation of a part of the or- ganic or ganglial nervous system will be transmit- ted by the communicating branches to the spinal nerves, and produce convulsive actions of the muscles they supply, without the brain experi- encing any evident lesion; whilst, in other cases, the irritation may be conveyed to the brain, either directly by the organic nerves, or through the medium of the spinal cord, the cerebral functions suffering accordingly. But irritation or organic change of any of the parts contained within the cranium will also occasion convulsions, the gene- ral sensibility and mental manifestations being then more or less obscured or perverted during the paroxysm or subsequently. These facts, which might be illustrated by numerous cases, the history and results of which I have attentively observed, naturally point to a division ofthe caus- es, first, into those which act upon some portion of the organic nervous circle, or the viscera which it supplies; and, secondly, upon the cerebro-spi- nal system itself. But, although it is useful to make this distinction, particularly for practical purposes, yet it should not be overlooked, that irritations affecting the former would rarely be followed by convulsions, unless the latter posses- sed a marked disposition to disease, as far as re- gards increased suceptibility and proneness to experience alterations from the healthy condition of its circulation. 43. A. The exciting causes which act more immediately upon the organic nervous system, and through it upon the spinal nerves or brain, or both, are the following:-—a. In infants and chil- dren, the retention of the meconium; a morbid state of the umbilical cord; unwholesome milk, or improper feeding; acid or acrid sordes, and various diseases of the alimentary canal; an over- loaded stomach; suppression or retention of the urine; accumulated flatus, or morbid secretions, and the presence of worms, occasioning irritation of the bowels; the ingestion of acrid substances —as very irritating purgatives (Gohl and Len- tilius), or emetics (Riedlin), — acrid ene- mata; noxious or indigestible substances taken as food; acidity ofthe prima via; dentition at either of its epochs, particularly cutting the eye and molar teeth; the irritation of pained or carious teeth; and calculi in the urinary organs, &c. b. In persons about, cr subsequently to, puberty, and occasionally in children, organic diseases of CONVULSIONS —Causes of. 423 the stomach, bowels, or collatitious viscera ; af-' causes now mentioned are especially productive fections or lesions of the heart; constipation, colic, of convulsions, particularly anxiety or distress of ileus, and intus-susception ; incarcerated or stran- mind in unmarried females ; violent straining guluted hernia (Graaf and myself) ; organic during labour ; and sudden changes from the hor- change of the kidneys, and suppression of urine ; izontal to the sitting or erect postures. manustupratio or inordinate sexual intercourse ; | 45. ii. The efficient causes have been partially and nervous and vascular excitement, or other dis- alluded to. Their nature may be in some meas- eases of the female organs, particularly the ovaria ure inferred, from what has been stated above. and uterus, c. In puerperal females, a loaded It seems evident, from a careful consideration of stomach, or disorder of this organ brought on by the exciting causes, of the character and progress indigestible or unsuitable articles of diet, particu- of the symptoms, and the lesions usually detected larly shell-fish (Clarke) ; rapid or premature on dissection, that convulsions arise from several distension of the uterus during pregnancy ; long pathological states, the grosser or more palpable continued and exhausting labour ; excessive, fre- parts of which only we are enabled to recognise quent, and inefficient pains ; distension of the by the senses ; and that, in addition to these, a urinary bladder during or after parturition ; a certain susceptibility of the nervous system, par- loaded state of the bowels ; excessive depletion ticularly of the cerebro-spinal centres, is requisite, or flooding ; venereal indulgences during the last nevertheless, to the full developement ofthe seiz- two months of utero-gestation. ure. It is extremely probable that convulsions 44. B. The causes which act more directly on the frequently arise from some considerable change cerebro-spinal nervous system are, a,the improper in the state of the circulation within the cranium; exhibition of narcotics, and of spirits and various and that such change may be either active cere- quack medicines, by the lower classes, to infants bral congestion, —in some cases connected with and children ; the admission of a strong light, or general plethora, but in others not thus associated, the impression of loud noises, on very young in- and, even in a few, accompanied with marked fauts ; the continuance or excess of pain ; inju- deficiency of blood, — or local or general ana-- ries received on the head during or subsequent- mia. Moreover, it may be. presumed that the ly to birth ; fear, and sudden fright, or fearful seizure very often is accompanied with but little dreams, b. In adults more especially, and in child- . disturbance of the cerebral circulation or functions ren also, the most common causes of this descrip- ' at its commencement; and that it chiefly depends tion are, the influence of imagination and imita-; upon irritation, in some manner induced in the tion ; the action of the sun's rays on the head ;' organic nerves, and, through them, in the spinal excessive mental labour or anxiety ; extreme I nerves, either partially or generally. We have no bodily sufferings, or long watching ; injuries of the proof of the circulation of even the spinal cord or brain, spinal cord, or nerves ; irritation of nerves j its membranes being disordered in these cases, al- by tumours, abscesses, or by ligatures in opera-! though it may be affected in convulsions, either tions, or injuries of them by wounds and accidents; i primarily or consecutively. In cases which more incipient curvatures of the spine (Wichmann, manifestly proceed from disease within the cra- Bonet) ; the impression of excessive or long; nium, and that of an organic kind, as from tu- continued cold, or of a cold bath; the influence of j mours, abscesses, aqueous effusion, &c, it by no particular odours on some constitutions ; the abuse : means follows that the circulation in the brain is of spirituous liquors; the influence of various ' generally, or even at all, either accelerated or con- poisonous substances on the nervous system, be-' gested, although these lesions may safely be ns- longing to the animal, vegetable, and mineral j sumed in many instances. In some cases even of kingdoms, as nux vomica, and nearly all the class : organic change, the general amount of circulation of narcotics; deleterious gases and metallic fumes, in the head seems, as far as we can judge from as the nitrous oxide, sulphuretted hydrogen, &c, symptoms, much below the natural standard, and the vapours of mercury and lead ; and the irri- yet convulsions will supervene ; whilst in others, tating and inflammatory operation of many mine- signs of inflammatory action ofthe membranes ral preparations and acrid vegetables (see Pois-! are apparent. In many cases, moreover, judging ons); all emotions ofthe mind which excite the ; from the states of pre-existing disease, from what nervous power, and determine the blood to the is known of the operation of various causes, and head, as joy, anger, religious enthusiasm, excessive from the symptoms connected with the head,— desire, &c; or those which greatly depress the ! the weak and small pulsation of the carotids, the an- nervous influence, as well as diminish and derange tecedent fainting or leipothymia, the low temper- the actions of the heart, as fear, terror, anxiety, sad- ature of the scalp, and pale, sunk, and pinched ness, distressing intelligence, frightful dreams, &c; features,—it maybe inferred that the vital endovv- numerous lesions of the encephalon or its mem- ment and the circulation of the brain are momen- branes, particularly effusions of fluid, abscesses, tarily deficient both in activity and in quantity. tumours, ossific deposits, and various other adven- 46. Therefore, while I subscribe to the justice titious formations — indeed, nearly all the organic ! or the aphorism of Hippocrates, that convul- changes described in the articles on the Br a i n,Ep- j sions arise from repletion or inanition as respects ilepsy, and Spinal Cord; also exhaustion from the circulation within the cranium, I would qualify previous disease, particularly by large losses of it, and add, that they often originate thus, but blood (Schroeder) ; inanition and want (Aha- that either of these states forms a part only ofthe tus Lusitanus); the erect position suddenly as- changes that produce them, even when most irre- sumed ; lightning (Gr apkngiesser); abscesses fragably present, — that in many cases the circu- about the neck ; the suppression of eruptions and j lation in the brain is not materially disturbed, discharges, particularly on the head or from the i whilst the spinal nerves are affected either by ears ; the syphilitic poison ; and repulsion of gout or | irritation conveyed to them from the organic ner- rheumatism. c. In puerperal females, many of the | vous system or from the spinal cord itself, more 424 CONVULSIONS —Treatment. frequently the former,—that even when the brain is disordered, general convulsions will arise only when the disorder extends to, or influences the parts more immediately related to, the locomotive actions of the body, as the spinal cord or its mem- branes, — and that we cannot contemplate the origin of convulsions in any way, and leave out of view changes primarily induced in the organic nervous or ganglial system — which changes will more readily produce, than be produced by, dis- ordered circulation in the cerebro-spinal organs. We know that the movements of the feetus in ute- ro are automatic — are the consequence of irrita- tions affecting the organic nerves, extending to the spinal nerves, and, through them, inducing motions of the limbs. To the production of these, any change in the brain or spinal cord is not required ; and a great many cases of convulsion have a sim- ilar origin, the difference being only as to the grade of irritation relatively to the susceptibility of the patient, and to the effect produced. As to the opin- ion entertained by the older humoral pathologists, from Galen to Willis, that a morbid state of the fluids also occasion convulsions, some impor- tance may be attached to it. We do not, howev- er, find convulsions much more prevalent when the blood is manifestly morbid, unless in those cases where a previous, and, at least, an equal change has been produced upon either the organic, or the cerebro-spinal nervous systems. The convulsive movements that occur in common and pestilential cholera, in malignant fevers, in rabidity, and in organic lesions of the kidneys, with suppression of urine, are proofs of this position. That, however, a morbid state of the blood sometimes constitutes a concurrent proximate cause of certain diseases, in which convulsions either incidentally occur, or form a part of the circle of advanced phenomena or effects, may be admitted, in the absence of suf- ficient evidence to the contrary ; for, when the blood itself is primarily changed, we may with reason infer that convulsions will sometimes man- ifest themselves as a part of the effects thereby produced upon the nervous system ; but I believe that convulsions seldom arise from this cause only. 47. VI. Treatment.—i. Of Convul- sions generally. The means of cure hr all cases of convulsions, are directed with the view, 1st, of subduing the fit, when called to a patient labouring under it; and 2d, of preventing its re- turn. A. To subdue the paroxysm, it is necessary to have prompt recourse to active measures : but these should not be employed indiscriminately, and without taking quick cognizance ofthe cause, and the existing pathological states, as far as they may be readily ascertained. The circum- stances principally to be observed by the prac- titioner, are the presence or absence of active cerebral congestion and sopor, the existence of general vascular plethora, the temperature of the head and lower extremities, the pulsation of the carotids, and the character of the countenance and of the convulsive motions, These may be ascertained in a very few moments, and at the same time that enquiry is being made into the cause of the seizure, and the peculiarities of the case, as respects the age, constitution and habits of the patient. 48. a. A person in convulsions ought to be placed so as to breathe an open cool air, and to facilitate the restoration of one of the earliest functions disordered ; and no more attendants be permitted than are absolutely necessary. Those susceptible of, and liable to, nervous affections, should not be allowed to remain in the same room, or even in the same house, with the patient while in the fit.—b. When the habit of body and the ce- rebral symptoms, &c. present no contraindication, general or local blood-letting, or both, should be resorted to, and carried as far as circumstances may warrant. When the cerebral congestion is very active and extreme, the jugular vein may be opened ; but the depletion should never be pushed too far, with an expectation of stopping the convulsions; nor should it ever be carried to deliquium, for the system may be thereby injur- ed, and a return or immediate recurrence of the seizure be favoured by it. Revulsive bleedings, as from the feet while they are held in warm water, may be preferred, if the seizure be con- nected with difficult or suppressed menstruation. Local depletions, in other instances, are best practised by cupping behind the ears, particularly in children, and upon the nape of the neck, and between the shoulders. In other instances, when the brain is not affected, — when the head is cool and the carotids are pulsating neither more fully nor more strongly than natural, — the state of the spinal column should be carefully enquired after, by pressing a warm sponge along and be- tween the vertebras; and the abdominal regions and the evacuations ought to be daily examined. If signs of inflammatory action exist in either of these quarters, particularly if they be connected with plethora, general and local depletion — pre- ferably the latter, when plethora is wanting — should be resorted to. But there are many cases, especially those produced by copious evacua- tions, by inanition, and the exhaustion of painful and protracted disease, where depletion would be most injurious ; and there are intermediate grades, in some of which local blood-letting might be either beneficial or of no advantage, according as the case approaches nearer to the one extreme than the other. When the convul- sions are partial, then local depletions are to be preferred. 49. c. There are certain states of convulsion, in which it at first seems difficult to determine as to the propriety of resorting to blood-letting in any way. One of the most common of these, is that characterised by a pale and somewhat sunk countenance, and by tonic convulsions. This appearance may mislead the practitioner, if he do not examine carefully into other symptoms. If, in addition to these, the carotids pulsate strongly, the temperature of the head be increased, the pupils contracted, and the brows knit, we should suspect inflammatory irritation of the arachnoid — notwithstanding the absence of all plethoric or sthenic signs — and resort to depletions, and the means about to be noticed. (See also Brain — Treatment of Inflammation of its Membranes.) Another state sometimes occurs, with very violent general convulsions ; a broad, open, throbbing, and frequent pulse ; pale countenance and sur- face, often with sopor or delirium, or both. These symptoms may mislead the inexperienced, and depletions — occasionally the very cause of the mischief—may be improperly employed to relieve it. But when the history and symptoms of the case are more minutely examined, we shall CONVULSIONS—Treatment. 425 find precisely that state which is described in the article Blood (§ 53—60.), and that, instead of congestion, there is general anosmia, with cerebral irritation, combining with the physical condition of the brain, to determine to it the greater part ofthe blood in the system. In other cases, there is apparently anaemia of the brain, at least at the commencement of the fit, and either conscious- ness is retained, or it is lost from the state of the cerebral circulation. These forms of seizure may be called anamial; inasmuch as they arise either from a general deficiency of blood, or from anaemia of the brain, although the vessels of this organ soon become partially congested from the impeded respiration, and interrupted circulation through the lungs and heart, at the commence- ment of the paroxysm. In these, a very opposite treatment to depletion is required. The obser- vations of Latham, Hall, Gooch, North, and the author, on this important practical topic, have, however, induced the practitioners of the present day to resort to blood-letting in convul- sions in a much more discriminating manner than formerly. 50. d. Next in importance is the judicious employment of cold and heat — of cold in the form of cold affusion on the head and spine, and of heat in that of warm bath or semicupium. An appropriate use of these is more generally serviceable, and often less dangerous, than deple- tions. The cold affusion to the head, and, in cases where there seems to be irritation of the spinal envelopes, along the vertebras; and cold, in the form of epithems, evaporating lotions, pounded ice to the head, when convulsions are produced by inflammatory action in the brain or spinal cord; are among the chief forms in which this agent is admissible. The cold bath, although advised by Currie, Loeffler, Beaumes, Baynard, and others, is, in my'opinion, a haz- ardous experiment during the paroxysm, and sometimes even in the interval. The warm bath, or semicupium, is frequently of much service, and particularly when there is either high nervous irritation, a dry harsh skin, or cold surface or extremities; and my experience accords with that of Heilbronn,Henrischen, Doerner, and Stutz, respecting the propriety of adding a quan- tity of the fixed alkalies, or their sub-carbonates, to the water. When the head is much affected, either by inflammatory irritation of the mem- branes or active congestion, cold affusion, or cold epithems or lotions, may be employed whilst the patient is in the warm bath, or is using the semi- cupium or pediluvium. In slight cases of convul- sion, the aspersion merely of cold water over the face, head, or neck, is often of service. Large draughts of cold water were recommended by Hoffmann; and they, as well as water ices, and cold clysters, have been several times employed by myself with much benefit. Cold injections are praised by Langhans and Marx. Cold affusion, cold aspersion, and cold epithems, have been pre- scribed by Currie, Dupont, Doemling, and others; but the two former were usually directed by them to the surface generally, instead of to the head,—a circumstance which accounts for the dis- use into which it had fallen, when the practice was revived some years since by the author. 51. e. If the patient can swallow, and the mus- cles of the jaw are not much affected, cathartic \ 36* medicines should be given by the mouth; but in most instances it will be preferable to delay them until after the seizure. But I have under no circumstances been prevented from directing a cathartic and antispasmodic enema to be thrown up. Either of F. 131—136. may be employed and repeated, if it be not retained, as is frequently the case. When purgatives can be taken, a full dose of calomel, either alone or with jalap, followed soon afterwards by an active cathartic draught or mixture, consisting of senna, tincture of jalap, carminatives, and antispasmodics, par- ticularly the preparations of ammonia and cam- phor, is, upon the whole, the most appropriate. But under every circumstance the operation of these should be promoted by enemata. When we wish to produce an active derivation from the head and spine, as well as alvine evacuations, the croton oil, elaterium, ol. terebinthinte, &c, may be employed. But, where the object is chiefly to bring away offending secretions, and other causes of irritation, and at the same time to allay disordered action in the prima via, calo- mel, jalap, rhubarb, and senna, are, perhaps, the best purgatives we can employ. Their ac- tion will, in all instances, be much increased, and a marked change be often produced in the dis- ease, by an occasional dose of the ol. terebinth. and ol. ricini, assisted by the enemata already- recommended. If convulsions arise from worms in the intestines, anthelmintic purgatives, during both the paroxysms and interval, should not be omitted. Calomel may generally, with due address, be exhibited during the fit, and subse- quently other anthelmintics may be given. Be r- gius and Barton prefer the Spigelia Mary- landica in such cases; but the other means adopt- ed in verminous disorders may be employed ac- cording to circumstances. Emetics are some- times of service, when exhibited upon the first intimation of the seizure, particularly if there be indications of gastric irritation from offending or noxious ingesta, and acid sordes, or if the par- oxysms assume a periodic form. Schenck, ScHJEFFER, RlGEL, CoNRADI, HUFELAND, and Smith, advise them chiefly in such cases. Thom recommends them to be exhibited to the nurse, when convulsions attack infants. 52. /. Antispasmodics are sometimes produc- tive of instant relief, when employed in large doses, early in or upon the first intimation of the fit, particularly when it arises from debility, or irritation in the prima via, or morbid nervous susceptibility; but they seldom can be taken in the paroxysm, unless it be slight, or arise from exhausting causes, and then they are oft- en of great service, especially if they be com- bined with restoratives and opium, conium, or hyoscyamus. The aethers, camphor, musk, assa- fcetida, valerian, the preparations of ammonia, bismuth, zinc, &c, are amongst the most effica- cious in these cases. When inflammatory irri- tation seems to exist in the membranes of the brain, they are obviously contra-indicated; but congestion of a passive nature, especially when the pulsations of the carotids are not strong or hard, and the temperature of the head is not in- creased, should be no reason for omitting them. An extensive experience, however, of the effects of the spirit of turpentine in convulsive diseases, has convinced me that it is the most efficacious 426 CONVULSIONS — Treatment. and the safest antispasmodic that can be em- ployed for their removal. If it be given in doses so large as to act as a purgative, and seldom or rarely repeated, it is remarkably beneficial in the cases which arise from cerebral congestion or irritation; but when the seizure is connected with anaemia, or exhausted vital power of the brain, or general debility, it ought to be exhibited in small doses, often repeated, and be combined with restoratives and aromatics. MichaSlis, Schmalz, Albers, Hargens, Conkadi, Heilbronn, and Wiedemann, strenuously advise, in all convulsive affections, large doses of the fixed alkalies, either alone or alternated with opium. Of the antispasmodic action of these sub- stances, as well as of their soothing operation on the digestive mucous suiface, there can be no doubt. If the convulsions arise not primarily from organic disease within the head, I believe that opium thus combined will often be of great service, and particularly when they proceed from the nervous susceptibility and muscular irrita- bility often connected with debility, exhaustion, and excessive evacuations. The good effects of alkalies in disorders of the digestive functions, and the frequent origin of convulsions in these disorders, or their connection with them, must be admitted. Moreover, the alkalies, combined with opium, or hyoscyamus, conium, or belladonna, and ipecacuanha, &c, are among the surest means we possess of allaying irritations affecting the nervous system. Stutz, Bruninghausen, Doerner, and Henrischen, employ them also in fomentations to the abdomen, in baths, and in enemata; they using an ounce of the caustic alkali to about a quart of water for the foment- ation. I have prescribed the alkalies frequently and largely in the convulsions of children with much benefit. Other antispasmodics, and differ- ent modes of applying those in common use, have been adopted by various writers; but as these are better suited to fulfil the second intention of cure, I will notice them hereafter. 53. g. Anodynes and narcotics are often of the most essential benefit, when appropriately prescribed and combined, or preceded by other suitable remedies. They are seldom of service in the convulsions proceeding from active con- gestion and organic disease within the head; but when the affection is connected with irritation in other parts, or when the disorder of the brain or its membranes consists chiefly of irritation, they should not be omitted. They are seldom of use, — sometimes even injurious, in puerperal con- vulsions, and ought to be given with caution to very young children. In cases where the pro- priety of exhibiting them is doubtful, any un- pleasant operation will be prevented by com- bining them with camphor, or with aromatic tinctures or spirits. I have derived great advan- tage from employing them externally, selecting for this purpose opium or belladonna, in the form of embrocation or plaster — generally the former—applied during the paroxysm, over the epigastrium and abdomen, and combining them with rubefacient and stimulating substances, as camphor, ammonia, Cayenne pepper, &c, or with any of the liniments or plasters in the Pharmaco- poeias, or in the Appendix, suited to the case (F 108. 297. 307.). The practitioner should, how- ever, be cautious in the employment of the more I active of these narcotics, even externally, as very dangerous effects have resulted from them. Dr. Thackeray found that tobacco steeped in brandy, and placed over the epigastrium, pro- duced a most dangerous state of vital depres- sion. 54. h. Revulsants, and counter-irritants are of great service in all states of the disease ac- companied with cerebral congestion, or irritation of the membranes of the brain or spinal cord. Sinapisms to the extremities; rubefacient lini- ments (F. 299. 305.), and embrocations, particu- larly those with Cayenne pepper, horseradish, &c; the turpentine fomentation; the immersion of the hands and feet, or the lower extremities, in a salt and mustard bath; dry-cupping on the nape ofthe neck, occiput, between the shoulders, or along the spine; are the preferable means of this description. These will often, of themselves, shorten the seizure; but if they fail of having this effect, after slight redness of the skin has been produced, advantage will frequently arise from placing over it a liniment or embrocation contain- ing opium, or the acetate or muriate of morphine, or any of the other anodynes in use, either of which may also be employed in the form of plaster, combined with antispasmodics, &c. 55. i. Convulsions arising from exhaustion, hamorrhagy, inanition, &c. require restoratives, stimulants, &c. in small quantity, and frequently exhibited, with strict attention to the temperature of the head, which should be lowered whenever it rises above natural, by cold applications. (See Abstinence—Treatment of; and Blood—De- ficiency of, § 48, 49.) The combination of hy- oscyamus with gentle tonics; the preparations of opium, conium, or hop, with those of ammonia and camphor; the preparations of valerian or assa- fcetida with the sub-carbonates of the alkalies; the muriate or acetate of morphine, with the aromatic spirits and tonic tinctures; and emolli- ent and antispasmodic enemata, are most appro- priate to those cases. In these, as well as in the more clonic forms of convulsions, the preparations oftVora, particularly the ammonia-tar trite of iron * alone or combined with hyoscyamus, will be of much service. The occurrence of these affec- tions towards the close of febrile or acute diseases (§ 13. 33.), particularly when they manifest signs of greatly depressed vital power, requires nearly similar remedies, or such as exert a still more stimulant and antispasmodic operation. The sul- phate of quinine, with hyoscyamus and camphor; the decoction of cinchona, or infusion of arnica or serpentaria, with liquor ammonite acetatis and aether; warm negus, with aromatics; and stimula- ting embrocations or liniments over the epigastrium, may be resorted to in these cases. If convulsions occur in the course, or towards the crisis of fevers, the treatment must altogether depend upon the state of the cerebral functions, and the disposi- tion that may be evinced towards spontaneous or critical evacuations, to the promotion of which our means should be directed; taking care, at the same time, to guard the head from mischief, by employing local depletions, cold affusion, cold * A most valuable and beautiful preparation very latelv in- | traduced by .Mr. AlKEX ; and from its very pleasant, sweet I taste—reicinblin* that of liquorice—eMreinelv well adapled for children. Dose from half a grain to five or six "rains CONVULSIONS — Tre atm ent. 427 epithems, and internal and external revulsants, if it exhibit appearances of congestion or inflam- matory irritation; and warm diaphoretics, gentle tonics, and antispasmodics, and other means of supporting the manifestations of vital power in the nervous systems, and of promoting the se- creting and excreting functions. 56. k. When convulsions are produced by narcotic or acro-narcotic poisons, the immediate evacuation of the noxious substance by the stom- ach pump, or by emetics, the cold affusion on the head, followed by stimulants and antispasmodics, green tea, or coffee, stimulating enemata, and frictions of the surface, are chiefly to be depended upon. If they proceed from the fumes of lead or mercury, antispasmodics, tonics, stimulants, strychnine, or nux vomica, with purgatives, are most serviceable, particularly when assisted by the warm bath, and by frictions of the surface afterwards with stimulating liniments. Serpen- taria, the arnica montana, and camphor, are often beneficial remedies in those cases. 57. /. Convulsions either of a partial, a gene- ral, or irregular and anomalous form, arising from irritation of the female organs, require local de- pletions, cooling aperients, and antispasmodics ; the internal use of soda and nitre ; cold clysters; the cold affusion or aspersion ; the tepid bath, or the shower bath, while standing in warm water ; and draughts of cold water. In a case of general convulsions arising from inflammatory irritation about the neck of the uterus, with leucorrhoea, I directed the patient to take a lemon ice, or to drink as much as she could of cold spring water upon the intimation of the seizure; and she has hitherto done so with uniform benefit. Having seen her during the paroxysm, and perceiving that she retained her consciousness, cold water was given, and swallowed with some difficulty. The benefit was almost instantaneous. If the convul- sions be connected with difficult, or suppressed menstruation, general or local depletions, and af- terwards the warm general or hip bath, full doses of the preparations of assafcetida and ammonia, particularly the spir. ammon. succin., the spir. amnion, foetid., or the spirit, guaiaci ammon., also camphor and the boracic acid, or the sub-borate of soda, have proved the most effectual remedies in my practice. But the means already advised to prevent congestion or irritation within the cra- nium should be resorted to upon the first intima- tion of the fit. Bleeding by leeches from the inside tops of the thighs are indicated in these cases; but it can be practised only in the interval. 58. B. The prevention of the paroxysms is to be attempted, with due attention to the remote and proximate causes, the former of which should be removed as completely as possible, and the latter energetically but cautiously combated ; re- collecting always that convulsions are the outward manifestations of certain lesions of the nervous, acting on the muscular, functions ; and that our knowledge of such lesions extends not beyond the inference that they consist of depression or exhaustion of vital power, or of irritation, or of congestion, and, occasionally, of two or all these states conjoined, some one of them predominating over the others, and being associated with addi- tional, and even opposite changes. Many ofthe means already noticed are requisite in the inter- vals, as well as in the paroxysm, especially when judiciously modified to the circumstances of the case. a. Vascular depletion is often required, and in similar states of disease to those already pointed out; but it should be directed with great circumspection, and to a moderate extent, unless the signs of active cerebral congestion, or of in- flammatory irritation, or of general plethora, be unequivocal. If, however, opposite states obtain, viz. exhaustion, and deficiency of blood, very different means must be employed. In most in- stances of convulsions, the quantity of the cir- culating fluid is not so frequently either much above or much below the usual proportion, as the influence,—vital or nervous, or by whatever name it may be called,—by which the distribution of blood throughout the frame is regulated, is dis- turbed so as to determine or attract a larger proportion to one part than to another. In no peculiarity of constitution is the old doctrine, " ubi irritatio, ibi fluxus," more frequently il- lustrated than in that in which convulsive com- plaints are most commonly observed ; and, in these diseases, we are continually finding fluxion one of the earliest consequences of irritation. I have long thought, and on several occasions con- tended, that, in the common routine of practice, blood-letting is too indiscriminately employed to remove such determinations or irregular distri- bution ofthe circulating mass; and that, although it sometimes succeeds, owing to its being asso- ciated with other and more appropriate means ; it often fails, or even augments the mischief, by increasing the debility and susceptibility of im- pressions from exciting or irritating causes, that generally characterises the nervous system of persons subject to convulsive seizures. Therefore, when the abstraction of blood is really necessary, it should be performed in such a manner, and be accompanied with, or followed by, such medi- cines as are most likely to equalise the circulation; and it is chiefly in this way that many of those about to be noticed are productive of any service in the disease. Local depletions, in moderate quantity, repeated according to circumstances,— from the nape of the neck or occiput, when the head is affected, and along the spine, if irritation ofthe membranes of the cord is suspected,—and assisted by such other means as the case may require, are more generally applicable in the in- tervals than large venacsections. 59. b. There are few remedies more beneficial in convulsions than mild purgatives, or aperients, taken daily, and conjoined with tonics and anti- spasmodics. Active purgation, if long persisted in, will lower the vital energy, and thereby favour the return of the fits ; but the more deobstruent and eccoprotic medicines of this class, particularly when thus combined, may be given, so as to procure two or three faeculent evacuations daily. Thus prescribed, purgatives will increase the patient's strength, and often procure a prolonged immunity from the seizures. Aloes, with quinine or iron, and camphor; or with myrrh, assafoetida, the tonic extracts, &c, and occasionally with blue pill, or with extract of hop, hyoscyamus, or conium (F. 450—471.); senna, with gentian or bark, the preparations of ammonia, asther, &c. , (F. 266. 872.); and either of these with the liquor potassa', or the alkaline sub-carbonates, are most to be relied on. But advantage will accrue from changing the forms and mode of 428 CONVULSIONS —Treatment. combination and exhibition of purgatives from time to time, and from assisting them with such other remedies as the special characters of the case may require. A full dose of calomel, fol- lowed by the turpentine draught (§ 51.), may occasionally be resorted to ; and enemata will also be of service. In every instance, the ap- pearance and quantity of the discharges, intestinal and urinary, should be examined ; and when the sensibility of the bowels seems to be increased, oleaginous or mild purgatives, with alkalies and hyoscyamus, ought to be preferred. Morgagni recommended, as an aperient, two ounces of the ol. amygdal. dulc. to he taken every night,— a medicine well suited to cases of this descrip- tion; but the ol. olivae, ol. lini, or the ol. ricini, and even the cod or tusk-liver oil, may also be thus used. Where we find the tongue much loaded or furred, active purgatives, particularly full doses of calomel, with cathartic extracts, &c, are especially required in the first instance ; and mild laxatives, with tonics and antispasmodics, subsequently. 60. c. In many cases, particularly when the convulsions proceed from inflammatory irritation of the membranes of. the brain or spinal cord, bleeding and purgatives will be advantageously followed by an alterative course of mercury, pushed as far as to affect the gums, and by low diet. Much tact is, however, required in deter- mining as to the cases and period of treatment, in which this practice should be adopted. It is admissible only when the disease proceeds from the pathological state just mentioned, or is con- nected with a syphilitic taint, or has originated in the abuse of spirituous liquors, &c, and the too great indulgence of the appetite for food; and it will be injurious in cases of exhaustion, unless combined with active tonics and nutritious diet. Plummer's pill, the hydrarg. cum creta, or the blue pill, may be given, in small and frequently repeated doses (from half a grain to a grain of the last, thrice a day), with anodynes, as conium, hyoscyamus, ext. humuli, and small quantities of camphor. In more doubtful cases, or when we suspect that effusion of fluid has supervened upon disease of the membranes, the corrosive sublimate may be prescribed, either in the compound tinc- ture of cinchona, or with the compound decoction of sarsaparilla, or diuretic infusions or spirits, ac- cording to the symptoms and circumstances of the case. 61. d. Various antispasmodics and tonics, be- sides those already adduced, have been directed, chiefly in the intervals; and others in more com- mon use have been employed in novel forms. The cuprum ammoniatum has been prescribed by Home, Duncan, and Bianchi; the nitrate of silver, by Powell and Hall ; the animal oil of dippel, by Herz ; the oil of rue, by Abra- hamson ; cajeput oil, by Thunberg ; the misletoe, by Colbatch and Home ; and the preparations of zinc, by Goodsir, Bell, Beaumes, Duguid, White, and many more. Krebs has advised the trunk ofthe body to be enveloped in camphorated cloths, if we suspect convulsions to arise from intestinal worms. War- burg has recommended musk in large doses, combined with nitre; and Sidren and Frank- furter the internal use of nux vomica, ap- parently upon the principle of Hahnemann, that similes similibus curantur. Ca z a l s directed about half a drachm of bismuth to be taken in the twenty-four hours, with castor. Vogel thought that benefit has been derived from the flowers of the white lily; and Baker, Pallas, Thom, and Home, entertained a similar opinion as to the effect of the cardamine and anemone pratensis, artemisia, and the radix paonia. Digitalis was employed by Shaal ; emollients, by Kortum ; ipecacuanha, by Plenk; and various narcotics by the majority of authors, chiefly in combination with stimulating antispasmodics, in order to en- sure their effect. Of the substances now enu- merated, the most deserving of notice seem to be the preparations of zinc, bismuth, musk, and the misletoe. Of the former of these I have had much experience; but, upon the whole, they are inferior to camphor, valerian, assafcetida, am- monia, and the athers, judiciously combined and assisted by other remedies, particularly when taken upon the first intimation of the seizure. If the disease be the result of exhaustion or inanition, and particularly if it assume a periodic form, the preparations of cinchona, the sulphate of qui- nine, iron (Buechner, Reidlin, Loeffler, Hutchinson, Elliotson, &c), especially the sub-carbonate in large doses, or the ammonia- tartrite, and the arsenical solution with potash, are the most appropriate remedies, either alone, or with aperients, or antispasmodics, or anodynes and- narcotics, according to the peculiarities of the case. I have, for many years, employed the infusion of green tea, if the convulsions arise not from inflammatory action within the head, and generally with great success. The good effects ofthe medicines now mentioned, when they pro- duce any, are to be imputed chiefly to their in- fluence in overcoming the susceptibility of the nervous system, giving tone and energy to the moving fibres, and increasing the secreting and excreting functions. In order to ensure their effects, they should be varied and changed from time to time, and differently combined with one another. 62. e. There is scarcely any anodyne or nar- cotic substance, that has not been employed in convulsions. The preparations of opium, of poppy, of belladonna (Stoll, Bergius, &c), of conium (Stoerck, &c), of hyoscyamus, stramonium (Stoerck, Sidren, Waden- berg, &c), and tobacco (Riverius, Currie, Thackeray, Haygarth, &c), have been prescribed in various modes and states of com- bination—with aperients, or stimulants, or tonics, &c.'—internally and externally—in enemata, and in suppositories. The most successful modes of exhibiting either of these substances, in convul- sions, are internally with camphor, assafcetida, or the sub-carbonates of the alkalies ; and ex- ternally, either in the form of liniment, embro- cation, or plaster on the epigastrium, or along the spine, combined with the substances just men- tioned, or with any of the liniments or plasters in the Pharmacopoeias, or in the Appendix. 63. /. Various derivatives or revulsants have been used in the intervals, as well as in the parox- ysm. Blisters may be employed; but they are not so generally appropriate as the production of a number of pustules by meais ofthe tartar emetic ointment or solution (F. 749.), or of the croton oil, rubbed upon the inside of the thighs, or on the epi- CONVULSIONS — Treatment. 429 gastrium, or along the spine. Several writers have directed blisters to the head ; but the pathological states admitting of their application in this situa- tion are comparatively rare, and require the most intimate knowledge of disease, and appreciation of symptoms for their recognition. It is only when the vital energy of the brain is profoundly sunk or exhausted, and not suppressed by con- gestion, or active determination of blood, or the pressure of effused fluids, or adventitious forma- tions, that a blister on the scalp can be of any service. When applied to the nape of the neck, or behind the ears, or between the shoulders, they are seldom of much use, unless kept open for some time. The pea or mezereon issue in the insides of the thighs, and antispasmodic liniments or plasters along the spine, or over the epigas- trium, are sometimes useful auxiliaries. 64. g. Electricity and galvanism have been proposed in convulsions ; but I agree with Gra- pengiesser in thinking them hazardous, h. Cold bathing has been very commonly recom- mended ; but it requires discrimination. It will benefit chiefly those cases which are unconnected with organic lesion, and which depend upon gen- eral debility and susceptibility of the nervous sys- tem. In these the salt water bath should be pre- ferred, and its use commenced in the tepid state, the temperature of successive baths being gradu- ally reduced. The cold shower bath is more gen- erally applicable, particularly upon getting out of bed ; and when it cannot be resorted to, the pa- tient ought to sponge or bathe the whole head with cold water every morning. The strictest attention should, at the same time, be paid to the state of the digestive functions, and of the alvine evacuations. Cutaneous excretion also ought to be promoted ; for, not only are all the other func- tions thereby improved, but contingent disturb- ance of any of them, and the irregular distribution of blood, in which convulsions often originate, are less likely to take place whilst the circulation in the surfaces is uninterrupted. It is probably from this mode of operation, as much as from their an- tispasmodic action, tliat service has been obtained from several diaphoretics, particularly the kermes mineral, and other antimonials, recommended by Unzer, Gulbrand, Struve, and Harder. i. Warm baths, hip baths, semicupium, &c, when any advantage is derived from them in the intervals, act chiefly in this manner. But I be- lieve that they will seldom be productive of much benefit, unless in cases connected with suppressed eruptions, or the exanthemata, or with irregular or difficult menstruation, and with disorders of the digestive canal in children ; and in these the effects of warm baths will be much enhanced by stimulating or irritating frictions of the surface im- mediately upon coming out of them. 65. k. The almost epidemic prevalence of con- vulsions during states of religious enthusiasm and mental excitement, as shown by the occurrences already referred to (§ 16—18.), and by the seiz- ures that affected many of the Jansenists who made pilgrimages to the grave of Deacon Paris, during the persecution of this sect in 1724, as well as by the convulsions at one time so uncom- monly frequent in the Methodist meetings in va- rious parts of Cornwall, as described by Mr. Cor- nish, should lead the physician to recommend I j such moral regimen as the circumstances of par- ticular cases may seem to require. The above facts, as well as the circumstance recorded by Boerhaave, of almost all the girls and boys in the hospijtal of Haerlem being seized by convul- sions from their seeing a girl who had been frightened into them, will alone show the import- ance of separating the affected from females or other susceptible persons. There can be no doubt that simple hysterica] or epileptic convul- sions occurring in one among a crowd of females will often occasion convulsive seizures in others, particularly in those of a delicate frame and nervous temperament, although they may have never previously been similarly disorded. I have met with such an occurrence more than once. Indeed, the number of these attacks on the public occasions referred to, is a sufficient proof both of the influence of the mind in producing thein, and of the propriety of the immediate separation of a person thus seized, as was judiciously and suc- cessfully practised by Dr. Haygarth. The propensity to become affected by convulsions from seeing one in a fit appears to have been well known to the Romans, and from its fre- quency on occasions of public assembly, as much as from other considerations, they obtained the name of Morbus Comitialis, which has been un- derstood as applying only to epilepsy, but which I believe had a much wider signification, and comprised all convulsive seizures. That fear or terror will not only occasion convulsions, but also remove them, or at least often prevent their accession, might be inferred a priori, even if it were not proved by experience. The actual cau- tery employed by Boerhaave soon put a stop to them in the hospital at Haerlem : and their prevalence in certain of the Zetland Isles was said to have been arrested by the unceremonious ducking inflicted upon two or three of those af- fected ; the fear of being treated in the same way having effectually prevented others from being attacked. 66. I. Regimen.—The circumstance of those convulsions which arise in crowded assemblies from mental excitement and religious impressions being often ushered in by faintings, and signs of congestion of the cavities of the heart, of the large vessels, of the lungs, &.c, should suggest the avoidance, by susceptible persons, of warm and crowded assemblies, where the foul and moist air conspires with moral emotions in de- pressing the nervous power, and in favouring congestions of the heart's cavities and large ves- sels ; as well as the propriety of removal to the open air, and of having recourse to antispasmodic stimulants upon the approach of the sinking and oppression at the epigastrium and prsecordia, which often usher in the fit. The importance of administering to the mental affections and emo- tions—of relieving as much as possible anxiety or despondency—ought to be pointed out to those concerned, and the patient encouraged strenuous- ly to resist the invasion of the paroxysm. Per- sons subject to convulsions should never receive indulgence on account of them, but be made to know that they may be warded off, by not yield- ing to the feelings which often favour or produce them. Regular hours of rest, of recreation, and of eating, should be adopted ; sedentary habits 430 CONVULSIONS OF CHILDREN —Treatment. avoided ; exercise in the open air taken daily, and both the mind and body duly occupied with- out fatiguing either the one or the other. In some cases, depending upon disease of the brain or its membranes, the appetite is morbidly in- creased, and much more food is taken than is requisite to the Wants of the frame. Others are connected with indulgence in spirituous liquors. It is almost unnecessary to add, that unless these excesses be guarded against, and the diet and regimen duly regulated, medical treatment will not be efficacious. 67. ii. Treatment of Convulsions in In- fants and Children.—A. Many ofthe meas- ures already recommended in the paroxysm may be also employed in this class of patients ; but in a suitable form, and with strict reference to exist- ing pathological states. Where we observe the indications of cerebral irritation and congestion (§ 21, 24.), cupping on the nape ofthe neck, be- hind the ears or occiput; the warm bath or semi- cupium, with cold affusion; cold epithems, &c, on the head, the hair having been removed or cut close ; a dose of calomel, or of calomel and scam- mony if the child can swallow, and a cathartic and antispasmodic injection ; are suitable reme- dies. The jugular vein may be opened in robust or well-grown children ; but care should be taken not to bleed them to syncope, as a return of the convulsions may be thereby occasioned. Children ought to be blooded with great caution during a fit; for although I cannot go so far as to say, with Harris, that it is dangerous to bleed in the paroxysm, yet I believe that the convulsions will occasion a hurtful quantity of blood to flow with- out any immediate effect, if the evacuation be pushed with the view either of subduing them, or inducing syncope. It is as improper as it is futile to lay down any rules as to the extent to which depletion may be carried. It is obvious, that when the child is plethoric, the head large and hot, the eyes suffused and prominent, the carotids throbbing, &c, it may be practised freely, even in the fit, without risk. 68. a. Convulsions sometimes proceed from the nature of the ingesta. If this be the case, and if the abdomen be distended, an emetic should be exhibited without delay. Seizures not infrequent- ly arise during the period of dentition, from in- digestible or irritating substances in the prima via, and in such cases often commence in simple flatulent colic. After an emetic has been exhibit- ed, or even independently of it, a purgative, if it can be taken, should be prescribed, along with carminatives or antispasmodics, and a clyster thrown up. In cases of this description, I have found a dose of calomel, with soda or potash, or the hydrarg. cum creta, followed by either of the following mixtures, a carminative enema, and friction with an antispasmodic liniment on the ab- domen or spine, the most successful means :__ No. 158. K Magnes. Usta; Jss. ; Saccliari Albi V)j.; Olei Anisi It] v.; tere bene simul, et adde Auuie Foeni'culi Dul. gjss.; Spirit. Amnion. Foetid. TT) xv. j Pulv. Khei xvj.; Syrup Papaveris ^ij. Fiat Mist., cuius capiat coch. unum, vel duo n unma, teitiis vel quartis horis. No. 159. K Olei Ricini ?, iij.— - J5., Olei Terebinth. SJ-— 3'.l-i tere cum Vitel. Ovi, et adde Aq. Funiculi 5ss. — ^j.; Syrup. Papaveris et Syrup. Rosa- aa ^ij. M. Fiat Mist., cujus suiuat partem quailam vel leitiain, teitiis vel quartis horis. 69. b. Clysters, containing valerian, assafcetida, or a terebinthinate substance, triturated with the yolk of egg, and any of the carminative waters, to which oleum ricini or ol. olivae may be some- times added, are the most appropriate to those cases. Much discrimination is required as to the choice and continuance of cold applications to the head, particularly if the warm bath or semicupium be simultaneously resorted to. These combined means should never be left to the discretion of a nurse, at least without the personal superintend- ence of the practitioner in the first instance. In general, as soon as the temperature is reduced, and the features become pale and shrunk, or the fontanelle (if unclosed) level, or at all depressed, whether the convulsions, or sopor, when present, disappear or not, the application of cold to the head, in any form, should be left off, to be again resumed when the symptoms requiring it recur. 70. c. During dentition, or even before the teeth approach the margin of the gums, free scarifications ought to be practised, and repeated as soon as the scarified parts cicatrise, otherwise the obstacle to the passage of the teeth will be thereby increased. If general or cerebral ple- thora be not present, or has been removed, und the bowels have been fully evacuated, any of the alkaline or earthy sub-carbonates, with aqua foeniculi, or aq. pimentae, Eether, camphor, &.c, with the extract of conium or hyoscyamus, or the syrup of poppies, or small doses of laudanum, may be prescribed with the view of soothing the susceptibility and irritability of the frame at this period. Form. 347. 442. 865. have been order- ed by me very generally in such cases, at the Infirmary for Children. In very young infants, convulsions may be occasioned solely by the re- tention and accumulation of acid and acrid sordes in the prima via. These are readily removed by a dose of calomel, followed by oleaginous or other purgatives, the semicupium, and clysters. Tissot and Sharp state that they have been pro- duced by the retention of the menconium owing to spasmodic stricture of the sphincter ani. This is, however, a rare occurrence. Emollients, olea- ginous laxatives, the semicupium, clysters, and anodyne liniments, are appropriate to such cases. It has been repeatedly contended for by most of the older, although denied by many modern writers, that the anxieties, the more violent pas- sions, and the irregularities of the nurse, may change her milk so as to disorder the digestive organs, and thereby give rise to convulsions in delicate infants. This fact is established by re- peated observation. I perfectly agree with Mr. North, who has taken a very judicious view of this subject, that it should never be overlooked. The obvious remedy in such cases is to change the nurse ; and, if this cannot be done, to re- move as far as may be the cause of disorder ; to promote her digestive and excreting functions ; to tranquillise or subdue any mental disturbance or febrile action that may affect the state of the milk, and to prescribe for the infant aperients with soda or ammonia, or other antacids and anti- spasmodics. I have often employed the oxyde of zinc or of bismuth with soda, or the pulvis creta? compos., and either the pulvis ipecacuanha; comp. or small doses of conium or hyoscyamus with much advantage in these cases; or simply the sub- borate of soda in camphor mixture or aq. fcenicuh. CONVULSIONS OF CHILDREN —Treatment. 431 71. d. The cold bath is a very doubtful re- medy in the seizure: it is much less efficacious than the cold affusion on the head ; and, when the child retains its consciousness, it even some- times aggravates the mischief. Of the recom- mendation of Dr. Bronn, to employ gradually increased pressure on the epigastrium during the fit, I have had no experience: it, however, de- serves a trial. 72. e. Of the use of blisters in convulsions, as well as of alkaline rubefacients, as the liquor am- monae, no favourable idea should be entertained, as they require the utmost discrimination, and are far from being unattended by risk : for, although they will often cut short the paroxysm, yet they will also occasionally produce so violent irritation and inflammation as to be rapidly followed by sphacelation of the integuments. This is liable to happen particularly in ill or insufficiently fed, in delicate and irritable children; in those of a gross or flit habit of body, who have been al- lowed to feed upon the richer sorts of. animal food too exclusively ; in the state of vital ex- haustion observed in the latter stages of disease, as well as in the early periods, when the pulse is very quick, irritable, or sharp, the skin dry and burning, and the cerebral organs much excited or oppressed;—under such circumstances, I have usually directed a liniment composed of equal quantities of the lrniment. saponis et opii (Ed. Phar.), and of the liniment, terebinthinee, or either of F. 308. 311. to be rubbed on the epigastrium and abdomen, or along the spine. Thunberg advises the cajeput oil to be applied to the epi- gastric region during the fit; Hf.rz directs the animal oil of dippel to the same region, and Abrahamson the oil of nie. Either of these will frequently cut short the paroxysm, but I can assert, from a very extensive experience, that the liniments I have recommended are the safest and most efficacious. 73. /. When convulsions occur in the invasion of any of the exanthematous fevers, or upon the retrocession of the eruption, the treatment must depend, in a great measure, on the habit arid strength of body, and the extent to which the brain is affected. If cerebral congestion or irri- tation, with general heat of suiface, exist, local depletions, the cold affusion on the head, whilst the patient is plunged in a warm bath, to which some vegetable or mineral alkali has been added, cooling aperients, cathartic injections, the tartar- emetic ointment and solution F. 749. rubbed on the spine, and diaphoretics, are generally most serviceable. After the bowels have been freely evacuated, the carbonate of soda and nitrate of potash, given in mucilaginous vehicles; the spirit. astheris nitrici, with the liquor ammoniae acetatis, in camphor, jalap, &c. ; may be prescribed. If the skin be cool, and the pulse weak, or if the fit have occurred after the disappearance of the eruption, salt and mustard may be put in the bath; and if the countenance be pale and collapsed, and the cerebral functions not materially disturbed, warm and cordial diaphoretics, as the preparations of ammonia, camphor, serpentaria, &c, exhibited from time to time. Frictions of the surface, im- mediately after the patient is taken out of the bath, will generally promote its good effects. 74. g. If convulsions occur in the course of hooping cough or croup, we may conclude that ' congestion, or inflammatory irritation ofthe mem- branes of the brain, has supervened, and should direct local depletions, the cold affusion on the head, semicupium, and the sub-carbonates of the fixed alkalies, with opium, hyoscyamus, or bella- donna, in minute doses, unless the patient is al- ready much reduced by repeated or large evacu- ations, when we may infer that the convulsive seizures are connected with ansemia, and should prescribe the treatment already described in re- lation to this state (§ 55.). 75. h. The convulsions which occur so fre- quently as a consequence of chronic or severe bowel complaints, and of exhaustion from other diseases, and which have been too frequently imputed to dropsical effusion in the ventricles, require cordial antispasmodics, tonics, and light nutritious diet. Although sometimes attended'by more or less effusion, arising from the physical condition of the cranium and its contents; and serving to prevent any vacuum from being occa- sioned by the deficiency of blood in the cerebral vessels, yet the convulsions should not be viewed as proceeding from the effused fluid, but rather from the irregular and imperfect supply of blood to the cerebral structure. 76. i. The seizures that follow great losses of blood in children are generally characterised by too active determination of this fluid to the cere- bral structure ; and require the head to be kept cool and elevated, the bowels to be acted upon, and restoratives, antispasmodics, cordials, and tonics to be administered, with the extract of poppies, conium, or hyoscyamus, according to the peculiarities of the case. 77. k. If convulsions follow the disappearance or repulsion of chronic eruptions, we should dread the existence of inflammatory irritation of the membranes ofthe brain or medulla oblongata or spinalis, with a tendency to serous effusion. Local depletions, the warm bath ; frictions of the suiface, particularly of the part whence the eruption had disappeared, with irritating lini- ments ; the use of sinapisms, and deobstruent purgatives, as calomel, &c; are chiefly to be confided in. 78. /. When the seizures have recurred several times, particularly in infants, and are attended by dilated pupil, squinting, slow pulse, &c, then- connection with hydrocephalus may be inferred. In such cases, even local depletions should be employed with caution: but in many instances they may still be resorted to, in small quantity ; and followed by alterative doses of calomel, or hyd. cum creta, diuretics, small doses of digitalis with spirit, tether, nit., and the use ofthe liniment (F. 311.) to the head and loins both in the fit and in the interval. 79. B. The preventive treatment, a, In ple- thoric, fat, and gross-living children, should chiefly consist of a proper regulation of diet, as advised by Beaumes. Farinaceous food ought to be adopted, with only an occasional indulgence of the less stimulating meats. No rationaf plan of treatment, however, can be attempted with the view of prevention, without strict reference to the remote and proximate causes ofthe affection; the former of which should be carefully avoided, ami the latter removed by suitable treatment. When we detect cerebral irritation, or determin- ation of blood to the brain, or active congestion, 432 CONVULSIONS, PUERPERAL —Treatment. cupping, as already directed; the daily affusion of cold water on, and a constantly cool state of, the head; a moderate, but continued, action on all the secreting and excreting organs ; tranquil- lity, and the abstraction of all excitement of the mind and senses ; a bland and low diet; the use of revulsants, and warm clothing on th,e lower extremities; are the most appropriate remedies. 80. b. In very delicate children, where no evident inflammatory irritation within the head exists, a tonic treatment is obviously requisite. The sub-carbonate or animonia-tartrite of iron may be given, either alone, or with other anti- spasmodics, or any of the other preparations of this metal. The sulphate of quinine, or the pre- parations of cinchona, with liq. ammoniac acetatis, and a little of any of the compound spirits of ammonia ; suitable diet, attention to the state of the bowels, and change of air, will also be of service. Calomel, in frequently repeated doses, either alone, or with purgatives or anodynes, has been most injuriously resorted to by practitioners, upon the mistaken notion that convulsions are always connected with irritation within the cra- nium, and that this medicine alone can remove this state; whereas, if calomel be prescribed in small and frequently repeated doses, it will actu- ally increase the susceptibility and irritability of the body generally. When, however, it is given in full doses at distant intervals, or only occasion- ally, and either combined with jalap or some more active purgative, or followed by cathartics and enemata, it is a valuable remedy. Where the bowels are thus judiciously acted upon from time to time, and particularly if this be accom- plished by a terebinthinated draught, tonics, com- bined with antispasmodics and anodynes, will be of the greatest benefit, especially if there be no disorder of the cerebral functions to forbid their exhibition. The sulphate or oxide of zinc, or the sulphate of quinine, or the oil or other prepara- tions of valerian, or assafcetida, musk, &c, with either conium, hyoscyamus, or the extract of poppy ; the tonic decoctions and infusions, with the alkalies; and various other remedies already recommended in the intervals (§ 61. 75.), may be severally employed, according to circumstan- ces, after purgatives have been duly prescribed, and the stools have become natural. 81. c. When we have reason to infer that the convulsions proceed from intestinal worms, calo- mel with camphor, and the other cathartics noticed above ; the occasional exhibition of an active terebinthinate draught, followed by enemata, containing aloes, assafoetida, camphor, &c, and subsequently, by the preparations of iron, as well as any other ofthe remedies and modes of com- bining them described in the article Worms, may be directed. It is generally remarked by the German writers, that worms never form in the alimentary canal previously to weaning, if the milk be healthy; and the observation is con- firmed by my experience. It is, therefore, after this period that convulsions can be referred to this cause. 82. d. The marked hereditary and constitu- tional tendency to convulsions in the same family of children, and the very frequent connection of this affection with cerebral irritation, or with dropsical effusion in the ventricles, or between the membranes, in such cases, have presented difficulties to every practitioner. I believe that the disease, when qccurring in this manner, has been too frequently ascribed to inflammatory ac- tion, and a too lowering treatment adopted. Mr. Hill recommends the arsenical solution, with musk, in these cases; and I doubt not their utility, if carefully employed*; but other tonics and anti- spasmodics, particularly the weaker preparations of bark, or calumba, with the liquor potassae, and small doses of conium, or syrup, papav., or opium, if the child be not too young, and if the watchful- ness or erithism of the brain be present, will be found still more serviceable, especially if the head be kept cool, the secretions and excretions care- fully promoted, and the kidneys occasionally ex- cited by the addition of diuretics to the tonics, as the spir. aether, nit, digitalis, syrup, scillae, &c, or by the application of a suitable liniment (F. 311.) to the loins. In several cases of this description, I have directed, after other means had failed, and while tonics, as now prescribed, were given, the hair to be cut off, and the lini- ment to be rubbed upon the head immediately after the cold affusion. In cases connected with inflammatory irritation of the membranes, local depletions, the cold affusion, &c. (§ 67.) should precede the above treatment. 83. e. The diet and regimen of children that have once experienced a seizure of convulsions, ought to be carefully attended to. The stomach ought never to be overloaded, either by the/ mother's milk or by its ordinary food, which should be always recently prepared, and easy of digestion. As cr) ing often brings back the seizures in infants and young children, it should be prevented as much as possible. When the bowels have been sufficiently evacuated by the medicines suggested, from one to three grains of the hydrargyrum cum creta, either alone, or with the sub-carbonates of the fixed alkalies, may be given at first every night and morning, and afterwards every night, or every other or third night. The head should be always elevated ; and whilst in bed or indoors it ought to have no other covering upon it than that with which Na- ture has provided it. On no occasion should the warm fur or beaver hats, which are very im- properly worn by children, be used ; nor ought the mental powers to be prematurely or inordi- nately excited. In a word, the head should be kept always cool, the mind tranquil, the lower limbs warm, and the bowels open. A free, temperate, and healthy atmosphere, with occasional change of air, is also as necessa.y as medical treatment. 84. iii. Treatment of puerperal Con- vulsions.—'I he more frequent occurrence of convulsions in a first pregnancy, during a protract- ed labour, in those who have experienced them previously; the period ofthe puerperal state, and the progress ofthe labour and state ofthe os uteri when they do occur; the characters they assume —whether those of eclampsia, of epilepsy, of hys- teria, or of simple clonic convulsion ; the causes which induce them, the circumstances connected with them, and the fact that they, more than any ofthe other forms of convulsion, are the result of active determination of the blood to the head__ which, however, is merely the effect of irritation primarily seated in the abdominal viscera ; are CONVULSIONS, PUERPERAL—Treatment. 433 all to be taken into consideration in the treatment of them. The intentions of cure are the same in this as in the foregoing'states of convulsion; and they should be promptly fulfilled. '85. A. In order to cut short the seizure, — a. After having resorted to suitable means to protect the tongue, as the introduction of a cork between the teeth, &c, blood-letting from the arm, but preferably from the jugular vein, when it can be easily performed, should be employed, and car- ried at once to a decided extent relatively to the vigour and habit of body of the patient; and it should be repeated after a short interval, if the convulsions recur, and there be no circumstances to forbid it Simultaneously with the flow of blood, or immediately after it, the affusion of cold water or the application of a bladder of pounded ice on the head, and the exhibition of ten grains of calomel, and from five to ten grains of camphor, previously reduced to a powder by a few drops, of spirit, with or without an equal quantity of musk, and shortly afterwards of two or three drops of croton oil, should never be omitted. These me- dicines may readily be administered, by mixing them in sweet butter, and introducing a portion from time to time over the root of the tongue, upon the end of an ivory letter folder, or upon the handle of a spoon. A cathartic and antispasmod- ic enema (F. 141. 149.) should also be thrown up without delay; and immediately repeated, if it be returned. The combined effects of these will seldom fail of producing a solution of the parox- ysm. My experience of the excellent effects of camphor is fully confirmed by Dr. Hamilton, although Chaussier expresses an unfavourable ' opinion of it, and of all heating antispasmodics; and the recently published observations of Mr. Michell are strongly in favour of musk, which he gives in doses of from one to two scruples. Depletion may be carried further in those states of the disease which assume the characters of eclampsia, or which are attended by great fulness about the head, or stertorous breathing, than in almost any other malady. Chaussier advises, after general depletion has been practised, local bleeding from the nape of the neck and occiput, or from the epigastric region. 86. ({. As to the propriety of prescribing opium in puerperal convulsions, very opposite opinions have been given. Petit, Hamilton, Merri- man, and Dewees consider it most injurious; Manning and Bland recommend it; and Leake and Burns, with a judicious discrimina- tion, state, that when the disease is not accompa- nied with fulness ofthe vessels ofthe head, it may be exhibited with advantage after blood-letting. In this decision I concur, and add, that it should always be given either with camphor, as directed by Stoerck, or with the sub-carbonates of the alkalies, as advised by Stutz and Bruning- hausen, or with both; more particularly when the convulsions occur from excessive irritability, or previously to the period of full gestation, or after delivery, or when they assume chiefly the char- acters of hysteria. Rinck applies it to the abdo- men, and Hufeland to the soles ofthe feet. 87. y. Some difference of opinion exists as to the propriety of exhibiting emetics in this disease. Denman is in favour of them, but Mauriceau, Chaussier, and Hamilton Condemn them, unless after blood-letting, and when the seizure has been excited by improper ingesta,—the only circumstances under which, in my opinion, they should be given, and in which Dr. Blundell also recommends them. Of the good effects of active cathartics there cannot be the least doubt. I have always observed, as Dr. Merriman has stated, that the stools procured by them are mor- bid and offensive. 88. S. The next practical point of importance is, whether or not the patient should be immedi- ately delivered; and on this the sentiments of the most eminent accoucheurs are at apparent, rather than actual variance. No person will deny that the state of the uterus is connected with the cause ofthe seizure; therefore it would obviously seem requisite to remove that state. But the objectors reply, that convulsions also occur after delivery, when this state of uterus no longer exists: I have, however, never met with any, of several cases of convulsions after delivery for which I have prescribed, that did not arise from analogous causes of irritation, viz. an over-distended urinary bladder, the retention of the placenta or of coag- ula in the uterus, or the accumulation of faecal or irritating matters in the bowels. I therefore would adhere to the opinion I have often given, namely, if the above means have failed, and if the labour be so far advanced as to enable the accoucheur to deliver immediately without force or injurious interference, then let it be done. If the labour be not so far advanced, but yet the os uteri is considerably dilated, then the membranes may be ruptured, particularly if they be very tumid, — if, indeed, they have not been already ruptured, which is often the case, — and either full doses ofthe sub-borate of soda (q j. to t, ss.) given, or the ergot of rye. If the os uteri be rigid or undilated, the former of these will be preferable. If, however, the labour has not pro- ceeded far, then any interference, excepting by the exhibition of medicinal substances, may be more injurious than beneficial. La Motte, Os- borne, Leake, Hamilton, Dubois, Ash- well, Nauche, Miguel, Burns, Osian- ders father and son, Duges, and Ramsboth- am, are favourable to as early delivery as possible without violence; whilst Bland, Garthshore, Baudelocque, Hull, Gardien, Denman, and Blundell, are against forcible dilatation of the os uteri, and attempts at delivery in the early stage of labour. After all, the difference is more in words than in intention; for the general object is to hasten delivery, without injurious in- terference, if the labour be so far advanced as to render the attempt prudent; and those who have espoused either side have stated their opinions with such exceptions and limitations, and with so little precision, as to leave the subject nearly where they found it, and to render it no easy matter to ascertain under what circumstances they would either have recourse to art, or trust to nature. When the treatment already recom- mended fails, or is followed by an exasperation of the convulsions,—-which will very seldom occur if it have been judiciously directed, — then I conceive that the active interference of art should be called to our aid. There is, perhaps, no subject on which opinions are stated to be so much at variance as on this,-—each succeeding writer placing those of his predecessors in oppo- sition, even where no real difference exists, and 434 CONVULSIONS, PUERPERAL— Treatment thereby bewildering the inexperienced, in order that he may have the credit of giving a decision respecting it. 89. j.Chaussier recommends, in rigidity of the uterine orifice, the application of a pomade containing belladonna, with the view of relaxing the spastic contraction, which, he states, is not limited to this part, but extends to the whole of the organ. I believe, however, that the body ofthe womb is generally free from spasmodic contrac- tion. This preparation consists of two drachms of the extract of this narcotic, softened with an equal quantity of water, and triturated with about an ounce of prepared lard. A piece, the size of a small nut, is to be introduced into a female sy- ringe, open at the extremity, and conveyed to the os uteri, where it is to be applied by pushing on- wards the piston. In about half an hour the rigidity subsides, and the labour proceeds. Of this practice I have no experience. M. Chaus- sier discourages any other attempt at dilatation of the os uteri, as irritating the parts, and induc- ing a recurrence of the convulsions. 90. c. I have never omitted, in any case treat- ed by me since 1819, to employ the affusion of a stream of cold water on the head, and the injec- tion of turpentine clysters, sometimes with cam- phor, assafoetida, or valerian, and the results have been most satisfactory,—a much less quantity of blood having been detracted than is usually re- quired in such cases. I am not aware that either of these two remedies had ever been employed in puerperal convulsions, until long after I had given publicity to the practice,—a practice which I know to have been recommended very recently by those, who, at that time, ridiculed it. In the more rare states ofthe disease, which are attend- ed by a weak quick pulse, pale features, and hy- sterical symptoms, enemata containing valerian, assafoetida, or camphor, are very serviceable. In those which assume the comatose or apoplectic characters, blusters applied to the nape of the neck, and sinapisms to the ankles and calves of the legs, are useful adjuvants of the measures al- ready recommended. 91. r\. In all cases occurring previously to, during or after parturition, the state of the blad- der, and of the bowels, ought to be carefully en- quired into. Early in 1823,1 was called to the Queen's Lying-in Hospital, by the house pupil, to a patient who had been seized with puerperal fever on the second day after delivery, but was convalescent from it, when she was attacked by convulsions, brought on by a distended urinary bladder. I found that the urine had been drawn off, and that she had been blooded once largely. The case was one of extreme severity and dan- ger; the convulsions were unremitting, and at- tended by profound coma and asphyxy. The vein was re-opened, and, while the blood flowed, a stream of cold water was kept playing upon the vertex, and, at the same time, a clyster with turpentine and camphor was thrown up. Thus, the three most powerful—the almost only, rem- edies to be confided in, were simultaneously in operation. The patient rapidly recovered. Pur- gatives were given by the mouth, upon the solu- tion of the convulsions; deglutition having been entirely abolished during the whole seizure. This was one of the earliest cases in which I had ven- tured upon the simultaneous employment of these powerful agents, the use of them in succession having been generally adopted by me previously. I allude more particularly to this case, because of its uncommon severity; of its occurrence soon after a most dangerous disease, as late as nine days after delivery, in a public institution, and at a time when my public recommendation of the practice apparently received but little attention; although it will not now be looked on with scep- ticism. 92. ■&. Of other remedies but little may be said, as they should be viewed as auxiliaries merely. I have already expressed myself favour- ably of camphor (§S5.). Burns condemns it; but, when exhibited after depletion, and at the same time with the cold affusion on the head, and cathartic and antispasmodic clysters, it is a valua- ble medicine. Under the same circumstances, musk, assafcetida, and the other antispasmodics, will also be of use; for all risk of their injurious action on the brain is prevented by the cold affu- sion, whilst they co-operate with the terebinthin- ate injections to excite the contractions of the body of the uterus, and remove spastic constric- tion of its neck. Of the ergot of rye, my expe- rience is limited. I have given it only in one case of this disease, and then it was combined with borax, — a medicine undeservedly fallen into dis- repute— but which I have prescribed for many years. The labour in that case proceeded rapid- ly, and the patient recovered. Much difference of opinion exists as to the effects of, and propriety of giving, the ergot in convulsions. If the 03 uteri be dilated, and the external parts free from rigidity, blood-letting, the cold affusion, and cath- artic injections, having been actively but unsuc- cessfully employed, there can be no doubt of the propriety of exhibiting it. Opinions will always be at variance as to the benefits derived from substances recently introduced into practice; for, as all medicines are remedies only from their ap- propriate use, experience of their operation is re- quired to ascertain the circumstances in which they are truly of service. In a case of puerperal convulsions—I believe the first in which the er- got was exhibited — Dr. Brinckle gave it after the means usually adopted had failed. Twenty minutes after the first dose had been taken, uterine action came on, and the patient recovered. It is strongly recommended by Dr. Waterhouse, of Massachusetts, and by Air. Michell. 93. i. In cases of unyielding rigidity or callo- sity of the os uteri, Van Swieten advised an incision to be made through its margin. Dubosc, and, subsequently, Lauverjat, Bodin, and Coutouly, who considered it perfectly justifia- ble after blood-letting, the warm bath, and other means usually employed, had failed, have had recourse to this operation. M. Coutouly has recorded four cases (two of which are quoted by M. Miguel), in which it was resorted to; three of these recovered. The death of the fourth he imputed to the circumstance of it having been too long delayed. M. Nauche also favours this op- eration in the above circumstances, especially if emollient and narcotic injections into the vagina have failed to relax the rigidity. 94. y.. The warm bath, and emollient fomen- tations, followed by the use of an anodyne lini- ment on the abdomen, have been recommended by De n m an and Nauche; and the tepid bath by CONVULSIONS, PUERPERAL — Treatment. 435 Capuron after bleeding has been practised. Much advantage will accrue from assiduous fric- tions of the abdomen, more particularly if they be performed with an anodyne and antispasmodic liniment (§53, 54.), independently of the use of a warm or tepid bath ; for either of these can sel- dom be used with advantage in the circumstances of puerperal patients. In every case the hair should be 'cut closely off. This may be done in a very few minutes; but shaving the head is merely a loss of time. Burns,Ryan,and Clarke ad- vise the application of a blister on the head ; but I believe that it will be required only in extreme cases ; it certainly ought to be ventured upon only in such, where the coma is profouud, and the pulse weak, and the patient sinking. The advantages stated to have been derived by Dr. Clarke from acrid carthartics, and clysters, are confirmed by my own experience. If the convulsions occur im- mediately after delivery, the placenta should be re- moved, and the existence of internal haemorrhage enquired after—if at a later period, the state of the urinary bladder and bowels, as well as of the womb, demands attention. In all such cases, active purg- atives and cathartic clysters are especially required, but the choice of them should be made with due reference to the state of constitutional power, and to the presence or absence of cerebral congestion, or of exhaustion and nervous susceptibility. 95. X. When the convulsions attack epileptic females, they generally have all the characters of epilepsy or eclampsia, generally with unremitting sopor and stertorous breathing passing almost into asphyxy ; and they require the treatment describ- ed above. When they occur in hysterical females, they may also assume the same forms, and de- mand the same method of cure ; or they may present the features of simple hysteria, particular- ly borborygmi, quick pulse, &c, with very slight cerebral affection. In these latter cases, the ner- vine remedies mentioned in the next paragraph, will be adopted with advantage, especially after the cold affusion on the head. Cold enemata may be also thrown up, as advised in Hysteria. In the majority of these seizures, neither bleeding nor artificial delivery is required, unless cerebral con- gestion supervene, or the patient be strong or plethoric. 96. ft. Convulsions in the puerperal states may occur from great exhaustion, from want and inan- ition, and losses of blood. In these, the practi- tioner should trust chiefly to the cold affusion, per- formed only momentarily ; to the keeping of the head cool and elevated ; to sinapisms on the lower extremities ; to the exhibition of camphor, ammonia, the vegetable alkalies, and musk, with small doses of opium, or of the aethers with hy- oscyamus or conium ; to the administration of valerian, assafcetida, or turpentine clysters; to the warm bath ; to anodyne frictions of the abdo- men ; and to as early delivery as may be safely attempted ; the vital energies being supported by gentle cordials during the remissions. If the seizure be complicated with hamorrhage from the uterus, or haematemesis, prompt artificial delivery, the turpentine clyster in the first instance, and tur- pentine draught in the second, are the most certain means. 97. B. The prevention of puerperal convul- sions is of great importance. The means calcu- lated to attain this object can be put in practice only when the premonitory symptoms (§28.) manifest themselves.—a. If these indicate fulness ofthe vessels ofthe head, bleeding from the arm, or cupping on the nape ofthe neck, will be neces- sary ; and in every instance the bowels are to be freely evacuated. There are few cases of the disease, at whatever period it may occur, entirely unconnected with feecal accumulations ; and al- though this state of the bowels may not excite the attack, it certainly remarkably disposes to it. Ca- thartics should therefore be given by the mouth and their action promoted by clysters. Dr. Blun- dell advises an ipecacuanha emetic to be taken in the first instance ; and, where there is a loaded or disordered stomach, this practice may be adopt- ed. In addition to these, the warm bath may be used ; and if, notwithstanding, signs of active de- termination continue, the cold affusion on the head, or cold applications, should be also resorted to, either previously, at the same time with, or subse- quently to, the warm bath. Dr. Home and Dr. Blundell favour the exhibition of digitalis in such circumstances. 98. 6. If the premonitory symptoms be char- acterised by leipothymia or sinking, rapid weak pulse, particularly ofthe carotids; coolness of head, sunk features, &c,—the internal use of camphor, or musk, ammonia, assafcetida, the aethers, the warm bath, with small doses of opium, purga- tives, sinapisms, blisters, and the turpentine fo- mentation applied on the abdomen, are the most approved means of prevention. 99. c. If the patient have had two or three at- tacks at some former period, and if the above preventive treatment have not rendered the acces- sion ofthe disease less probable, Dr. Blundell advises the membranes to be punctured. 100. C. During convalescence, the states of the urinary bladder and ofthe bowels should be care- fully watched, and evacuated; the diet regulated; and both body and mind kept tranquil. If cere- bral symptoms continue for some time afterwards, the head should be preserved cool, and sponged with cold water night and morning, and a blister applied to the nape of the neck, and kept open for some time, whilst a course of eccoprotic and de- obstruent purgatives is continued for several days. Biblioo. and Refer.—i. Convulsions in Geneiial. Hippocrates, Aphor. sec. vi. §39. vol. i. p. 101. edit. Vander, Linden.—Galen, De Locis Affect. 1. iii. c. 6.—Oribasius, Sy- nop. 1. viii. c. 16.—Paulus JEgineta, 1. iii. c. 19.—Ziumtus Lusitanus, Prax. Hist. 1. i. cap. 11., 1. v. cap. 2.— Willis, De Patliologia Cerebri, cap. i. 4.—Baillou, Op. omnia, vol. iv. p. 134.—Amatus Lusitanus, cent. vii. cur. 11. (Inani- tion.)—Bonet, Sepulch. 1. i. sect. xiii. observ. 26. Morgagni, De Sed. et Caus. Morb. ep. x. art. 21.—Hoffmann, De Con- vulsionibus, in Oper. vol. iii. p. 31., et Supp. vol. ii. p. 2.__ Collbatch, Sur le Gui de Chene, in Malad. Convuls. Paris, lllS.—Baynurd, On Hot and Cold Baths, &c. Lorid. 1722.— /. Juncker, De Morb. Spasmodico-Convulsivis, kc, Hala?, 1739.—Monro, in Edin. Essays and Observ. vol. iii. p. 551. —S hrocder, De Convulsion, ex Harmorrhagia nimia oriun- dis. Marb. 1752.—Marx, De Motions Convulsivis, &c. 4to. Hahe, 1765.—Stoll, Rat. Med. par. iii. p. 412.—Stoerck, Do. Stramonio, Hyoscvamo, &.c. Vien. 1762.; et Ann. Med. vol. i. p. 15.—Wedenberg, De Stramonii Usu in Morb. Convul. Up-. 1772.—Sidren, De Stramonii Usu in Malis Convuls. Ups. 1773.; et in Act. Med. Suec. t. i.—Whytt, Works, 4to. p. 582.—Home, Clin. Exp. Hist, and Diss, kc 8vo. p. 153.— Evans, in Med. Observ, and Inquiries, vol. i. ail. 11.—GW- brand, in Act. Keg. Med. Hann. b. i. p. 26. —Bell, in Edin. Med. Comment, vol. i. p. 120.—Goodsir, in lb. vol. i.p. 467. —Warburg, Medic. Beobachlung. No. 10.—Clarke, in Med. Facts and Observ. vol. viii. p. 275.—Pallas, Reisen durch Kussland, ii. p. 387.—Unzer, in Hamb. Mag. b. viii. p. 369, —Bergius, Mat. Med. p. 121.—Arnot, Edin. Med. Essavs, kc vol. vi. p. 634.—J. Smith, Ed. Med. Comment, vol. Iii. p. 316.—P. Dugud, in Ibid. vol. v. p. 84. —White, In Ibid. 436 COUGH—Causes of. vol. vi. p. 330.—Armstrong, in Ibid. vol. ix. p. SOl.—Albers, Edin. Annals of Med. vol. vii. p. 406. (From abscess of the ear.); et Horn's Archiv. b. i. p. 329.—Conradi, in Hufe- land's Journ. der Pract. Heilk. b. vii. st. 2. p. 6.—Har- gens, in Ibid. b. vii. st. 1. p. 114.—Doerner, in Ibid. b. xv. st. 4. p. 94.—Henrischen, in Ibid. b. xv. st. 4. p, 79.—Mi- chaelis, in Ibid. b. iii. p. 344.—Wiedemann, in Ibid. b. vi. p. 418.—Struve, in Ibid. b. xxiii. st. 4. p. 8.—Schmalz, in Ibid. b. xi. st. 4. p. 169.—Heilbronn, in Hufeland und Harles N. Jour, der Ausl. Med. Chir. Lit. b. ii. st. 1. p. 187.—Pow- el, in Trans, of College of Phvs. of Lond. vol. iv. art. 8.— Latham, in Ibid. vol. vi. p. 248.—Cornish, in Lond. Med. and Physical Journ. vol. xxxi. p. 373.—Loeffler, in Richter's Chir. Biblioth. b. viii. p. 732.—Krebs, Medicin. Beobachtun- gen, b. ii. heft 2d.—Sumeire, in Journ. de Med. t. xxi. p. 224.—Dupont, in Ibid. t. xxxii. p. 130.—Parry, Mem. of Med. Soc. of Lond. vol. iii. art. 8. (Compression of the ca- rotids.)—Bianchi, in Brera's Comment. Medici, dec. i. t. ii. art. 2. — Grapengiesser, Versuche, p. 98.—Plenk, in Ab- handl. der Joseph-Acad. b. i. p. 318. (Ipecacuanha.)—Thun- berg, De Oleo Cajeputi. Ups. 1797.—Herz, Briefc, st. 1. art. 1.—Abrahamson, in Meckel's N. Archiv. b. l.st. 3. art. 21. —Hufeland, Bemerkung. uber Blattern, &c. p. 349.—Frank- farter, Med. Wochenb'l. b. v. p. 229.—Savary, in Diet, des Sciences Med. t. vi. par. ii. p. 197.—P. Jolly, in Diet, de Med. et Chirurg. Prat. t. v.'p. 473.—Naumann, in Encyclo- pad. Worterbuch der Med. Wissensch. b. viii. p. 341.— Thackeray, in Med. and Phys. Journ. vol. x. p. 410., and vol. xii. p. 503.—Barton, in "ibid. vol. viii. p. 428. ; Edin. Med. and Sure. Jour. vol. iii. p. 441.—Clarke, in Ibid. vol. v. p. 26B.—Hill, in Ibid. vol. v. p. 318.—Thomson, in Ibid. vol. xiv. p. 614. (Dissections in.)—Haygarth, Of Imagin- ation as a Cause or Cure of Disorders. Bath, 1800.—Portal, Anatomie Medicale, t. iv. p. 69. et seq. (Results of dissec- tions in.) — Dessesurtz, in Journ. de Med. t. xlvii. p. 114.— Rinck, in Stark's Archiv. b. v. p. 389.—Kortum, in Hufe- land's 3 omn. der Pract. Arzneyk, b. iv. p. 381.—Cazals, in Journ. Gener. deMed. Dec. 1810, p. 371. (Bismuth.)— Schaeffer, in Hufeland's Journ. der Pract. Heilk. Feb. 1810, p. 105.—Gebel, in Ibid. b. xvii. st. 3. p. 103. (Musk inlarge doses.) ii. Convulsions of Children. — Harris, De Morbis Infantum, p. 102.—Rosen, Traite de Malad. des Enfans, 8vo. —Beaumes, Trait6 des Convulsions dans l'Enfance, 8vo. Pa- ris, 1805.—Capuron. Des Maladies des Enfans, Svo. Paris, 1813, p. 407.—Gardieu, Traite de Malad. des Enfans, t. iv.; D'Accouchemens, 3d ed. p. 239.—J. Clarke, Commentaries on the Diseases of Children, 8vo. p. 80. (Too exclusively re- ferred to cerebral irritation.)—Jacques, in Journ. Gener. de Med. t. xxix. p. 280.—Bronn, in Ibid. t. xxxi. p. 457.— Piorry, De 1' Irritation Enecphal. des Enfans. Paris, 1823.— Underwood, On Diseases of Children, by Merriman. Lond. 1827, p. 233.—Bracket, Sur les Convulsions des Enfans, 8vo. Paris, 1824. (A good book, with too partial a leaning to ce- rebral irritation.)— J. North, Practical Observat. on the Convulsions of Infants, 8vo Lond. 1826. (An able and ju- dicious work.) iii. Puerperal Convulsions.—J. Leake, On the Acute Diseases of Females, kc 6th edit. p. 338. (Convul. from hczmorrh. and inanition well treated of)—Manning, On Female Diseases. Lond. 1775, p. 357.—Denman, Introd. to Practice of Midwifery, 5th ed. p. 569.—Hamilton, Edin. Ann. of Med. vol. v.p. 318.—Coutouly, in Journ. Gener. de Med. t. xxxii. p. 157.—Fritz, De Convuls. Gravid, et Par- turientium. Wirceb. 1810.—Michailis, in Siebold's Lucina, b. vi. p. 37,—Briickmann, in Horn's Archiv. Jan. 1811, p. JO.—Gasc, Memoir'es sur divers Points d'Accouchemens. Pa- ris, 1810.—Gardien, Traite Complet d'Accouchem. t. ii. p. 418.—Stutz, Michailis, Wiedemann, and Bruninghawsen, in Hufeland's Journ. &c. b. x. No. 4.; and in Lond. Med. and Phys. Journ. vol. v. p. 473. and 557.—J. F. Osiander, Deutsche Zeitschrift f. Geburtskiinde, b. ii. st. 3. p. 538.—,/. L. Boer, Abhindl. und Versuche Geburtshuf. Inhalts, kc kc. 1791, b. iii. p. 192.— Hufeland, Journ. der Pract. Heilk. Dec. 1816.—Wagner, De Eclampsia Exquisita in Partu. Morb. 1817.—T. Clarke, in Trans, of Irish College of Phvs. 1.1. p. 381.—Merriman, On Difficult Parturition, with Re- marks on the Managem. of Labours, 8vo. Lond. 1820 p 135.—Dewees, in Amer. Med. Record. No. iii.; and in John- sons Med.-Chirurg. Rev. June, 1820, p. 128.—Brinckle, Philadelphia Med. Journ.. vol. vi. p. 126,-Goupil, in Journ. des Progres des Scien. Med. t. iii. p. 161.—Duges, in Rev. Med. 1.1. 1826, p. 378.; et Manuel Obstet. Paris, 1830, p 275.; et Diet, de Med. Prat. t. vi. p. SSI .—Chaussier, Sur les Convulsions qui attaq. les Femmes Enceintes. Paris 1824.-.MigW, De Convulsions chez les Femmes Encein tes, en Travail, kc 8vo. Paris, 1824.—Blundell, Lectures, in Lancet, vol. xiv. p. 484. et 513.—Burns, Principles of Midwifery, 6th ed. p. 484.—Ryan, Manual of Midwiferv 2d ed. p. 2S5.—Miche/l, On Difficult Parturition, and the" Use of Ergot of Rye, kc 8vo. 1828.—Nauche, Des Maladies prop, aux Femmes, kc Svo. Paris, 1829, p. 449. CORPULENCY. See Obesity. COUGH.—Syn. Bl£, Gr. Tussis, Lat. Bex, Good. Pneusis Tussis, Young. Der Husten, Germ. Toux, Fr. Tossa, Ital. Classif.—2. Class, Diseases of the Respi- ratory Function ; 2. Order, Affecting the Lungs (Good). II. Class, III. Order (Author.) , 1. Defin. Violent and sonorous expulsion of air from the lungs, preceded, rapidly followed by, or alternating with, quick inspiration. 2. I. Pathology.—Dr. Cullen and several other nosologists have considered cough as chiefly a symptom, which undoubtedly it is most frequent- ly; but I agree with Dr. Young and Dr. M. Good in believing that it is entitled to be viewed, on some occasions, as an idiopathic affection. Dr. Good, however, has ranked it as a genus, and comprised under it various affections, which are either mere- ly slight forms of Bronchitis, or the results of organic changes in the Lungs, and which I have treated of in these articles, and in those on Bron- chorrhosa, Catarrh, and Influenza. He has, moreover, subdivided it into more varieties than can easily be recognised in practice, and has viewed Hoopingcough as a species of the genus, instead of a distinct disease. 3. Causes.—Cough, in either of the forms about to be particularised, commonly attends dis- orders of the air-passages, and of parts in their vicinity, particularly of the larynx ; also those of the lungs, and their membranous coverings; and sometimes diseases of other organs by which the respiratory functions are affected sympathetically —or rather, from continuity of tissue or nervous communication. It is thus occasioned by affec- tions about the fauces, tonsils, pharynx, and neck; by the irritation of dentition ; by diseases of the oesophagus, particularly when inflammation and ulceration of this part extends to, or penetrates, the membranous part of the trachea (Kappel- hout, Mr. Byam, and myself); diseases of the spine and its contents (Wichmann); by creta- ceous or calcareous formations in the ramifications of the bronchi (Morgagni, Bonet, Baillie, Portal, and myself in several cases, two of which occurred in gouty subjects); by all organic changes of the thoracic viscera ; by the acciden- tal passage of foreign substances, solid or fluid, into the air-passages ; by the lodgment of the eggs or larva; of insects in the same situation (Vogel and Percival, &c); by the irritability of parts attendant upon the nervous temperament and debility; by the influence of irritation and imagination,—a cause which did not escape the observation of the acute Montaigne; irregular or misplaced gout; the irritability of the parts con- tinuing some time after measles, or inflamma- tions of the air-passages or lungs; disorders of the digestive organs, particularly the stomach and liv- er, &c.(VVinther, Stf in, Percival, &c); by accumulations of bile in its receptacle; by the irri- tation of worms ; by the repulsion of cutaneous eruptions, and the healing of old sores, and sup- pression of chronic or accustomed discharges. From this enumeration it is evident that cough is chiefly a symptom of numerous pathological states, which will be found very fully described under different heads, as indicated above. The epidemic cough noticed by some writers falls under the article Influenza. In the act of coughing, the COUGH —Cause s — Treatment. 437 Jungs are passive; and in the idiopathic states of the disorder they are not organically affected; the disorder being chiefly seated in the trachea, larynx, and vicinity. In very many cases, the irritation occasioning the cough exists chiefly in the poste- rior fauces and pharynx, and extends no further than the epiglottis and rima glottidis. 4. i. A. Dry Cough occasionally occurs in an idiopathic form,—a. From exposure to cold in any form; the attendant symptoms not amounting to completeCATARRH; and it may, or may not, in a very short time terminate with slight mucous ex- pectoration. When, however, it arises from this cause, it usually runs the course described in that article, b. It is occasionally produced by acrid or acid fumes and gases, or by various foi'eign sub- stances inhaled, or accidentally passed, into the trachea, and from several of the other causes enumerated above (§ 3.). c. It also, in some cases,—first noticed by Montaigne, and well de- scribed by Whytt,—presents a strictly nervous character, particularly in nervous, hysterical, and irritable persons, d. In those especially, and also in feeble or delicate constitutions, a short, frequent, and dry cough is sometimes met with, without any disease of the lungs, air-passages, or other organs; and the only change that can be detected is slight redness at the margin of the soft palate, or in the posterior fauces; sometimes only in the pharynx ; and occasionally near the ton- sils; but this is not uniformly, although frequent- ly, observed. Here it is obvious that the irritation of these parts extends to the glottis, or to the epi- glottis only; and that it is either strictly local, or connected with slight derangement of the stomach and prima via. In the former case it is idiopathic, in the latter symptomatic, or at least a complicated ailment. 5. B. Dry cough is more frequently symptom- atic—a. Of the 'first stage of diseases of the larynx, trachea, and lungs; of organic changes of the large blood-vessels of the chest; and sometimes of complaints of the more superior of the abdominal viscera, b. It is frequently oc- casioned by elongation of the uvula, and the ir- ritation this part produces about the root of the tongue and epiglottis. But when the uvula is elongated, there usually is also more or less co- existing irritation about the posterior fauces and pharynx, extending to the glottis or epiglottis. And- it should be, moreover, kept in view, that these ailments are principally dependent upon, even although they may not be always produced by, disorder of the stomach and digestive organs generally, c. In many instances, also, it will be found that the cough is owing to irritation of the mucous surface of the stomach and asophagus, although it may not extend so far as to be ap- parent in the pharynx, or be so severe as to occa- sion redness of this part. d. Cough is often pro- duced by diseases of the liver, and by collections of bile in the gall-bladder and hepatic ducts. In many of such cases, the cough is severe and spasmodic, often very obstinate and of long du- ration; the symptoms of hepatic disorder being sometimes so slight as to escape detection, unless the attention of the practitioner is awakened to the connection; the chief indications of its exist- ence being the loaded or furred tongue, pains about the diaphragm, fulness at the epigastrium, and indigestion, e. Lastly, dry cough is often occasioned, in young and delicate patients, by the irritation of worms in the prima via. The more particular consideration of these associations will be found in the articles on the diseases of which the cough is merely a symptom. 6. ii. Humid Cough,—a. may follow upon the preceding; or it may occur primarily from the usual causes of catarrh. In such cases, it is merely a slight form of that affection, the matter expectorated being mucous or serous, and the cough unattended by manifest febrile or con- stitutional disturbance. This form of cough is very liable to recur, or become chronic, in deli- cate persons, during the winter (winter-cough;) or from vicissitudes of season and weather; and, like the former variety, the irritation exciting it may be chiefly seated in the pharynx and vicinity, or in the larynx and trachea. In many cases the serous, or sero-mucous secretion, following the cough, entirely proceeds from the fauces and vicinity, b. In old persons, however, it is se- creted chiefly by the bronchial surface, and is then, particularly in its more severe forms, the affection described under the name of Bronchor- rhtea. c. Humid cough is generally less frequent, but more prolonged, and recurs in severe pa- roxysms. It is sometimes complicated with rheu- matism and gout. It also presents the same pathological relations as described in connection with the dry variety; but it is not so often symp- tomatic of diseases of the abdominal viscera, as the foregoing, d. In the old and weak, humid cough is usually very severe, owing chiefly to the want of vital power of the respiratory organs, and of the system generally, to throw off the mucus secreted in the air-passages; and which is either very abundant, from the relaxation of the ex- treme vessels; or very tenacious,from absorption of its more fluid parts during its retention on the surface that secreted it, or from both conjoined. In such cases, the paroxysms of coughing are very severe and prolonged; and the affection is liable to be exasperated upon every change of season and weather, e. In other cases of humid cough, the exacerbations are also very severe, particularly in the morning; but the excretion is thin and frothy. This is observed most frequently in persons ad- dicted to intoxicating beverages; and in those de- bilitated by sexual indulgences. When humid cough depends upon hepatic disease, it often as- sumes this form. 7. II. Treatment.—i. A. The idiopathic states of dry cough require demulcents, emollients, with diaphoretics and narcotics or anodynes (see F. 238. 244. 38.9. 426., and R 98. and 99. at p. 297.). The conium, hyoscyamus, solanum, cenan- the, and phellandrium aquaticum (Theussink and Frank,) may severally be employed, and the functions of the abdominal viscera improved by suitable means. But the pathological states, as well as their eauses, on which this form of cough depends, should be investigated, and the treat- ment modified accordingly, a. If it follow the impression of cold in any form, the treatment described in the article Catarrh (§ 15.) will be appropriate, b. If it be produced by the in- halation of irritating fumes, or the molecules of either mineral, vegetable, or animal matters float- ing in the air, the removal of the cause, and the use of demulcents, emollients, and emetics, and subsequently narcotics, are most to be depended 438 COUGH —Treatment of. upon. c. When it assumes a nervous character, particularly in hysterical and delicate females, the state of the uterine functions, and the existence of irritation in some part of the digestive tube, or in the sexual organs, or spinal cord, should be en- quired after, and the treatment directed according to the information acquired. In many such cases, the exhibition of a gentle purgative, and after- wards small doses of camphor, ipecacuanha, am- monia, oxydes of zinc and bismuth, hyoscyamus, extract of hop or poppy, the sub-carbonate of soda, &c. variously conlbined, will be of service. If there be evident debility, and the cough as- sumes a periodic form, the preparations of bark or of iron, the sulphate of quinine, or gentle ton- ics, with anodynes and narcotics, will be required. The cold bath, which has been much recom- mended by Whytt, will also prove beneficial. d. When it proceeds from irritation of the fauces or pharynx, demulcents, emollients, &c. with ipecacuanha, or with diaphoretics and anodynes, will be required. But the greatest advantage will be derived from the use of cooling and astringent gargles, and stomachic purgatives (F. 266.). 8. B. The symptomatic occurrence of cough must be treated as pointed out in the articles on the primary affections occasioning it.—a. If it be referred to the respiratory organs, the means ap- propriate to their diseases must not be departed from. b. When we observe elongation of the uvula, either with or without signs of irritation of the pharynx, disorder of the digestive functions may be inferred; and, after having had recourse to purgatives, cooling and astringent gargles, prussic acid, and mild stomachics will be useful. c. The dependence of cough upon diseases of the biliary organs, whilst it suggests a treatment chiefly directed to these diseases, will also indicate the propriety of ascertaining, with as much pre- cision as possible, their nature. If indications of accumulated bile in the gall-bladder and he- patic ducts are detected, calomel or blue pill, with, or followed by, purgatives, and a course of alteratives, taraxacum, &c. will be requisite. In some cases, a gentle dose of either of these cholo- gogues will produce copious discharges of morbid bile, and the immediate disappearance of a con- stant, severe, dry, and harsh cough, of which alone the patient has complained. In others, repeated and large doses will be required to ac- complish this object. In all these, purgatives should be exhibited until the tongue becomes clean. If tenderness or pain exist in the region ofthe liver, with febrile symptoms towards even- ing, or restlessness through the night, blood-let- ting, general or local, ought to precede other measures ; and the hepatic disease should be treated with reference to the form it presents, and as described in the article on Diseases of the Liver, d. When the cough is attended by a tumid abdomen, and other signs of worms, the treatment recommended in such cases, according to their numerous modifications, must be em- ployed. 9. In almost all the idiopathic and symptomatic forms of dry cough, more advantage will be ob- tained from demulcents, ttan from heating or stimulating expectorants, which should always be laid aside when there is evident vascular ex- citement of a sthenic or tonic kind. Those ex- pectorants, however, which are of a mild nature, or which act chiefly by exciting slight nausea, will • generally be of service, particularly when com- bined with emollients, diaphoretics, and narcotics; and there are few conditions, in which the pre- parations of antimony or ipecacuanha, with liquor amnionic acetatis, and the warm bath, will not be extremely beneficial. In this variety of cough, also, appropriate medicines, exhibited in such a manner as will favour a prolonged impression on the palate and pharynx—as in the form of lozenge or linctus—will thereby have their effects mani- festly promoted; and advantage will also accrue from wearing warm, antispasmodic, or rubefacient plasters between the shoulders, both in this and the humid variety of the affection. No. 160. R Confect. Ros. Canin. et Confect. Ros. Gal. aa s j.; Olei Amygdal. Dulc. ^ vj.; Svrup. Papaveris Albi 5»s.; Spirit. .Ether. Nit. 5ij.; Acfdi Sulphur, dil. 'jss.; Pulv. Ipecacuanha; gr. ij. M. Fiat Linctus, de quo sumatur pauxillum subind -. No. 161. It Emplavt. Picis Comp. part. ij.; Emplast. Auimoniaci (vel Emp. Ammon. cum Hydrarg.) et Emplast. Opii aa part. i. M. Fiat Emplastrum perlargum inter scapulas impositurnm. 10. ii. Humid cough, when it presents the cha- racters of slight catarrh, requires the treatment described in that article, a. If it frequently recur, or become chronic, or assume the form of winter cough, the more tonic demulcents, as the decoction of Iceland moss, or of the sea moss, with lemon and candy,—the mistura ferri compos. with a decoction of liquorice root,—attention to the digestive and excreting functions,—warm clothing,—and careful avoidance of exposures to the vicissitudes of season or weather,—are most to be depended upon. 6. When the cough occurs in old persons, with increased secretion obviously from the bronchi, gentle tonics, and ex- pectorants, as myrrh, galbanum, assafoetida, ben- zoin, the oxide or sulphate of zinc, the terrebin- thinates, camphor, ammonia, the balsams, and, indeed, the whole of the treatment described in the articles on Chronic Bronchitis (§ 91.) and B r o n c h o r r h os a are mostappropriate, e.When it is complicated with gout or rheumatism, purg- atives, combined with tonics or stimulants, in order to carry off collections of morbid bile, and other vitiated secretions; and afterwards the med- icines now enumerated, or the preparations of ammonia or camphor, combined with colchicum will generally afford marked relief. The depend- ence of this variety upon the diseases already noticed as occasioning the other form of cough, requires the several measures pointed out with re- ference to each of them (§8.). d. If the cough be very severe, in old and exhausted persons, and in those who have injured their constitutions by venereal indulgences, atonic and stimulant treat- ment, and the remedies instanced in this para- graph in increased doses, will be requisite. It will be found in these, as well as in broken-doton drunkards, that the cough will be aggravated by remedies which in any way depress the vital en- ergies. In these last, the cough is frequently connected with hepatic disease, the treatment of which will depend upon its nature; but, although depletion may be occasionally required for the primary malady, the powers of life must be at the same time supported. 11. In this variety, generally, the mild expec- torants, with demulcents ; the jelly of sub-acid fruits; the inhalation of emollient, stimulating, or astringent vapours (see Bronchitis, § 76. 98.); CRANIUM AND ENVELOPES. — THEIR LESIONS. 439 the use of acid beverages; warm, rubefacient, sti- mulant, and tonic plasters; the warm bath, made gently stimulating by salt and mustard; a light, demulcent, and nutritious diet, with strict atten- tion to the functions of the stomach and bowels; change of climate, or of air, and a judicious choice of residence according to season, with gentle but regular exercise, and warm clothing; are severally of advantage, and some of them of the utmost importance. (See Bronchi, § 104.) BlBLIOO. and REFER. — Fernet, Consil. xxiv. — Forest, xvi. n. 1— 6. — Horst, Opera, vol. ii. p. 128.— Willis, PJiar- macop. Ration, par. ii. sect. i. cap. 4. — Montaigne, Essais, 1. i. cap. 20. — Bonet, Sepulchret. Anat. I. ii. s. iii. obs. 11. — Morgagni, De Sed. et Caus. Morb. epist. xv. art. 22, v3. — Stein, De Tussi Stoinachali Humida. Argent. 1749.— Winther, De Tussi Stomachali, kc Marb. 1719. — Hal- ler, De Tussi. Goet. 1749. — Whytt, Works, 4to. p. 432. — Biichner, De Tussi Humida, kc. Hala-, 1763. — Finck, De eo, quod Tussi proprium est et Communi. Bamb. 1779. — Kappelhout, Sectiones Cadaverum Pathologies, p. 5.— Vogel, Beobachtungen, kc No. 7. — Portal, Anat. Med. t v. p. 43. — Percival, Essays, &c. vol. i. p. -Sli.; and Med. and Phys. Journ. vol. iv. p. 65. — Mudge, On Coughs, &c. 8vo. Lond. 1789. — Doubleday,.Med. Observ. and Iiiquir. vol. v. — Douglas, in Ibid. vol. vi. p. 163. Bell, Duncan's Med. Comment, vol. xiv. p. 307. — Frank. Institut. Clinica Vilnensis, ann. ii. p. 27. — Wichmann, in Loder's Journ. b. ii. st. 1. p. 31. — Young. Introduct. to Med. Literature, 8vo. p. 187. — Stanger, Trans, of Med. and Chirurg. Soc. vol. i. p. 13. — M. Good, Studv of Med. bv Cooper, 3d edit. vol. i. p. 580. — Brooke, On "Liver Coug'h, Trans, of Irish Col- lege of Phys. vol. iii. p. 245. COW-POX. See Vaccination. CRAMP. See Convulsions (§ 4.), Spasm, and Tetanus. CRANIUM.—Syn. Kqurlor (from x^aroe, a helmet, as defending the brain from injury.) Die Hirnschale, Ger. Le Crane, Fr. Cranio, Ital. The Skull. Classif. Pathology.—Special Pathology — Morbid Anatomy. 1. The cranium and its envelopes, the scalp and the pericranium, are often the seat of diseases which are of much moment, not only as respects these parts themselves, but also as regards the important organs and membranes which they contain. 2. 1. Diseased Appearances of the En- velopes of the Cranium.—These are princi- pally the same as are observed in analogous structures in other parts of the body. Nearly the same changes are remarked in the scalp, and subjacent cellular tissue, as in the integumental coverings of other parts; and in the pericranium, as in other parts of the periosteum. These struc- tures, forming the envelopes ofthe cranium, will, therefore, require but little remark. 3. A. The scalp is subject to the same inflam- matory states as other parts of the body; and these require the attention of the physician, from their occasional extension to the bones of the cranium and membranes of the brain. Inflam- mations of the scalp vary in character with the condition of the vital energies and digestive and biliary organs. Sometimes this structure is the Beat of active phlegmonous inflammation, but more generally ofthe erysipelatous. When ery- sipelas attacks the scalp, a copious exudation of a serous or sero-albuminous fluid takes place in its subjacent cellular tissue. Occasionally this tissue is affected by inflammatory action of an unhealthy kind, but limited in extent, and closely resem- bling carbuncle, and of which I have met with some cases in children. The scalp is also par- ticularly liable to certain specific inflammations of a chronic kind, especially to pityriasis, porrigo, sycosis, lepra, psoriasis, eczema, rupia, and syphilitic ulceration. Tumours, generally en- cysted, sometimes form beneath the scalp, most frequently between it and the tendinous expan- sions of the occipito-frontalis, and other muscles I attached to the pericranium. These expansions, | and the muscular structure attached to them, and perhaps occasionally the pericranium also, | are often the seat of rheumatism and rheumatic inflammation. They are not infrequently, also, affected by common inflammation and its con- sequences, particularly after external injuries. Dropsy of the cellular tissue beneath the scalp, independently of inflammation, is very rare. It has, however, been observed in young subjects, and received the appellation of hydrocephalus ex- ternus, and adema capitis. 4. B. The Pericranium is subject to the same changes as the periosteum in other parts of the body; amongst these are chronic and specific inflammations, giving rise to thickening of the membrane; to nodes, frequently terminating in suppuration and exfoliation of the subjacent part of the bone; and, in cases still more chronic and slight, to unnatural deposits of bone upon the external surface ofthe skull. (See Periosteum —Inflammation of.) Inflammations of an acute or sub-acute character sometimes, also, attack this, structure, and, when not arrested in their progress, give rise to its separation from the bone ; and not infrequently, owing to the exten- sion of the morbid action through the tables of the cranial bones, to a corresponding separation of the dura mater from the diseased part of the skull. It seems probable that morbid action of any kind is seldom continued long in the peri- cranium, without the dura mater, which performs the office of an internal periosteum, suffering in a corresponding degree, and ultimately trans- mitting the disease to the subjacent membranes, and even to the brain itself. Specific inflamma- tion also of this structure, of a most painful and dangerous kind, occasioning death of the portions of bone beneath the parts chiefly affected, is produced by syphilis and the inordinate and pro- longed use of mercury. 5. II. Mokiiid Changes in»the Cranium. —The bones of the cranium are subject to various diseased appearances, many of them having a close reference to the state of the system, and its morbid dispositions, and still more so to those slowly formed lesions which frequently affect the brain and its membranes. — A. Enlargement, or rather distension, of the bones of the cranium, is frequently an attendant upon chronic hydro- cephalus, and the hypertrophy ofthe brain some- times accompanying rickets. When the accu- mulation of fluid is great, and has taken place before ossification is far advanced, this process frequently commences at several more distinct points than in the healthy state, thus generating as many distinct bones. In the majority of these cases, although the surface of the cranial bones is greatly extended, there is a general deficiency of the ossific deposit, rendering the skull more than usually thin. The Museum of (Juy's Hos- pital contains the cranium of an hydrocephalic man, who lived to the age of 29 years. Its cir- cumference is 33£ inches. There is also in the 440 CRANIUM — Morbid Changes in. Museum of St. Thomas's, the skull of a child of two years, that measures 29 inches. 6. B. Deficient deposit of bone, as now re- marked, is often connected with the foregoing lesion; in which case it is commonly general, the whole cranium being more or less thin as well as enlarged : but the thinness may also, although less frequently, accompany a natural-sized skull. The deficient deposit, or thinness of bone, may also be partial. In this case, partial or cir- cumscribed accumulations of serum, or tumours, generally exist beneath the part of the cranium thus changed; and we have reason to believe that it is to the pressure exerted by these that the unusual thinness is to be imputed. It should, however, be kept in recollection that the cranial' bones vary exceedingly in thickness, without hav- ing seemingly diverged from the healthy state. 7. C. Imperfect ossification is chiefly a lesion of early age, being merely a slow or impeded developement of the bones, arising from one or both of the following causes :—a. From deficient powers of the constitution, in which the process of ossification 'either generally or locally in re- spect of the cranium participates; b. From the distension arising from the accumulation of fluid. The imperfect ossification in such cases may con- tinue to the age of three, four, or five years, and generally consists merely of a more than usual openness of the sutures, or a deficient deposit of bone at the parts most remote from the centres from which the ossific process proceeds. In some cases, however, the imperfection exists in about the middle of one ofthe bones; a patch of membrane, or a narrow stripe being surrounded by bone. When these patches or clefts in the bone are considerable, or remain for any time unfilled up, a portion of the membranes often protrude, forming large watery tumours, owing to the pressure of fluid effused between or under- neath the membranes,—a circumstance which occasionally obtains. An interesting case of this description, successfully treated by ligature, has been recorded by .Mr. E. Thompson. The ma- jority of these cases are congenital, but the pro- trusion is often not noticed until long subsequent to birth. Sometimes a portion ofthe brain itself protrudes, forming a congenital hernia cerebri. 8. D. The b/ines of the cranium may be insufficiently evolved. In this case they are generally formed with more than sufficient ra- pidity, and their sutures are closed prema- turely, so that they cannot give way before the growing brain, which thus becomes, with the case enclosing it, imperfectly evolved. The cranium may thus appear unnaturally small, as is sometimes observed in idiots and epileptics; but this state may arise not only from early closing of the sutures, but also from imperfect developement of the brain itself. Microcephalia was considered by Hippocrates as a cause of idiotcy; and facts, showing that great diminution ofthe size of the head is very generally connect- ed with weakness or privation of intellect, have been adduced by Greding, Gall, Spurz- heim, Georget, and many others not believ- ers in the doctrine of Gail. 9. E. The shape of the cranium is often some- what changed by these and other causes. When the cranium is much deformed, it is more com- monly a congenital vice arising either from the pressure in utero of a deformed pelvis, pelvic tumours, &c.; or from deficient developement, early disease ofthe embryo, and monstrosity; or from congenital change of the structures which it contains. But deformity of the cranium may also take place after birth, from deficient or irre- gular developement of the brain, or from the effusion of fluids in the cranial cavity. The early closing, also, of some sutures, and the protracted closing of others, whereby the yielding of the bones is prevented in one part, and facilitated in others, are often productive of deformity. Rickets, dropsy of the brain, softening of some of the bones, particularly of the base, whereby it is thrust up into the cavity (Otto), cretinism, &c, are all often productive of deformity. A species of deformity has several times come be- fore me, and generally attended by epilepsy, and idiotcy, which I have seldom seen noticed. This consists of obliquity in the halves of the cranium; one half being much more depressed, both at the top and base of the skull, than the other. This deformity is sometimes thus simple, consisting only of comparative elevation and depression ol the sides of the cranium. But I have observed it more commonly connected with an equal obliquity posteriorly and anteriorly; the elevated or depressed half, either receding or advancing much more than the other. In cases of this de- scription, the cranium has also presented a certain angular form, so that I have been led to de- nominate the appearance, the diamond-shaped obliquity or deformity ofthe skull. 10. F. Hypertrophy, thickening, or enlarge- ment of the bones, assumes two principal forms. 1st, That of a superabundant deposit ofthe ossific matter, giving rise to uncommon density, and to the disappearance of the diploe, and converting both tables of the skull into one dense bone, resembling, but much harder than, ivory. This appearance of the cranial bones is almost na- tural to the negro. It is observed, also, in per- sons advanced in life, who have been subjected to laborious employments, physical and mental; and it is often seen in epileptics, in maniacal epi- leptics, and in some who have been long insane. It may or may not be accompanied with increased thickness of the bone. Greding found the skull too thick in 151 out of 196 insane persons; and Georget observed it one twentieth and up- wards too thick in 480 out of 500, belonging to the same class of patients. The second form of en- largement is rather the result of a loose or spongy formation of the bones, in which, although most remarkable in the diploe, both tables of the bone often participate more or less. In this form, the actual quantity of bony matter is not much augmented. Increased thickness of the bone generally obtains here, and sometimes reaches an enormous extent, and closely resembles in appearance a piece of pumice stone. 11. G. Irregular deposits of ossific matter are very frequently observed on both the internal and external surfaces of the cranial bones, particular- ly the former. They are often found adjoining the sutures, sometimes with a mammilated ap- pearance on the external surface. On the internal surface, they frequently assume an irregular bo- tryoidal form; sometimes they present large masses, particularly on the frontal bone, and encroach considerably upon the cavity. Not CRETINISM. 441 infrequently these deposits are prolonged into the form of irregular processes : occasionally the pro- longation is in the seat of particular parts or pro- cesses, as in the clinoid process. These exostoses are sometimes very prominent and acute. In some instances they encroach upon the foramina through which the nerves and vessels pass. In these cases, symptoms of pressure or of irritation are present, and vary according to the seat, form, and extent of the ossific deposit. Epilepsy, in- sanity, irregular convulsions, spasmodic contrac- tions, and neuralgia, are amongst the most promi- nent effects of these productions. 12. H. Vascular engorgement is sometimes ob- served in the cancellated structure forming the diploe, in cases where great congestion, or very active inflammation, has existed in the head, membranes, or pericranium ; the vessels passing from or into the bone being congested, and the diploe of a deep or purplish red colour. 13. /. A softened state of the diploe is not in- frequently observed in cases where active inflam- mation has affected the pericranium, or dura ma- ter, and extended to the bone. In these cases the tables of the bone are more friable than natu- ral. A similar appearance is also observed when the system has been much contaminated by car- cinomatous disease. 14. K. Ulceration of the cranial bones is also not uncommon ; and is generally attended with more or less absorption, exfoliation, and the de- posit of irregular bony spiculas. Ulceration and absorption result very frequently from lupus, and the formation of bony spiculae generally attends upon osteosarcoma. 15. L. Caries, or death, ofthe bone is not in- frequently observed to follow upon inflammation extending from the pericranium, or dura mater, to the bony structure. It is a very common conse- quence of inflammation of the ear long neglect- ed, or imperfectly treated. It may be limited to either of the plates, or it may extend to the whole thickness of the bone. In either case, the dead part is detached from the living by the absorption which takes place around it, and in the surround- ing inflamed and ulcerated parts. Owing to this process, a distinct line of separation is frequently formed, and the dead portion is completely ex- foliated. While the dead bone is being removed in this manner, or after its removal, if the dura mater, which acts as the periosteum of the inter- nal table, is not destroyed, new bone is deposited, and thus the mischief is often repaired.—I have met with two such cases in children. 16. M. Fungus cranii, or medullary sarcoma of the bones of the skull, is occasionally observ- ed. It has been described as occurring on the top of the cranium by Crell, San di fort, Wishart, Abercrombie, Landmann, and Otto. A distinct tumour is often produced by it on the internal as well as the external surface of the skull,—the part forming a spongy growth. It is more rarely met with about the base of the cranium. It may originate in the bones, or their internal or external periosteum ; but, in which- I ever of these it may commence, it soon involves j them all. When originating in the bones, it usually assumes the characters of osteosarcoma, and those of fungus when it commences in the pericranium or the dura mater. 17. N. Perforations of the cranial bones are also observed, generally as a consequence of the pressure of internal tumours, of an encysted, scrofulous, or fungoid description, attached to the membranes underneath, or of aneurisms, &.c. Cases of this description are recorded by Pal- letta, Le Clerc, Richter, Pelletan, and Otto. After artificial perforations of the skull, as after trephining, and fractures with loss of bone, osseous matter is sometimes regenerated, radiating from the surrounding divided surface of bone. The exuberant formation of ossific matter after fractures of the cranium is sometimes pro- ductive of serious effects. (See § 11.) 18. 0. Depressions and fractures require little notice further than that they are the most frequent causes of inflammation, and its consequences in the surrounding membranes, and contained organs, and of irregular bony depositions. Depression of the superior and lateral bones of the skull may take place in early age to a very great extent, and remain through life, without affecting the mental manifestations. Several instances of this have come before me, in some of which the de- pression was fully larger and deeper than the bowl of a large table-spoon. One of my earliest and most talented friends has a depression to this extent in one of the parietal bones, from an ac- cident in childhood. Bibliog. and IIeff.r.—Le Clerc, in Haller's Biblioth. Chirurg. t. i. p. 469.—Kaufmann, De TumoreCapitis Fun- goso, &c. Helinst. 1743.—Sand if art's Exercilat. Acad. I. ii. t. 3.—Siebold, in Arnemann's Magazin fur die Wundarz- nein-iss. Got. 1797. vol. i. part iv p. 389__Cheston Browne, in Philos. Transac. vol. Ixx. p. 323.—Home, Trans, for Im- provement of Med. and Surg. Knowledge, vol. iii.—Sandi- fort, Observ. Anatom. Pathol. 1. iii. cap. 9. t. 9., et I. iv. rap. 10.; et Museum Anatom. vol. ii. p. 61—2.—Blumen- bach, De Anomalis et Vitiosis quibusdam nisus forinativi Aberrationibus Comment, p. 17.—Esquirol, in Diet, des Scien. Med. t. xxiii. p. 521.—Georget, De la Folie, kc. Paris, 1820, p. 478.—Landmann, Comment. Patholog. Analaro. &c. 4t . Lips 1820.—Pinel, Sur les Vices de Conforma- tion du Crane des Alienes ; in Bullet, de la Societ. Philo- math. Ann. t. iv. p. 103—109.—Wenzel, Ueber den Crete- nismus. Wien. 1802.—Baillie, Engravings, kc. fasc. x.— J. P. Frank, Opuscula Posthuma, p. 102. t 4—S, 8 o. Vien. 1824.—Krebel, De Anatomia Patholog. Ossium Capitis, 8vo. Halae, 1823.—Otto, Verzeichniss der Kreslaiier Anat. PrS- paratensamlung, No. 163. 165. 210. 3057. 3068. 8046, &c— Palletta, Exercitat. Patholog. v I. i. p. 127.—Abemombie, Path, ml Pract. Researches on Diseases of the Brain, kc. Edin. 1828. Bright, Medical Reports, &c. t. ii. p 686, &.c. —Cruveilheir, Anatomie Pathologique. Levr. 8vo Paris, 1830, fol.—Ballingall and Russet, in Tran«act. of Med. and Chirurg. Soc. of Edin. vol. i. p. 68. 74.—E. Thompson, in Lond. ,\Ied. Repos. vol. xxii. p 353. (P'ery interesting.)— (See also An. Cranium, in Ploucquet's Med. Digesta ; and in Otto's Lehrbuch der Pathol. Anat. des MenscheD, &c. Berl. 1830.) CRETINISM.—Syn. Cagots, Struma Tyrolen- sium, Gautier. Cretin, Critinisme, Fr. Classif. — 6. Class, 1. Order (Good.) I. Class, IV*. Order (Author.) 1. Df.fin.—Imperfect formation or develope- ment of the cranium, and the whole of the body, with mental imbecility, and physical imperfection, varying chiefly in degree. 2. This state of imperfect physical and mental developement, rather than of diseased action, was first noticed by Plater among the poor of Ca- rinthia and the Valais, where, and in the valleys of the lower Alps and Switzerland, it is endemic. But it is not peculiar to these places; for it has been observed in the valleys of the Pyrenees by Raymond, in some parts of Salzbourg by Knolz, and in various other localities in the cen- tral and southern countries of Europe, as well as in Chinese Tartary, according to Sir G. Staun- 442 CRETINISM — Description or. ton. M. De Saussure, Ackermann, Fo- dere, Iphof, Erhard, the Wenzels, and Knolz, have given us the best descriptions of this state of mental and bodily deformity, in respect both of its nature and causes. The brief account pf it by Dr. Good is both imperfect and errone- ous, and must have been written in perfect igno- rance of the descriptions of the above eminent ob- servers, as well as of others deserving of perusal. He very inaccurately associates it with bronchocele on the one hand, and with rachitis on the other ; with the former of which it is not necessarily, al- though very frequently, connected, and from the latter it is totally distinct. 3. I. Description.—Cretinism presents va- rious modifications in kind, and every intermediate grade between that extreme degree of physical and mental debasement which is characterised by the utmost deformity and entire absence of mental manifestation, the organic or vegetative functions only being performed, and that condition which may be considered as very nearly approaching the healthy constitution of man. There are cer- tain circumstances which distinguish cretins from other idiots, viz. a. They present certain bodily deformities, which are seldom or never observed in other idiots ; and, b. Their physical and men- tal infirmities are always the result of endemic causes. 4. In general, some degree of goitre is attend- ant on cretinism, but not invariably. Professor Knolz states that it is sometimes absent, and oc- casionally slight, the thyroid gland being enlarged in no greater proportion than several other glands are in the same subject. The stature is seldom above four feet and a half, often much less ; the cranium is deformed and has a conical shape— the forehead being thrown backwards, narrowed, and flattened, and the occiput being nearly on a line with the neck ; the flesh is soft and flaccid ; the skin wrinkled, yellowish, or pale and cadave- rous, dirty, and covered by chronic eruptions ; the tongue is thick, and hanging out of the mouth, which is open, large, and slavering ; the lower jaw is elongated and prominent; the eyelids are thick, the eyes red, small, but prominent, watery, and frequently squinting ; the nose is flat; and the whole countenance is idiotic or expressive only of lasciviousness. The belly is large and pendulous; the neck either short and thick, or long and thin ; the limbs crooked, short, distort- ed, &.c; and the gait imperfect and waddling. The senses are more or less defective, or alto- gether abolished ; the cretin being often deaf and dumb, and those who possess the faculty of speech expressing themselves imperfectly and with difficulty. The intellectual functions are either entirely absent or imperfectly developed, whilst the organic or vegetative functions are in a state of increased activity ; cretins being vora- cious, lascivious, and addicted to masturbation. They appear to have no other enjoyment than eating and sleeping ; and their insensibility is often so great, that they obey not the calls of na- ture. In some instances, the bodily deformity is not so remarkable as that now described ; im- becility, flaccidity of the soft solids, with bron- chocele, constituting the extent of infirmity.* * The following account of the " Fexes," or cretins of Salzbourg, is abridged from that given by Professor K.NOLZ: 5. The cretin, like most idiots, seldom attains an advanced age ; indeed, few of them reach up- wards of thirty years. Clayton remarks, that although they die early, they soon present the appearance of age. They are usually of the lymphatic temperament, with light hair and gray eyes ; the female cretin having enormously large and pendulous breasts. The less debased among them marry, rarely with one another, but do not propagate cretinism, the predisposition only to it being derived by the offspring from the parents. Malacarne (Mem. de 1'Acad. de Turin) at- tributes the mental debasement to the contraction of the bones of the cranium, which prevents the cerebral organs from acquiring their natural di- mensions and functions; and Ackermann es- pouses a nearly similar opinion. The conforma- tion of the body is generally stated not to be con- genital, although, at birth, the cretin may appear weak, puny, or sickly. It usually conies on gradually from birth ; and M. De Saussure states, that children who, living in the localities where it is endemic, and are not affected at eight or ten years, generally escape it; and that infants who are brought into these districts at a very early age, are equally subject to it with those who are born in them. —The whole body is stunted, its height not exceeding four feet. There is a total want of due proportion between its diflerent parts: the height of the head, with reference to the rest of the body, being l-4th or l-5th, instead of l-8th, the natural proportion. The neck is strong, and bent down- wards. The mamma: are very voluminous and pendent; the upper limbs reach below the knees; the arm is shorter than the fore-arm ; the chest narrow; the abdomen hemispherical, and of a length not exceeding the height of the head ; the penis and scrotum come down to the knees; the thighs are, with the haunches, of a greater width than the shoulders, and are shorter than the legs, the calves being almost wanting ; the foot is small, and the toes partly distorted; the lower ex- tremities are shorter than the upper half of the body. In the head, the masticating organs, the lower jaw, and the nose, preponderate considerably over the organs of sense and intelligence. The skull is depressed, and forms a lengthen- ed and angular ellipsis ; the receding forehead presents, in- ternally, large frontal sinuses, to which the brain has yielded a part of its place ; the top of the head is not vaulted, but flattened ; the occiput projects but slightly, and runs almost even with the nape of the neck, as in ruminating animals. The face is neither oval nor round, but spread out in width; the parts of which it is composed being wide and short, and the maxillary bones projecting greally. The forehead is narrow, flattened, and low ; the eyes are unusually far apart, diverge slightly, and are small, and seated deep in the orbit; the pupil is contracted, and not very sensitive to light; their external angles are situated higher than the internal; the eyelids, unless when dropsically swollen, are flaccid and pen- dent ; the look is a fixed stare without expression, and turns with indifference from all that is not eatable. The root of the nose is widened and depressed, the bones of the nose square; the zygomatic bones are wide, and extremely pro- jecting: the external ear is large, stands out from the head, and hearing is very defective. The elongated form of the lower jaw of the cretins, and their thick and padded lips, make them resemble ruminating creatures more nearly than man. The tongue is thick, and rather cylindrical than flat j the saliva is continually running from the angles ofthe mouth. Enlargement ofthe thyroid gland is recognised as one of the, signs of cretinism ; but its size is no sure guide to the extent of the existing infirmity. The throat presents, also, other ob- structed glands. The thorax is generally narrow and flat; the abdomen is usually distended with gases, and largely de- veloped towards the chest; the flesh of the extremities is flabby; the knee of an irregular shape, and usually bent; the fingers are very long and lank, and the nails very small. The upper part ofthe vertebral column being directed more or less forward, and the lower part, with the basin, being pushed backward, the sacrum assumes a more horizontal, and the other pelvic bones a more vertical position, than in the healthy formation. Besides the masticating and digestive organs, those of generation are also strongly developed, es- pecially in the male. (Medecin. Jarbucker des k. k. JEsterr Staates, b. i. st. 1. 1829, p. 86.) CRISIS. 443 6. II. Causes.—The principal, if not the only, cause of cretinism is dwelling, during in- fancy und childhood, in deep, narrow, moist, and malarious valleys, situated at a lower level than 3000 feet above the ocean, where the air is stagnant, and the solar beams intercepted by the mountains. MM. Ferkus, Georget, and the authors already referred to, state, that cretins be- come numerous in proportion as the valleys sink below this elevation. In addition to those causes, may be added the poverty, ill-feeding, drunken- ness, indolence, dirtiness, sensuality, and low debauchery of the parents,—circumstances tend- ing to the production of an infirm and deformed offspring; the inactivity and filth into which chil- dren who begin to evince signs of cretinism are allowed to sink, and the influence of water hold- ing calcareous and other mineral substances in solution. MM. De Saussure and Fodere, however, deny that the water is concerned in the production of this infirmity ; but MM. Bally and Rambuteau show that much is owing to it in the causation of cretinism, as well as Bron- chocele (see that article). The last named authority states that the offspring of the natives of Valais, who intermarry with persons from the Italian side of the Alps, are more subject to cre- tinism than those born of native parents; that females who have husbands from the higher Alps seldom have children affected by this infirmity ; that wherever cretins are seen, goitre is also prevalent; but that the latter is found in places where the former does not exist; and, conse- quently, that the same causes that occasion goitre, when present in an intense degree, also produce cretinism. 7. III. The Treatment of this infirmity is necessarily preventive rather than curative, and consists of the amelioration of the physical and moral condition of the parents; of the removal of infants, as soon as signs of the malady mani- fest themselves, to more elevated and open locali- ties, and to mountainous districts, to enjoy a purer air and stronger light; of obliging them to exert themselves in some useful and suitable employ- ment, and to pay attention to personal cleanliness; of frequent ablutions, followed by active and stimulating frictions of the whole surface of the body; of the use of stimulating tonics (Erhard); and of allowing them a stimulating and strength- ening diet, with a large proportion of animal food. Josias Simler, who wrote in 1574, states that the malformation, constituting the physi- cal infirmity, is sometimes congenital; and proba- bly it is so occasionally. In such cases, it is not likely that much advantage will accrue from any means. M. Rambuteau, however, states that it is scarcely ever congenital; but it is not un- likely that experienced observers may predicate, from the appearance of the newly born infant, whether or not it is likely to become the subject of this dreadful infirmity—may observe that state of developement and formation, which, if not actually the incipient malady, is predisponent to its occurrence. Bibliog. and REFER.—Stoi-r, Alpeureise Vorborei- twng, par. Iv.—De Saussure, Voyage dans les Alpes. Gi':- nev. 11UB.—Clayton, in Mem. of the Lit. and Philos. Soc. of Manchester, 1790, vol. viii. art. 13.— Ackermann, Ueber die Kretinen, &c. Gotha, 1790, '■vo.—Fodtre, Sur le Goi- tre et le Crelinismc, 8vo. Turin, 1792.—Erhard, in Hufe- land's Journ. der Pract. Heilk. b. xiv. st. 2. p. 30.—J. et C. Wenzel, Ueber den Cretinismus. Vien. 1P02.—Iphof, De Cretenismo. Viteb. 1804.—Michaelis, in Blumenbuch't Biblioth. b. iii. p. 640.—Virey, in Diet. Scienc. Med. t. vii. p. 343.—Georget, Diet, de Mtdecine, t. vii. p. 184.—Ram- buteau, in Ibid. t. vi. p. 186.—F. Sensburg, Der Cretinis- mus, 8vo. Wurzbourg, 1825.—C. Londe, Diet, de Med. Prat. t. v. p. 550.—,/. J. Knolz, in Bulletin des Scien. Med. t. xxi. 1830, p. 390.—J. Johnson, Change of Air. or the Pursuit of Health ; being an Excursion through France, Switzerland, and Italy, kc Svo. Lond. 1831, p. 56. CRISIS.—Syn. Koiaic, a judgment or decision (from xoiiw, I judge or determine). Judicium, Judicatio, Lat. Entscheidung der Krankheit, Ger. Crise, Fr. Crisi, Ital. Classif.—Prognosis. 1. Crisis may be defined a sudden change during the height of a disease, tending either to recovery or to death. Critical changes have been much regarded in the prognosis and treat- ment of diseases, from the time of Hippocrates, who first mentioned them, and the days on which they occur, down to the present period. As- clepiades, and the methodists, however, de- nied their influence, and disputed the existence of critical days. Galen and his followers at- tached great importance to them. It is recorded, that, having been called to a patient—a young man—with two disciples of Themison, Galen prognosticated a favourable change by a critical haemorrhage. The opinion was ridiculed by the two methodists, who advised blood-letting; but it was soon verified, for the patient had a copious epistaxis, after which he recovered. It is un- necessary to allude to the writers who have con- tended for the importance of this subject: they comprise most of the eminent names in medi- cine, from Hippocrates to Cullen, Pinel, Frank, Hildenbrand, and Kreyssig. The titles of many hundred volumes that have been written upon it might be adduced in proof of the consideration attached to it: and although much more has been imputed to critical evacuations, and days, particularly by the humoral patholo- gists, than legitimately belongs to them, and granting that too devoted an attention to them has induced many to adopt injudicious indications, and weak measures of cure, yet some reputation will be acquired from the prognosis which an ac- quaintance with them will enable the physician to give; and much benefit will result to the pa- tient from the treatment which this knowledge will suggest. 2. Since the overturn of the humoral pathology, the doctrine of critical evacuations has undeserv- edly fallen into disrepute, although the eminent writers who contributed most to the overthrow are amongst its most rational and warm espousers. In our own country, at the present time, too little attention is paid to these evacuations, and still less to the periods at which they occur. There can be no doubt that the former is the most im- portant ; but the latter part of the subject should not be disregarded. After all that has been urged in favour of, or in opposition to, the doc- trine, I may conclude that, in temperate climates, a number of diseases, particularly fevers, run on for certain periods with regularity, and, after an exasperation of the symptoms, or some violent perturbation of the economy, terminate by evacu- ations of different kinds, which tend to remove the train of morbid actions, and to restore the healthy functions. In other cases, the exaspera- tion of disorder is followed by imperfect evacua- 444 CRISES—Description of. tions, occurring in an irregular manner; whilst in some it gives rise to additional phenomena of a dangerous or fatal character: hence crises have been denominated salutary and complete, im- perfect and fatal. It was considered by the older writers requisite to a salutary crisis, that the evacuations constituting it should be attended by favourable symptoms, and be copious and manifest; and not only appropriate to the disease, but also consistent with the state of the patient. An imperfect crisis was considered better or worse : the better state alleviating the malady ; the worse rendering it more severe and danger- ous, from the supervention of metastases and complications. Having described the phenomena which are critical, I shall next notice the periods of disease at which they are most frequently ob- served. 3. I. Crises manifest themselves,—1st. On the skin : A. by sweats; B. by acute or chronic eruptions. 2d. In the cellular tissue : A. by swellings in various parts; B. by boils and carbuncles ; C. by gangrene ; and D. by purulent collections. 3d. In the glands : A. by buboes; B. by swelling of the parotids; C. by salivation; D. by a flux of urine. 4th. On the mucous surfaces : A. by increased ex- cretion—a. from the nose; b. from the bronchi, &c; c. from the stomach (vomiting); d. from the bowels (diarrhoea); B. by sanguineous exhala- tion—a. by flux—«. the hremorrhoidal; (I. the menstrual; b. by hasmorrhagy ; a. from the nose (epistaxis); (t. from the bronchi (haemoptysis); y. from the stomach (hajmatemesis); S. from the intestines ; f. from the uterus (menorrhagia) ; i. from the urinary organs (hematuria). 4. 1st. A. Sweats are salutary crises in con- tinued and bilious fevers, in inflammations of tlie lungs and liver, in bronchitis, and less frequently in rheumatism. Fracastori describes an epi- demic putrid fever which generally terminated favourably in this manner. Acute dropsy, par- ticularly anasarca, when caused by interrupted perspiration, sometimes disappears after copious sweats. This evacuation is usually preceded and indicated by a soft, full, open pulse ; by a dimi- nution ofthe alvine evacuations; by softness, and occasionally slight itching, of the skin; and by increased colour of the cheeks. A salutary sweat should be distinguished from such as are limited to the forehead or face, and the neck or breast, whilst the rest ofthe body is dry; or those which cover only the lower extremities : these constitute merely partial or incomplete crises, and merely diminish the violence of disease. 5. B. Eruptions.—Miliary and vesicular erup- tions only are critical: the others are merely symptomatic, or even form a part ofthe disease; as erysipelas, purpura, petechia?, &c. A miliary eruption is favourable, if the symptoms subside, if the patient feels an itching or pricking, if they be general, and do not appear before the seventh day : if they be unattended by fulness of the sur- face; and if their subsidence be followed by vomit- ings, hiccup, or convulsions, they indicate a fatal termination (Landre-Beauvais). Sometimes a miliary eruption comes out at different periods, and prolongs the disease, when partial relief fol- lows it, each appearance being an incomplete crisis. Many chronic eruptions may not only be complications of visceral disease, but occasionally imperfect crises,—they alleviating the internal ma- lady. They are more rarely completely salutary. 6. 2d. A. Swellings ofva>-ious parts, as ofthe face or neck, the hands, the lower extremities, &c, have been considered as partial crises in ataxic and gastric fevers, and in exanthematous diseases. B. Boils are critical in some complaints, particu- larly towards the termination of acute diseases, especially small-pox. C. Gangrenous pustules or anthrax occur in malignant or pestilential fevers; gangrenous escars also are met with in similar cases, as well as in tvphoid or adynamic fevers, particularly about the sacrum, and in places which have been blistered, or pressed upon. If, in such cases, the febrile symptoms subside upon the sphacelation, and if the gangrenous change be rapidly and distinctly circumscribed, it may be favourably critical; but if the symptoms continue, and the pulse becomes more frequent, weak, small, and soft, the local mischief is entirely symptomatic, and indicative of an unfavourable termination. D. Purulent collections are indica- ted by the continuance of the disease without any considerable evacuation, or exhaustion; by a sense of chill, horripilation or rigor, occurring at inter- vals, without any manifest cause; by the discharge of much clear urine; by partial sweats; by a soft- ness of the pulse; by a remittent or hectic fever, and by flabbiness of the soft solids. The favoura- ble changes of this nature occur in the extremities, and suppurate easily and rapidly. Those that are unfavourable take place in some internal viscus. 7. 3d. A. Buboes chiefly belong to pestilential fevers; but they are occasionally observed in the adynamic fevers of temperate climates. They indicate a favourable or fatal crisis in the manner stated with respect to gangrenous escars. B. Swellings of the parotids occur in low or malig- nant fevers ; and appear either alone, or with other critical changes. They are commonly pre- ceded by a slight rigor; by severe headach, stupor, noises in the ears, and deafness, with paleness, swelling, and sometimes redness of the coun- tenance. This occurrence is rarely critical, and, of itself, furnishes no sure indication of the issue: if accompanied with favourable changes, it be- comes an additional sign of returning health ; but if the swelling is slow, or disappears in a very short time, the other symptoms still continuing, it is a dangerous circumstance. C. Salivation was noticed by Sydenham as a principal critical evacuation in the fevers of 1667 and 1668 ; and it occurred in the epidemic that prevailed at Bres- law in 1700. It occasionally supervenes in some forms of cynanche, and in bilious and gastric fevers. D. The urine is sometimes discharged copiously at the height of febrile and inflammatory diseases ; and is to be viewed as a favourable occurrence. It is usually clear when recently evacuated, but deposits soon afterwards a whitish or rose-coloured sediment. The symptoms indi- cating this discharge are very obscure. Some authors have noticed the "pulsus myurus," which consists of every three or four successive puls- ations being progressively diminished. A sense of weight below the hypochondria ; of gravative tension in the hypogastrium, and of heat in the urinary organs, is stated by M. Landre-Beau- vais to precede this evacuation. 8. 4th. A. a. Coryza, or sero-mucous excretion from the nose, is sometimes critical in continued CRISES—Description of. 445 fevers; but little importance is to be attached to it. 6. Mucous excretion from the bronchi is fre- quently a partial crisis in several fevers, and in inflammations ofthe thoracic viscera (see Bron- chi and Lungs.) c. Vomitings are rarely indi- cations of a perfect crisis; they occasionally, how- ever, favour the developement of those changes which precede a favourable termination of disease. They are sometimes ushered in by a bitter taste in the mouth, yellowish fur on the tongue, subor- bitar pain, and headach, nausea, salivation, cold- ness of the extremities; and frequency, and oc- casionally intermissions, of the pulse, d. Diar- rhaa and copious alvine evacuations are favour- able crises in nearly all acute, and even in some chronic diseases. But it is necessary that they should be faeculent or bilious, and homogeneous— not watery or flocculent: if they approach to a natural, or have a yellowish brown, color, and are followed by abatement of fever, &c, a favour- able crisis may be confidently looked for. The chronic diseases, in which they indicate a change tending to health, are congestions and inflamma- tions ofthe liver and spleen, hypochondriasis and melancholy, slight or incipient dropsies, rheuma- tism, and gout. They are usually preceded by borborygmi, with slight flatulent distension of the abdomen ; flatulence and eructation ; a sense of tension and uneasiness in the lumbar region ; fly- ing pains in the extremities ; and a developed but unequal pulse, occasionally with irregular inter- missions. 9. B. Sanguineous exhalations are often critical in the more inflammatory states of fever, and in the phlegmasia?. According to Hoffmann and Lan- dre-Beauvais, discharges of blood from the nose, the haBinorrhoidal vessels, or the uterus, are equally salutary in ardent fevers. In general, these haemorrhages are preceded by depression of the morbid temperature, and erethism of the skin ; by slight horripilations of the limbs ; by a more open and rebounding pulse ; and a sense of heat, pruritus, and tickling, in the part whence the evacuation is about to proceed, a. The menstrual flux is sometimes a rapid crisis in fevers and phlegmasia?. It is indicated by dull heavy pains in the loins, groins, and tops of the thighs ; by tension in the hypogastrium ; heat and pruritus of the genitals ; pallor of the face, and a dark circle round the eyes ; swelling of the breasts ; pale, scanty urine ; horripilation, and erethism of the skin ; and by a quick, sharp, and unequal pulse. Very frequently the menses appear at the regular period, or a little earlier, or later, in fevers and inflammations, without affording any, or but imperfect relief. In these cases, they should not paralyse the activity of the treatment. When they occur at or before the usual time, are abundant, and are attended by evident benefit, they should be considered as critical: but if they are delayed, or are difficult or scanty, they are imperfect cruses, and should not interfere with the measures which the circumstances of the case may require, b. The hemorrhoidal flux is often critical in inflammatory fever, pneumonia, hepa- titis, and other phlegmasia?. Stahl states that a return of this discharge is sometimes favourable in inflammations of the brain, and particularly in hepatitis, nephritis, melancholia, hypochondriasis, and mania. The observation is certainly correct. This evacuation is indicated by pains in the loins 38 and the groins ; by a sense of uneasiness and pres- sure towards the anus and perineum ; by frequent desire to pass the urine and go to stool ; by flatu- lence and borborygmi, slight pallor of the face, and fulness of the hypochondria ; and by fulness and inequality ofthe pulse as to strength, c. Critical epistaxis was considered of great importance by the older physicians, who paid much attention to the symptoms indicating its accession : these are, redness, with slight tumefaction of the face and eyes ; reddish or brilliant objects floating before the eyes ; the involuntary shedding of tears ; weight of the temples, and beating of their arteries ; deaf- ness, or noises in the ears ; slight delirium, or ver- tigo ; a sense of tension in the neck, with disten- sion of its veins ; a dull pain in the forehead, and at the root of the nose, or an itching and tickling in the nostrils ; a quick, hard, full, and an unequal pulse ; frequent and slightly laborious respiration; sometimes with tension or oppression, without pain, at the prrecordia. Occasionally, pallor, and constriction of the whole surface, coldness of the lower extremities, and horripilations, also precede a critical epistaxis. This crisis is most common in young persons, and adults whose vital energies have been previously unimpaired, and who have been subject to this evacuation. It occurs most frequently in summer and autumn ; in the more inflammatory states of fever : in the acute phleg- masia? affecting the super-diaphragmatic organs ; and rarely in hepatitis. If the discharge consists of a few drops only, it is an alarming symptom ; and although it be copious, if not soon followed by amendment, it is unfavourable. When ex- cessive, and attended by syncope, convulsions, loss of power, partial or cold sweats, and cold ex- tremities, it is a fatal sign. A syncope, however, which terminates the epistaxis, is often followed by recovery (Landre-Beauvais.) 10. d. Hamoptysis, hamatemesis, hamaturia, and intestinal hamorrhagy, are always false or unfavourable crises. They are generally preceded by tension and tenderness of the hypochondria ; and supervene most frequently in adynamic, ma- lignant, and pestilential fevers ; in confluent small- pox, scarlatina maligna, and in scurvy : they oc- cur less frequently in females than in males. 11. A. The above are the phenomena which have usually been considered critical by the older, and which are admitted by the best modern, med- ical writers ; as well as the symptoms which indi- cate their accession. There are, however, still some circumstances connected with them deserv- ing of notice, a. The hamorrhagic evacuations occur most frequently in the spring, or in dry sum- mers, in persons from 15 to 35 years of age, of a sanguine or irritable temperament, and in acute complaints, b. The cutaneous evacuation is most common in summer and autumn, in robust and fat persons upwards of 30 years-of age, and in con- tinued, remittent, and intermittent fevers, c. A critical diarrhaa is most frequent in autumn, in persons of a bilious temperament, and in remittent and intermittent fevers, d. Discharges of urine are observed in all ages, in all seasons, particu- larly winter and spring, and in all acute diseases. 12. B. Critical evacuations are — a. rare, in persons enfeebled by age, or by some other ante- cedent disease ; in very moist and very cold, or ! very hot climates ; during remarkably sudden j and great vicissitudes of weather; and especially 446 CRISES —Causes. when the vital energies are much reduced by a lowering and an evacuating treatment. 6. They are not always similar in the same diseases ; and they vary in respect of the nature of the discharg- es, and of the periods at which they take place, as well as of the organs by which they are pro- duced. A favourable change in gastric, bilious, and adynamic fevers, is often attended by alvine discharges of a homogeneous, fluid, yellowish, yellowish brown, or brownish black appearance, —in inflammatory fevers, in young men, by epi- staxis, often occurring on the seventh day, — in these diseases, in young women, by a copious flow of the catamenia taking place on the same day,—and in men of middle age, by sweats, or by some other discharges coming on the fourteenth, or at a subsequent period. Catarrhal and bron- chial complaints terminate with expectoration, or with sweats, or a copious flow of urine, &c. 13. C. The duration of critical evacuations is very uncertain. The hemorrhagic, the alvine, and the urinary, seldom continue longer than twelve or twenty-four hours, sometimes even much less. Sweats and expectoration are occa- sionally of no longer duration ; but, in the major- ity of instances, these two evacuations are pro- longed several days before the disease is entirely subdued. Purulent collections and gangrene may take place in a few hours, but they generally re- quire a much longer period. 14. D. Critical discharges cannot be changed or determined in their route or period of eruption, by art; and when they supervene, they cannot be safely interfered with, unless they threaten life by their excess. If they be interrupted by accident, or by an injudicious and meddling prac- tice, they are followed by unfavourable metas- tases and complications, or sequela?, sometimes terminating in organic change, and death. Thus, when the perspirations which occur upon the change in fevers, and some of the exanthemata, are interrupted, effusion often takes place from serous surfaces, or into the cellular tissue. The most active vascular depletions can never com- pensate for the suppression of an abundant men- strual or haemorrhoidal flux, occurring at the acme of acute diseases ; -— the effects of art are here unequid to those produced by nature. Hence the advantage of recognising critical evacuations, even although we may not otherwise confide in them. Although it is thus important to attend to them in our prognosis, and especially in the treat- ment, when signs of their accession appear, or when they are actually present, yet the expec- tation of their occurrence ought never to inter- fere with or prevent the adoption of judicious in- tentions and means of cure. Even granting, with Hahnemann, that they are not to be imitated by art, still they furnish several useful indica- tions. " Quo natura vergit, eo ducendum est," may occasionally be adopted, after a careful con- sideration of the changes of which they are the effects, but not the causes. Much mischief has accrued from considering critical evacuations as the causes, and not as the consequences, of changes that take place in the economy at the acme of acute diseases. Rf.il has touched upon this fallacy, but has not considered the nature of the changes of which critical evacuations are the effects, or attempted to explain the manner of their accession. 15. II. Causes, &c.—A. We have seen that crises take place chiefly from eliminating or excre- ting surfaces and organs ; and that they consist of a copious irruption of either previously suppressed secretions and excretions, or an accustomed san- guineous evacuation ; but the causes which oc- casion, and the changes which precede them, are not so readily recognised. When we consider of what they consist, especially in relation to the fact of their occurrence only in maladies charac- terised in their earlier stages by interrupted se- cretion and excretion, and by morbid excitement of the vascular system — the vascular excitement being perpetuated and variously modified by sus- pension of the visceral functions now mentioned, or by local irritation, or by both—we shall arrive at a tolerably accurate inference respecting the causes of crises, and the importance that ought to be attached to them. There are few facts in pathology better established than that vascular excitement, when it reaches a certain height, or assumes an inflammatory form, impedes, inter- rupts, or even arrests, the natural functions of secreting or glandular organs ; whilst a lower grade of excitement, unattended by inflammation, generally increases the functions of the organ thus affected. Therefore, when excitement con- tinues to be expressed chiefly in the vascular sys- tem generally, secretion and excretion continue, impeded or entirely suspended ; and the effete materials, which, under other circumstances, are continually being removed from the circulation, accumulate in it, perpetuating and modifying the vascular excitement until it becomes exhausted, and until the accumulated noxious materials in the blood irritate the viscera destined to remove them, and thus incline the balance of excitement from the general vascular system to eliminating organs. Hence the occurrence of critical evacu- ations at the acme of acute diseases '; and hence their importance as indications of change in the states, — 1st, of vital power; 2d, of vascular action ; 3d, of the circulating fluid ; and, 4th, of the functions of secreting and excreting viscera. As crises have been neglected or confided in ac- cording as they agreed with the doctrines of the day, and have, in modern times, shared the fate of the pathology on which they had been so long grafted, I shall attempt to illustrate this view by a reference to one of the very common circum- stances in which they are observed. A person exposed to the causes of autumnal fever of a bilious and remittent form, experiences during the earlier stages the usual symptoms of impeded or interrupted secretion and general vascular ex- citement, with evening exacerbations. In conse- quence of interrupted action of the emunctories, the blood contains an increasing proportion of effete materials, particularly of the elements out of which bile is formed. These for a while in- crease and modify the vascular excitement, or, when excessive in quantity, or especially noxious in quality, even tend to exhaust or depress it ; but they, at the same time, being appropriate stimuli to the biliary and depu/atory viscera, serve to restore their impeded functions, to turn the bal- ance of excitement in favour of them,—thereby to reduce the morbid vascular action, to cleanse the circulating fluid from its impurities, and to change in other respects its condition ; and thus the disease terminates with an apparent collapse, CRISES —Causes. 447 followed by a copious discharge from the bowels, consisting of morbid bile, and of the excretions from the intestinal mucous surface—the products of the noxious matters which had accumulated in the blood, but which is now being eliminated from it by a renovated, as well as an increased, secreting and excreting function. Now, this pro- cession of morbid phenomena is consistent with what I have repeatedly observed in both tem- perate and warm climates; and shows that the ancients were not so far wrong as many of the moderns suppose, when they believed that critical evacuations were beneficial chiefly because they conveyed a morbid matter out of the system; and therefore could never be perfectly compensated for, or imitated by, art. 16. But it may be objected, that this explana- tion is based entirely upon the opinion that the circulating fluid becomes altered, owing to inter- ruption of the various secreting and excreting functions ; and that it cannot obtain in those cases wherein no such interruption appears to occur. In this case, it is very probable that cri- tical changes are effected in a" great measure by the vital influence of the frame. Even according to the foregoing view of the subject, the agency of the vital endowment must not be left entirely out of consideration ; for, without its reaction, through'the instrumentality of the different inter- nal organs with which it is associated, upon the morbid matters affecting it, those matters could not be separated from the circulation and expelled from the system. It seems, therefore, more than probable that crises consist, in the majority of cases, of more than the simple excretion of the accumulated effete matters from the circulation— such excretion being merely the effects of an an- terior and still more important and more constant change. The attentive observer of the pheno- mena successively occurring during the progress of disease must have sometimes remarked, in those maladies especially, wherein the vital manifesta- tions are particularly implicated, certain perturba- tions or struggles occurring at their acme, either followed by recovery, but without any very mani- fest evacuation—at least to the extent of explain- ing the circumstance; or passing into exhaustion and death, sometimes without any organic change to account for the issue. In such cases, we can merely infer, that the vital endowment of the frame resists or opposes changes in the state of the structures with which it is associated ; that it does so successfully in the former, and unavail- ingly in the latter, of these cases ; and that, un- less its energies are overwhelmed by very pow- erful and noxious causes, as occasionally is ob- served, it thereby tends to prevent the dissolution of this association to which such changes might directly or indirectly lead. This vital manifesta- tion—whether denominated the " vis medicatrix natura," or vital resistance, or vital reaction, &c. —most certainly obtains in a very large propor- tion of diseases, and is instrumental in the de- velopement of those changes, which immediately or mediately conduce to recovery, and which, in the more extreme cases, are attended by various phenomena indicating the vacillating predominan- cy of vital and functional power, or of organic disease ; the acquired ascendency of either over the other, occasioning, as the case may be, a favourable or an unfavourable crises. That such a struggle for the ascendency should manifest itself favourably at certain periods, or on deter- minate days, in preference to others, can be ex- plained only by considering it a law of the living economy identical with, or related to, the period- icity of vital action observed in the healthy, and still more apparently in the diseased functions. 17. B. Numerous illustrations of the following propositions might be adduced, in addition to that now advanced : — a. Evacuations occurring at the height of acute diseases are often among the first indications of, and are, indeed, occasioned by, the subsidence of local or general vascular excitement. 6. In many febrile diseases, crises are brought about by the excretion—under the influence of vital reaction or resistance of the se- creting viscera — of the effete matters accumu- lated in the blood, or upon internal organs and surfaces, owing to interrupted excreting function, as shown above, c. When a crisis is attended by apparent collapse or change of action, tliis may arise either from the vital reaction of inter- nal secreting organs occasioning a derivation from the periphery to the more central parts of the frame, or, from the previous exhaustion or sub- sidence of the vascular excitement allowing the secreting and excreting organs to resume their functions when excited by their appropriate stim- uli in the accumulated'elements of their respective secretions, d. When crises consist of sanguine- ous fluxes or discharges, they are occasioned, in great measure, by the vascular plethora conse- quent upon impeded secretion, together with local determination to, or congestion of, such mu- cous surfaces or organs as are most disposed, by original conformation, previous disease, or esta- blished function, to these changes, e. That a favourable crisis may manifest itself in one organ or function, or in two or more, either simultane- ously or successively, as by sweats, or by alvine or urinary discharges, or by expectoration, &c. /. When, during the progress of disease, the aqueous and albuminous elements of the blood become excessive, or when noxious matters accu- mulate, and are not eliminated in the form of crises as above stated, or by medical aid, they may so affect the capillaries in the parenchyma of the organs, or in serous surfaces, as to give rise to various organic changes and effusions. These may be viewed as unfavourable crises, determined to vital organs and internal cavities, arising from deficient vital energy, or vital resist- ance and reaction, or predisposition, or constitu- tional vice of some organ or part; each of which may obtain either alone, or with local or general plethora produced by interrupted secretion, &c. 18. C. Critical terminations are observed most frequently in the more inflammatory, the bilious, the gastric, and the intestinal forms of fever ; in the different phlegmasia), in some haemorrhagic diseases, and more rarely in chronic maladies. They are more commonly remarked in some epi- demics than in others; and are seldom apparent, as justly remarked by Lentin, in putrid or ma- lignant diseases, and, I may add, in the pesti- lential fevers of warm climates. In these, the depressing and contaminating influences of then- causes, and of the states of the secretions upon the nervous energy, on the circulation, and subse- quently upon the soft solids, so far subdue the vital influence as to render its resistance unavail 448 CRITICAL DAYS. ing in the morbid strife ; and it becomes insuffi- cient to separate and throw of the polluting mat- ters, which ultimately increase so as altogether to overpower it. The chronic maladies in which crises are sometimes met with are—mania, hvpo- chondriasis, melancholy, and idiopathic dropsies. But there are numerous circumstances which prevent their occurrence in the above diseases. It this country they are more rarely observed than they would otherwise be, if the treatment of the diseases in which they commonly occur were left more to nature. 19. D. Amongst the most frequent causes that prevent the developement of crises, particularly such as are favourable, may be enumerated—old age ; the lymphatic temperament, and leucoph- legmatic habit of body; previous disease, and dis- position of structures or organs to organic change. Constitutional or local vice; the scrofulous, gouty, or rheumatic diathesis ; exhausted vital power ; inanition or general cachexy, particularly from innutritious or unwholesome food ; and a too low- ering or depletory mode of treatment relatively to the constitution and circumstances of the pa- tient, not only obstruct the developement of regu- lar or favourable crises, but render them imperfect or unfavourable. The large depletions, and the copious and repeated alvine evacuations, very generally resorted to in the early stages of acute diseases, even although they may frequently ward off a fatal issue, often manifestly prevent the ac- cession of regular crises,—1st, by debilitating the patient, and thereby rendering the vital resistance insufficient for their full evolution ; and, 2d, from the circumstance of these means of cure being substituted or artificial evacuations or crises, and preventing by anticipation and substitution those which are natural. 20. And here a most important question sug- gests itself, viz. Whether or not it is better thus to substitute artificial, for the mere chance of the accession of natural evacuations 1 As respects the phlegmasia?, and many diseases,—particular- ly those, on the one hand, in which vascular ac- tion is excessive, and those, on the other, in which it is insufficient, and the vital powers are greatly depressed,—there can be no doubt of the propriety of resorting to artificial means to pre- serve an organ from the disorganising tendency of excessive action, and to raise the prostrate powers of life. Besides, it is excessive, and not moderate and judicious measures, which obstruct the evolution of favourable crises : the latter are even requisite aids to nature, in bringing about salutary changes, and a felicitous termination of disease. In respect, however, of many forms of fever, I believe that the nimia diligentia of the practitioner is as often injurious as it is beneficial, and that it disturbs those changes which can be effected only by time, and sometimes disposes to metastasis, complications, and unfavourable crises, by depressing the vital energies, and checking salutary changes at the early periods of their evolution, and before they become fully manifested. This fact was established by Hil- denbrand in respect ofthe typhoid and adyna- mic fevers which were epidemic through Germany from 1810 to 1816. He observed, that a much greater number of cases recovered when left in a great measure to nature, the physician inter- ferring no further than to preserve vital organs from dangerous congestions, than when a medici- na perturbatrix was adopted. 21. III. The Critical Days (Dies indica- torii) are those on which favourable changes usu- ally occur. They are either simply or especially critical. The third, fifth, seventh, ninth, elev- enth, fourteenth, seventeenth, twentieth, twenty- seventh, thirty-fourth, and fortieth, are critical days ; the seventh, fourteenth, twentieth, and twenty-seventh being those which are especially critical. Galen, and some other writers, men- tion the fortieth, sixtieth, eightieth, hundredth, and hundred and twentieth; but these are more doubt- ful, and can apply only to chronic diseases. The third, fifth, ninth, and, by some writers, the eleventh, and seventeenth, are often called inter- calary days: on these, crises less frequently occur. The intervening days are non-critical or vacant, on which salutary changes very seldom take place. Forestus, De Haen, Bordeu, and various other authors, have entered upon calculations respecting the terminations of acute diseases on particular days ; and it results therefrom, that about three fourths have observed regular periods. These periods are, however, not always the same in similar diseases. They vary with the age, the constitutional powers, the temperament, and the regimen of the patients. They are earlier, and much more uniformly observed, in robust epersons, than in those who are weak and advanced in age. 22. That critical changes should so frequently occur on the days specified, cannot be explained otherwise than in the way attempted by Cullen. He remarks that, from the universality of the ter- tian and quartan periods in agues, we cannot doubt of there being in the animal economy a ten- dency to observe such periods ; and the critical days above mentioned are consistent with this tendency, as all of them mark either tertian or quartan periods. These periods are, however, not promiscuously mixed, but occupy constantly their several portions in the progress of the dis- ease ; so that, from the beginning to the eleventh day, a tertian period obtains ; and from the eleventh to the twentieth, and, perhaps, longer, a quartan period is as steadily observed. 23. In entering thus fully into the exposition of the doctrine of crises, according to my belief, as deduced from observation, and the recorded experience of the best authors, I would recom- mend a judicious, but not a too partial, attention to them, excepting in fevers where morbid action lias so far advanced that a determinate course must be reckoned upon ; but, when any vital organ is threatened by disease, either originating in it, or.attacking it consecutively, as in the pro- gress of fevers and of the exanthemata, or when the vital powers are greatly reduced, although favourable crises may occur, they cannot be reckoned upon, and the expectation of them ought not then to prevent the adoption of deci- sive measures. When, however, they do super- vene under such circumstances, the knowledge of the facts connected with them becomes of real importance, inasmuch as it acquaints us that the means of cure ought to be directed in such a way as not to impede or interrupt, but to devel- ope and promote them. Their occurrence on certain days, in preference to others, should also induce us to watch the phenomena of disease at these periods with the utmost attention. It is true croup—ri that critical days have been denied by many of the moderns, upon the ground of their not having observed them. But, as Dr. Cullen has well remarked, the fault is in the physician. He who will not observe closely and comprehensively, should not throw discredit on the results obtained by the more accurate and attentive enquirer. Authorities in matters of opinion are of little value; but in matters of fact, as in tins case, they are testimonies — are positive evidences ; and whoever will take the trouble to refer to several hundred authorities collected by Plouco_vet, or even to those below (nearly all of which he has omitted,) will find them sufficiently conclusive. Bibliog. and Refer.—Hippocrates, Opera, ed. yon- der Linden, t. i. p. 437. 686. et passim.—Galen, De Diebus Decretoriis, 1. iii.—Oribasius, Synop. 1. vi. c. 1.—Fra- castori, Opera, passim.—Wekerii, Practica, 1. ii. cap. 6—15. Ven. 1644. — Baglivi, Prax. Med. 1. i. c. 9. — Sydenham, Opera Universa. Ed. Lugd. Bat. 1726, p. 163. — F. Hoff- mann, Dc Nat. Crisium, kc. Hals, 1706. — Ettmuller, De Crisi et Tumor. Crit. Lips. 1717.—Mead, Works, p. 200.—Stahl, De Periods Acuatrum, kc Hala>, 1708; De Autocratia Naturae. Halae, 1696, 4to.; et De Svnergia Nat. in Med. Halae, 1695, 4to.—Boerhaave, Instit. §'931.— G. Martine, On the Periods and Crises of Diseases. Lond. 1740.—Busson, Ered a recta Crisium Doctrina et Observat. Medicina certior. 4to. Paris, 1741.—Delius, De Diebus In- tercalaribus, in Advers. fasc. iv. — Hebenstreit, Vis Vita? ad judicandos Morbos, aeu de Motibus Nat. Criticis, 4to. Lips. 1749.—Bordeu, Recherches sur les Crises, in CEuvres Com- pletes, Paris, 1818, p. 209.—Van Swieten, Comment, vol. ii. p. 464.—Lentin, Beytrage, p. 21.—De Haen, De Diebus Criticis et Crisibus variis, Rat. Med. vol. i. cap. iv. p. 50.— Soemmerring, De Perturbat. Critica et Crisi. Moy. 1786. —Eckhardt, Veritas Doct. Cris. Marb. 1796.—Reil, Me- mor. Clinica, fasc. ii. p. 28.—Cullen, Works, by Thomson, vol. i. p. 593.—Hecker, Ann. der Pr. Med. Jul. et Aug. 1820.—Henke, Speci lie Pathologie, b. i. p. 21.—Cappel, De Viribus Corp. Hum. qua; dicuntur Medicatrices. Goet. 1800.—A. T. Richter, Die Specielle Therapie, b. i. p. 57. —Sprengel, Institutiones Medica;, vol. iv. p.4l6.—Hahne- mann, in Hufeland's Journ. der Pract. Heilk. b. xxii. st. 3. p. 12.—J. P. Frank, De Curand. Hominum Morbis, vol. i. p. 56.—Landre-Deauvais, Semiotique, kc Paris, 1813,2d ed.; et in Diet, des Sciences Med. t. vii. p. 370.— Hildenbrand, Institut. Practico-Medicae, kc vol. i. p. 66.— Fourcault, in Mem. de la Societe Med. d'Emulation, t. ix. p. ill.—Kreyssig, in Encyclopftd. Worterbuch der Medicin. Wissenschaften. b. viii. p. 646. CROUP—Syn. Affectio Orthopnoica, Bail- lou. Angina Strepitosa, Ghisi. Angina Infan- tum, Wilcke. Cynanche Stridula, Wahlbom. Angina Suffocatoria, Bard. Angina Infantum Strangulatoria, Russel. Cynanche, vel Angina Trachealis, Cullen, Johnston, Rush, &c. Asth- ma Infantum Spasmodicum, Simpson. Suffo- catio Stridula, Home. Asthma Acutum Infan- tum, Millar and Cookson. Morbus Strangula- torius, Starr and Rosen. Morbus Truculentus Infantum, Van Bergen. Angina Polyposa, Michaelis. Angina Membranacea, Auct. Var. Cynanche Laryngea, Dick. Orthopnea Mem- branacea, Laudun. Tracheitis Infantum, Albers et Frank. Angina Laryngea Exudatoria, Hufeland. Laryngo-TracMite, Blaud. Empresma Bronch- lemmitis, Good. Cauma Bronchitis, Young. Die Hiiutige Brdune, Huhnerhusten, Germ. Tra- cheite, Croup, Fr. Strypsiucka, Swed. Croup, or Roup, Scott. Hives, Amer. Classif. — 1. Class, Febrile Diseases; 2. Diseases of Sanguineous Function ; 2. Or- der, Inflammations (Cullen.) 3. Class, Or- der, Inflammations (Good.) III. Class, I. Order (Author, in Preface.) 1. Nosoloc. Defin.—Accelerated,difficult, wheezing, or shrill respiration; short, dry, con- stant, clangous or barking cough ; hoarse or al- 38* Pathology. 44a tered voice; pain and constriction above the ster- num, with symptomatic inflammatory fever ; fre- quently, towards the close ofthe disease, expecto- ration of membranous, albuminous, or glutinous substances, occurring in children. 2. Patholog. Defin.—Inflammation of the trachea, sometimes of the larynx and trachea, and frequently also extending to the large bron- chi, occasioning albuminous and membranous exudation, more or less spasm of those parts ; and terminating either in suffocation or ex- haustion of vital power, generally in a few days, or within the period constituting an acute malady. 3. Lit. Hist.—Although we had no precise account of croup until the work of Home ap- peared, yet there cannot be any doubt of its oc- casional occurrence among children from the earliest ages ; and that it was confounded with other diseases affecting the throat and air-passa- ges. Hippocrates states, "Angina Gravissima quidem est, et celerrime interimit, qua? neque in faucibus neque in cervice quicquam conspicuum facit, plurimum verd dolorem exhibet, et difficul- tatem spirandi, qua? erecta cervice obitur, inducit. Ha?c enim eodem etiam die, et secundo, et tertio, et quarto strangulat." And Baillou, after des- cribing an affection of the respiratory passages, observed in Paris, in 1576, with the nature°of which he was unacquainted, remarks, " Chirur- gus affirmavit sesecuisse cadaver pueri ista dif- ficili respiratione et morbo (ut dixi) incognito sublati: inventa est pituita lenta, contumax, qua? instar membranae cujusdam arteria aspera erat obtenta, ut non esset liber exitus et introitus spiri- tuiexterno: sic suffocatio repentina." That the above observations strictly apply to croup, there can be no doubt. Dr. Blair, of Cupar Angus, first mentioned, and shortly described, the disease by its present name, in his medical papers pub- lished in 1718. Ghisi noticed it, as it prevailed in the north of Italy in 1747, by the appellation of Angina Strepitosa ; Starr, in the Philo- sophical Transactions for 1749 and 1750, by the name of Morbus Strangulatorius; and Wilck e , as it occurred in Sweden during some years pre- ceding 1764. After the descriptions furnished by Home, and his Swedish contemporaries, Halen and Wahlbom, it received a place among specific diseases, and became the subject of a number of works, and even of controversial discussion. The treatises of Simpson, in 1761, and of Millar, in 1769, on the acute asthma of infants, gave rise to this latter occurrence, es- pecially on the Continent. These authors, having observed the more spasmodic states of this dis- ease, described them under the above designa- tion ; subsequent writers differing widely as to their being distinct maladies, or merely varieties of inflammatory croup, with predominance of the spasmodic symptoms. This point was warmly contested in the numerous productions which the prize offered by Napoleon, in 1807, called forth. My opinions respecting it will appear in the sequel. 4. I. History of the Forms and Pro- gress of the Disease.—Croup has been viewed, since its description by Home, as an in- flammation of the interior surface of the trachea and larynx. Some authors have divided it into three distinct varieties, namely, 1st, Catarrhal 450 CROUP — History of its Progress. croup, or a slighter form of the disease ; 2d, Nervous or Spasmodic croup, or a slighter state of the inflammation, occurring in nervous and ir- ritable temperaments, which influence the form and issue of the disease, giving rise to a spas- modic form of it; and 3d, Inflammatory croup, or that in which the inflammation of the air pas- sages is carried to a greater height, and is always attended by the production of a membranous ex- udation. The opinion that croup consists of an acute inflammation, occasioning the production, in a number of cases, of a false membrane ; in others, of an albuminous concretion of various degrees of density; in some, of a viscid mucous secretion, and of the inflammatory lesions of the mucous membrane itself, already described (see Bronchi, &c. § 3, 55.); has been attacked by MM. Guersent and Bretonnf.au, who con- sider that the formation of a false membrane is the distinctive character of croup ; and that those cases in which it is not formed, are merely what they term false croup. I agree with JVI. Bricheteau in considering that the distinction here contended for is calculated more to puzzle the inexperienced, than to advance our knowledge. The experiments of Schwilgue, Jurine, Al- bers, Schmidt, and Chaussier, as well as pathological observation, prove that the form of disease called false croup by the above authors proceeds from a similar state of morbid action as that denominated the pure disease, and is merely a modification resulting from less intensity of the inflammation, peculiarity of the temperament and habit of body, the causes occasioning it, and the greater predominance of the spasmodic or nervous states. The experiments of the authors now re- ferred to demonstrate, that the injection of irritat- ing' matters into the air-passages sometimes pro- duces simple inflammatory irritation ; in others, a thick, viscid, mucous exudation ; and in many, particularly in young animals, a complete false membrane. These differences of opinion, which are not confined to the writers now mentioned, but extend to many of those quoted in the course of the article, will appear, from what is about to be advanced, as more apparent than real. That the disease should present numerous modifications, approaching acute bronchitis on the one hand, and identical with laryngitis on the other, and varying characters according to the portion of the air- passages chiefly affected, the temperament, habit of body, severity of inflammatory action, and association with other diseases, is an inference to which a priori reasoning may lead every prac- titioner. Without adopting the confined views of some writers, or the hypothetical doctrines of others, I shall be guided chiefly by an extensive experience in the disease, and consider it under the following heads :—1st, The symptoms and progress of true croup ; 2d, The varieties or modifications of the disease most frequently ob- served ; and, 3d, The complicated and consecu- tive forms. 5. i. The usual Form and Progress of true Croup.—The simple and usual form of croup generally commences with more or less of precursory symptoms, and runs its course in a few days. L has been divided by authors into differ- ent stages or periods, more,—I believe, with the view of giving precision to their description, and to the treatment recommended, than from any marked change in the character of the symptoms. M. Goelis has divided it into four stages, viz. 1st, the invading or catarrhal stage ; 2d, the in- flammatory period; 3d, the stage of the albu- minous exudation ; and 4th, the period of* immi- nent suffocation. A nearly similar division has also been adopted by Dr. Cheyne. The diffi- culty of determining these various stages must be evident; and yet the advantages arising from a division of the disease into distinct periods must be evident,—not so much, however, for the pur- pose of description, as for the more strict appro- priation of the means of cure. Premising, there- fore, that croup, particularly this form of it, is strictly progressive, with no great change in its features, until towards its close ; and that, there- fore, all divisions of its course are merely arbi- trary, and without any positive grounds in nature; I shall notice, 1st, its precursory signs; 2d, its developed and confirmed state; and 3d, the state of collapse and imminent suffocation. 6. A. The precursory period, period of in- vasion (Guersent,) of irritation (Royer- Collard,) catarrhal stage (Goelis,) febrile period (Duges.) These precursory signs are sometimes well marked, and of a distinctly ca- tarrhal nature, as observed by Goelis: occasion- ally they are slight, chiefly of a febrile description; and either from this circumstance, or from the shortness of their duration, attract but little no- tice. The febrile symptoms, when present, con- sist chiefly of alternating chilliness and heat, or, in the more acute cases, of slight chills, followed by heat of skin, frequency and hardness of pulse, slightly flushed countenance, want of appetite, headach, excited or variable spirits, alternating with sadness, lassitude, &c. Often, in place of these, or in addition to them, there are a short cough, hoarseness, sneezing, coryza, sometimes moroseness, and all the signs of common catarrh. Upon examining the phraynx and mouth, no trace of inflammation can be detected in this form of the disease ; but the tongue is generally white, and loaded at its base. The eyes are watery, red ; and the eyelids darker than usual. These symptoms are sometimes only of a few hours' duration, or they may be present for two or even three days. In very young children, they may be so slight as to escape detection, whilst a somewhat different train of phenomena, such as heat of skin, chilliness alternating with heat, frequent short fits of coughing during the night, want of sleep, restlessness, indications of uneasiness about the throat, furnished by the fre- quent application of the child's hand to this part, &c. manifest themselves. The importance of ascertaining the invasion of the disease have led several writers to pay much attention to its pre- cursory symptoms. Vieusseux has attached much importance to the catarrhal signs, and change in the voice. But these are not by any means constant; and, even when present, may be merely the commencement of a slight catarrh ; indeed, there is no symptom which can be relied upon, as indicating its approach, until the disease is nearly fully formed. 7. B. The developed state of the disease (the Inflammatory, of Ch r. v n e and Hosack.)—After the above symptoms have existed for a longer or shorter time, or in a more or less marked manner, hoarseness, if it have not previously existed ; CROUP — History of its Progress. 451 sometimes a peculiar shrillness or puling of the voice ; difficult, sibilous, sonorous respiration ; and an unusual, dry, loud, clangous or ringing cough, as if passing through a brass tube, or sometimes resembling the barking of a puppy ; are observed. This croupal cough scarcely ad- mits of description, although it is readily recog- nised after having been once heard. The suc- cussions constituting it are followed by a dry, hissing, slow, sonorous inspiration, resembling the sound produced by a piston forced through a dry pump, or by a crowing noise similar to that emitted by a chicken in the pip. Expiration be- tween the cough is more easy than inspiration, but with precipitation; the pulse is frequent and hard ; the skin hot or burning ; the face flushed, sometimes covered with perspiration; the eyes are watery and prominent; the carotid arteries beat strongly, and the jugular veins are tumid. The head is now generally thrown backwards; and the child, either by its speech or attitudes, expresses a feeling of anxiety, with pain and con- striction about the trachea and larynx, which are often slightly tumified externally. The above symptoms, which usually first appear during the evening or night, generally somewhat subside early in the morning, excepting the frequency of the pulse, the hoarseness of the voice, peculiarity of the cough, and the sibilous inspiration. This remission sometimes continues the greater part of the day ; but after falling asleep, or to- wards evening, all the symptoms become more severe than ever; and the difficulty of respiration, the sense of suffocation, the anxiety and distress, are increased. The patient constantly applies the hand to the throat, which is sometimes pain- ful to the touch ; the countenance is bloated ; the pulse still remains frequent, hard or small; the cough is short, precipitous, convulsive, ring- ing, and followed by a crowing, or shrill or hissing inspiration; and at the commencement of this stage is generally dry, or attended by a scanty mucous or sanguineous expectoration ; subse- quently it becomes husky and suffocative, some- times with fruitless attempts to excrete what is felt in the trachea. The patient constantly changes his position; breathes with great difficul- ty, all the respiratory muscles acting with great force; and at each inspiration, the tumid larynx descends rapidly towards the sternum, whilst the epigastrium is drawn upwards and inwards; and, during expiration, the former is carried towards the maxilla, and the latter comes on a plane with the surrounding surface. If any remission at all occur now, it is much less evident. All the symptoms become more severe. The cough is now more difficult, suppressed, or strangulating; the suffocation accompanying it more imminent, and the stridor or hissing noise of inspiration fol- lowing it much louder: sometimes it is followed by vomiting, and the excretion of a glairy mucus, occasionally containing flocculent or membranous shreds. The pulse is now very frequent, con- tracted, sharp, and small. The cheeks and lips are, particularly during the cough, somewhat livid, or extremely pale and tumid. There are also great irritability and somnolency, but no delirium. The hissing, sonorous, and croupy character of the inspiration increases; and the voice, which was shrill or hoarse, often be- comes broken, whispering, suppressed, or puling. When vomiting follows the cough, and partic- ularly when the excretion of glairy, albuminous, and membranous matters accompany it, a mo- mentary relief is obtained, sometimes followed by progressive diminution of all the urgent symptoms. Deglutition, particularly of fluids, is sometimes difficult, especially when the larynx is affected, and induces the fits of cough and strangulation. These symptoms seldom continue equally intense during the whole of this stage, but present several slight remissions, particularly at its commence- ment, and in the less severe cases. Throughout this period, and, indeed, during the whole disease, the bowels are constipated, and the urine in small quantity, of a high colour, and generally albu- minous. The stethoscope generally furnishes no further information in this stage than a louder sound than that already heard; unless when the disease extends to the large bronchi; when a dry, tubular, or bronchial respiration, unaccompanied with crepitous dilatation of the pulmonary cells, but attended with perfect resonance of the thorax, may be detected. 8. C. The third stage, or that of collapse and threatened suffocation (the Suppurative, of Ho- sack and Cheyne,) may commence from the first to the seventh day from the invasion, ac- cording to the intensity of the disease, and consti- tution of the patient. This period is characterised chiefly by the absence of any remission, and the increased severity of all the symptoms, par- ticularly the acceleration and diminished power of the pulse and respiration. The pulse is now small, weak, irregular, unequal, or even inter- mittent; the cough is less frequent, less audible, suppressed, but suffocative. The voice is whis- pering, low, or entirely abolished; and the speech quick, imperfect, or lost; the motions of the ala nasi and the parietes of the chest are forcible and remarkable, and accompanied with a similar descent and ascent of the larynx and epigastrium to that already described (§ 7.). The head is constantly thrown back; perspiration flows from the forehead ; the eyes become sunk, and lose their animation; the countenance often assumes a leaden hue; the tongue is dark and loaded, and its edges and the lips are purplish; the sur- face of the body is covered with a cold viscid perspiration; the feet and hands swell; the skin is extremely pallid, and shows the veins through it, particularly those of the neck, which are large and distended; and the stools are dark and of- fensive. The patient very seldom recovers from this state; but he sometimes obtains momentary, much more rarely permanent, relief, owing to the expectoration of a portion of the albumin ous, membranous, and muco-puriform matters obstructing the larynx and trachea. When the excretion is free, recovery sometimes takes place slowly; but where it is scanty, or when the dis- ease has extended downwards through the bronchi, as it usually does when thus severe, the issue is commonly fatal. In this case, the patient tosses about in great distress; he seizes on objects around him, and grasps them convulsively for a moment; he throws his head back; seizes his throat as if to remove an obstacle to respiration; makes forcible efforts to expand the lungs; and after a longer or shorter period of such distress, seldom above twenty hours, expires, sometimes with signs of convulsive suffocation, but as frequently with 452 CROUP — Modifications of. continued increase of the foregoing symptoms, and evidence of exhaustion of the vital energies, and in a state of lethargy. The stethoscope gene- rally furnishes information in this period of the extension of disease to the larger bronchi. This extreme state of disease seldom lasts longer than twenty-four hours. In young children, convul- sions sometimes occur, and occasionally terminate life. 9. D. Such is the usual course of the more severe cases of common and uncomplicated croup, when left to nature, or unmitigated by treatment. In its slighter grades, hoarseness, with a hard ringing cough, followed by a crowing or stridulous inspi- ration, present chiefly in the night and remitting in the day, are almost the only symptoms; the respiration and pulse being but little disordered in the intervals, and the febrile symptoms not very acute. But even these very favourable cases may experience sudden and dangerous aggrava- tions; whilst, on the other hand, the severe and acute disease now described may be soon amelio- rated by early and decided treatment at its com- mencement, or by the discharge of tubular, mem- branous, or puriform matters, at its more advanced periods. 10. E. The duration ofthe disease depends up- on the vital energies ofthe frame, and varies from two to eight or nine days; but I have seen it ter- minate somewhat earlier, and prolonged much later when partial or scanty expectoration takes place from time to time. A fatal issue is most common on the fourth day. I believe that it very rarely assumes a chronic state,^preserving at the same time its essential characters; although a somewhat different opinion has been advanced by Goelis. The cases, however, which he has ad- duced as instances of the chronic disease, are evidently either the partial removal of the more inflammatory, with recurrence of the more spas- modic, symptoms; or slighter relapses; or the extension of the inflammatory action to the larger bronchi, and its continuance in this seat for a longer period. Albers admits that it may be- come chronic, and supposes that the false mem- brane may sometimes adhere to the inflamed surface, and be gradually absorbed ; recovery at last taking place, without the excretion of the albuminous substances in such cases. These oc- currences, although not impossible, are at least very rare. Hildenbrand supposes, on the other hand, that it may become chronic after the excre- tion of the albuminous exudation; inflammatory irritation still persisting in a lower grade, and terminating at last in ulceration. This is a much more probable occurrence; and I believe that I have met with it on two or .three occasions, but I have never been able to verify it by dissection. In such cases, the disease continues in a slighter grade for several weeks, and is characterised by frequent remissions and exacerbations, emacia- tion, muco-purulent expectoration, slight sore- ness in the trachea, and the usual symptoms of tracheal consumption; the patient sometimes sink- ing at last, or occasionally recovering by judicious means. 11. ii.THF. Modifications of Croup.—The forms which the simple or uncomplicated disease assumes are attributable, as already hinted, to the particular part of the air-passages chiefly affected, to the temperament and habit of body of the patient, and the intensity of the causes. 12. 1st. Croup with predominance of the acute- ly inflammatory symptoms (the Acutely Inflamma- tory Croup of several modern authors.)—This is merely the more acute or severe form of the disease, occurring in robust plethoric children of the sanguine temperament, who have been for some time weaned, and have had their first teeth, and during cold and dry states of the air. It is commonly preceded by chills, and horripilations, and in older children by distinct rigors; and is characterised by the more continued and unremit- ting severity of the symptoms, by the strength of the pulse, heat of skin, great difficulty and force of respiration, the vascular injection ofthe cheeks and lips, the highly inflammatory appearances of blood taken from a vein, &c. (a.) When the in- flammation chiefly, or even partly, implicates the larynx (the Laryngeal Croup of Gu e r s e n t and others,) the strangulation, cough, and all the symptoms connected with respiration, voice, and speech, are extremely severe; pain is felt in the larynx and upper part of the trachea, and there is sometimes slight swelling in this situation. In young children convulsions, and in older children delirium, occasionally occur towards the close. The disease terminates in from twelve hours to five or six days, but most commonly in two or three days. (6.) When the inflammation is con- fined to the trachea (the Tracheal Croup of sev- eral Continental writers,) the cough is at first dry, shrill, or sonorous, as if passing through a brass tube, and accompanied with sharp and lacerating pain in the course of the trachea, sometimes with slight tumefaction. The patient speaks in an under tone, but there is little hoarseness, and the voice and speech are not lost, or at least not so much affected as when the disease is seated partly or chiefly in the larynx. Heat of skin, and the usual symptoms of severe inflammatory fever, are also present. As the disease advances, the cough becomes more frequent and severe, but without the distressing sense of suffocation attending the foregoing modification; neverthe- less there is still much difficulty of respiration in the intervals between the cough, sometimes with a species of rattle similar to that of bronchitis. The fits of cough are often followed by vomiting, or the rejection of membranous shreds, with a thick, glairy, and sometimes sanguinolent or purulent mucus. The excretion of this substance general- ly is productive of much relief, which is increased after each discharge, unless the inflammation has extended down the ramifications of the bronchi; and then the respiration continues extremely dif- ficult, and the disease assumes all the characters of an acute bronchitis, and frequently terminates unfavourably. The progress of cases of this de- scription is usually not so rapid, nor the termi- nation so fatal, as of those affecting the larynx chiefly. All the symptoms evince less severity, especially when treated early; and it sometimes continues twelve or fifteen days, but usually from five to nine. When its severity merely is sub- dued, the inflammatory action not being alto- gether removed; or when, from accidental causes, or the fault of the constitution, it passes down the bronchi; it may be much more prolonged, and approach the chronic character; but it will then present many of the features of the most severe CROUP — Modifications of. 453 bronchitis, into which, indeed, it will thus pass ; ! and, as was stated in respect of that disease, whilst bronchitis may be followed by croup, the latter malady may thus occasion the former. 13. 2d. Croup with predominance of bronchial symptoms (the Cynanche Trachealis Humida of Rush ; the Mucous Croup of some modern au- thors.)— This form is not infrequent in young children ofthe lymphatic temperament, who are fat and flabby, with a white soft skin. It is often met with soon after the period of weaning, and in j those who are brought up without the breast. It j commences with coryza, and the other symptoms of catarrh, and often with little fever. After these signs have been present for some time, or some- times without these being so marked as to attract I attention, it generally attacks the child in the eve- ning or during the night, and manifests itself in a decided manner by the sudden occurrence of a hoarse, suffocating, dry, sonorous, or shrill cough, with a sibilous inspiration. The seizure is usually severe, and is attended with manifest alarm to the patient. The countenance is pale, and covered by perspiration, and the lips are violet. Several slighter fits succeed to this first attack ; the voice remains hoarse and low, the respiration sibilous and slightly difficult ; but a remission usually j takes place in the morning, and there is gener- | ally but little return of the croupal cough until evening and night, when it recurs, but often in a slighter degree. In some cases, the invasion is more gradual; the remissions but slight, or hardly | evident, and the accession of expectoration much earlier; the disease approaching nearer, as re- spects its seat and character, to acute bronchitis. There is but little fever, the skin is not much j warmer than natural, and the powers of life are not remarkably depressed. The throat and pha- rynx are unaffected. After the first, second, or third day, the cough is no longer dry, its fits be- come shorter, is sometimes accompanied with a mucous rattle, and begins to terminate in the ex- pectoration of a thick glairy mucus. The disease now assumes many of the features of, or passes j into, bronchitis. M. Guersent considers that this is merely a false or bastard croup. I be- lieve that it is a milder form of the disease ; and that it consists of a slighter degree of the inflam- matory irritation of the same parts which are affected in the true croup ; but that, in conse- quence of the much less severity, or some other modification, ofthe diseased action, and constitu- j tion of the patient, glairy mucus merely, instead j of an albuminous exudation of a firm consistence, is thrown out ; and that, when the features of bronchitis are assumed, the inflammatory action has extended down as far as the small bronchi. I 14. 3d. Of croup with predominance of spas- modic and nervous symptoms (the Laryngismus Stridulus of Good; Spasmodic Croup of Wich- mann, MicHAeHs, Double, &c; and the Acute Asthma of Infants of Simpson and Mil- ! lar.) This variety of croup has been described by German and French authors, under the name of Millar's Asthma and has given occasion to much discussion relative to its being a variety of croup, or a distinct disease. Of its being the former, however, there cannot be the least doubt. It occurs chiefly in children who are weak, irri- table, subjects of worms, and ofthe nervous tern- j perament; and comes on most commonly in the j night, often during the patient's first sleep, fre- quently without well-marked premonitory symp- toms, excepting languor, listlessness, headach, fretfulness, and sometimes a short tickling cough; and these may be slight, or of short duration. The child is suddenly wakened by great difficulty of breathing/ cough, and general agitation, and continues thus affected for some time; the symp- toms gradually subsiding towards morning, or being more quickly relieved by the cough termin- ating in vomiting. This form of the disease al- ways presents complete remissions during the day, with exacerbations in the evening and night, and thus assumes a regular type ; but the remissions often become less complete and of shorter dura- tion, the exacerbations more frequent and prolong- ed, and the cough, difficulty of respiration, general agitation, and convulsive movements attending them, more severe. There is little or no increase of animal heat or fever, nor actual pain in the larynx and trachea, but a sensation of constriction and uneasiness. The countenance is generally pale in the remissions, and sometimes tumid and livid in the exacerbations, during which the respi- ration becomes sonorous, laborious, convulsive, and croaking: the extremities are usually cool. The cough continues dry, and accompanied with marked irritability, until the favourable termi- nation of the disease ; when slight or moderate glairy expectoration takes place, but without any membranous substances mixed with it. The pulse is very variable ; sometimes small, frequent, and constricted ; occasionally slow; but generally at last unequal, weak, or intermitting. The urine is paler than in the common and more inflamma- tory states of the disease, in larger quantity, and sometimes deposits a nebulous sediment. In this variety, the nervous and spasmodic symptoms are present from the commencement ; in the former, they appear chiefly in the two last stages; the more common and inflammatory croup some- times thus passing into the spasmodic. 15. Such are the usual characters of the well- marked spasmodic variety of croup; but cases of so pure and unmixed a form are comparatively rarely met with in practice; as the intermediate shades between the state of disease now described, and either of those preceding, are more commonly observed, at least in this metropolis and vicinity. I have scarcely ever seen a well-defined case un- connected with dentition; or one terminate fatally without the occurrence of convulsions in its ad- vanced stages, or towards its termination; and it has very commonly presented evidence of cere- bral congestion. On dissection of fatal cases, M. Guersent states, that albuminous concretions— sometimes extensive, but more frequently con- sisting of small isolated patches—are found in the larynx; whilst Millar and Rush detected little or no lesion ofthe air-passages. In the very few opportunities I have bad of examining the state of parts in the more purely spasmodic cases of croup, an adhesive glairy fluid, with patches of vascu- larity, were observed in the epiglottis and larynx, aid a similar fluid was found in the large bronchi., Congestions of the brain, particularly about its base and medulla oblongata, and of the lungs, cavities of the heart and large vessels, were also found; but these were most probably consecutive changes merely. 16. iii. Complications of Croup. — A. 454 CROUP — Complications or. With Cynanche maligna. This complication is distinctly alluded to by Johnstone, Wither- ing, Cullen, and several contemporary authors; and is common in the epidemic visitations of this disease, or of anginous scarlatina; the greater num- ber of fatal cases exhibiting soft fragments of false membranes, of a greyish or ash colour, covering the larynx and trachea, and a livid appearance of parts of the subjacent mucous membrane. This is one of the most dangerous complications of the disease. The affection of the air-passages is here consecutive, and the difficulty of swallowing usu- ally precedes the characteristic symptoms of croup, which are generally accompanied with great foetor ofthe breath.—«. In many instances of the ma- lignant sore throat, the exudation thrown out from the inflamed suiface forms a pellicle coextensive with the spread ofthe inflammatory process from the fauces to the pharynx and air-passages. In some cases, ulceration, and slight apparent slough- ing, occur in the central parts, and those first af- fected; whilst the surrounding surface, and parts subsequently diseased, become covered by a soft and easily lacerated exudation. In rare cases the inflammation commences in the pharynx (Cynan- che Pharyngea,) and spreads to the fauces on the one side, and down the larynx, trachea, and oeso- phagus on the other. In these, the pellicular ex- udation formed on the inflamed surface very nearly approaches that of croup; oftener, however, it is of a darker and dirtier colour, softer, and not so continuous: whilst in some cases it is formed in patches, is similar to thin sloughs, and is inter- rupted in parts by a dark, foul, but not concrete secretion; the subjacent mucous surface being of a dark, livid, or brick-red colour, or ulcerated, or even partially sloughed. Sloughing, however, or even ulceration, although mentioned by several writers, is comparatively rare; the more frequent commencement of the faucial or pharyngeal com- plication of croup being attended by the pellicular or concreted exudation now mentioned, without sloughing. The above changes are most remark- able in the pharynx, and are slighter in the larynx and trachea ; the exudation being there some- what paler, and from its colour and appearance very generally mistaken, both while adherent to, and whilst being detached from, the inflamed sur- face, for sphacelated sloughs, particularly as ob- served in the throat, and described as such. The complication, with croup, of various states of an- gina or sore throat — malignant, or epidemic — whether commencing in the pharynx, or in the fauces and extending to the pharynx, is not un- common. Epidemic visitations of it have occur- red in very modern times, and have been describ- ed by Hamilton, Deslandes, Bourgeois, Bretonneau, Trousseau, Moronval, Em- angard, Schmidtmann, and others. — (i. In some cases the affection originates in the tonsils, (Cynanche Tonsillaris, kc.) and extends to the adjoining parts. In the croup epidemic in Buck- inghamshire in 1793, and described by Mr. Rum- sey, the croupal symptoms were stated to have been coeval with " inflammation and swelling of the tonsils, uvula, and velatum pendulum palati; and large films of a white substance were formed on the tonsils." Similar appearances have like- wise been noticed by Ferriar, Hosack, Mac- kenzie, RoRERT.soN,and Bourgeois, and by myself; the pellicular exudation extending over the fauces, down into the pharynx and larynx. The croup which has been described by Louis, Hufeland, and others, as occurring in adults, was thus complicated. The complication with the malignant sore throat has been observed by me both in its simple form and in its association with scarlet fever. Some years since I attended, early in the winter, some of* the children of a numerous family residing a few miles from town, in a low and damp situation. They had had scarlatina, with very severe sore throat, two or three years previously. On this occasion, one of the oldest was seized with malignant angina, extending to the pharynx, and along the Eustachian tube to the ear, with foetid respiration, and irritation of the larynx, producing a constant tickling cough. A similar afiection spread to four of the younger children, and in two of them it was complicated with croup; the symptoms of which were severe, continued, and well marked in one, and more spasmodic and intermittent in the other. In these, ash-coloured exudations covered the greater part of the fauces and tonsils, and,extended down into the pharynx. They recovered with difficulty, by the means hereafter to be noticed. 17. B. Croup may also be complicated with Thrush. — Cases of this description are rare. I have seen only two of which I have taken any ac- count. This association has also been observed by Jurine, Double, Pinel,and Royer-Col- lard, who notice the adynamic or ataxic char- acter of the fever accompanying it; the adynamic state being the consequence chiefly of this asso- ciated disorder supervening upon pre-existing dis- ease, generally of the digestive mucous surface, and often, moreover, in a weak and cachectic system. The patches of pellicular exudation in the mouth and throat, characteristic of thrush, had extended down the pharyux, larynx, and part of the oeso- phagus, in these cases: death having been oc- casioned by the consequent irritation, and frequent recurrence of spasm of the larynx. In the only one I had an opportunity of examining after death, there was little or no inflammation in the trachea; but there was considerable vascular injection of the pharynx, epiglottis, and larynx, which were covered by a cream-like exudation, their mucous membrane being softened. The trachea and bron- chi contained some flocculent viscid mucus ; and the digestive villous surface, particularly in the upper part of the oesophagus, stomach, and por- tions of the small intestines, was softened and in- flamed. In all the foregoing complications, the affection of the larynx and epiglottis is generally more remarkable than that of the trachea. 18. C. With the exanthematous fevers.__a. Croup sometimes comes on during the eruptive fever, ot efflorescence of measles; when it oc- casionally assumes more of the remitting and spasmodic character, and is seldom very severe or dangerous. In this case it generally subsides as the eruption becomes abundant. But it also supervenes upon the extinction of the eruption ; or it does not appear until during or after de- squamation ; and, in some instances, not until advanced convalescence. When this occurs, the inflammatory fever soon passes into an adynamic state, and the disease assumes a severe form, with spasms of the larynx, often terminating with convulsions and suffocation. In one instance of this kind that occurred in my practice, much CROUP — Terminations — Prognosis. 455 swelling and oedema of the throat appeared ex- ternally, and aggravated the symptoms; recove- ry, however, unexpectedly took place, with a free discharge of glairy mucus, and concrete fragments of membrane. In another instance, emphysema of the throat occurred, and gradually extended over the neck, chest, and face. Permission was not obtained to examine the body, so that the channel through which the air had passed from the respiratory passages into the cellular tissue could not be exactly ascertained.—b. The complication with small-pox has been very particularly noticed by Pinel, Albers, Vieusseux, and Royer- Collard, and is not uncommon. It usually occurs in the more severe cases, particularly when the disease is confluent, and generally comes on slowly in the suppurative stage. In the more malignant cases, the difficulty of respiration is ex- cessive; the voice very hoarse or suppressed; the poroxysmsof sutibcation extreme; the cough dry, or giving issue merely to a small quantity of dirty serum, or muco-sauguineous matter ; and the at- tendant fever adynamic. On dissection, a mem- branous substance is seldom found iu the larynx or trachea, but merely portions of a semi-concrete matter, with spots of intense inflammation in these parts, the epiglottis, and large bronchi.—c. The complication with scarlet fever is never met with excepting this disease be associated with sore throat, especially when malignant or epidemic (§ 16.).—iti. The association, or rather the su- pervention of croup on erysipelas, particularly of the head and face, occurring in adults, has been observed by Forestls (Opera, I. xv. obs. 20.,) Latour, Stevenson, and Gibson (Trans, of Med.-Chirurg. Soc. of Edin. vol. ii. p. 95.). In those cases, the inflammation and characteristic ex- udation spread from the fauces to the air-passage. 19. D. With other diseases.—a. Croup is some- times associated with acute bronchitis ; and when it terminates fatally, it is often in consequence of extension of the inflammation to the bronchi, and thence to the substance of the lungs, pneumonia thus also supervening. But the croup may also, • although much more rarely, be consequent upon bronchitis, b. It may occur in the course of pertussis, and it then usually assumes the re- mittent and spasmodic, or the bronchial forms. c. Lastly, it may be associated with atsophagitis; but when this is the case the inflammation with albuminous exudation usually commences in the pharynx, and extends down the oesophagus, and to the larynx. This is not an infrequent occur- rence in children under two or three years of age; as, indeed, M. Guersent has remarked ; the larynx and epiglottis being the only parts of the air- passages affected ; and these chiefly with spasm, from the irritation of the portions of false mem- brane covering or coming in contact with them. 20. II. Terminations and Prognosis.— Croup may terminate—1st, in recovery ; 2d, it may pass into or excite some other disease,—a return to health, or a fatal issue, taking place me- diately through it; 3d, in death, either from ex- haustion ofthe vital energies, or from suffocation. A. A return to health is indicated by the mild form of the disease ; by the quiet respiration whilst the cough is absent; by the moderate excitement and frequency of the pulse ; by a looser cough and a more natural state of voice, followed by expec- toration of viscid mucus and membranous frag- ments ; by a copious and general perspiration on the third day, the symptoms being moderate ; by epistaxis on the second, third, fourth, or fifth days ; by the absence or subsidence of violent attacks of spasm of the glottis, and suffocation ; by the simple and uncomplicated state of the disease ; and the absence of exhaustion, or of great frequency or irregularity of pulse, and of other signs of adynamia. 21. B. It may excite additional disease, or pass into some other malady,—a circumstance which, although not necessarily fatal, may greatly increase the danger. The morbid state of the system, and general depression of vital power accompanying most of the complications now noticed ; the more constant affection, and dispo- sition to spasmodic action of the larynx, in all of them ; the interruption caused to the respira- tory processes, and the attendant or consequent congestion of the lungs, as well as the marked disposition they create to consecutive disturb- ance ; greatly augment their danger generally. The disorders consequent upon the simple and complicated states of croup are both direct and indirect. The direct are—a. Extension of in- flammatory action to the bronchi and substance of the lungs,—generally an unfavourable event, and indicated chiefly by the unremitting persist- ence ofthe symptoms, by deep suffocating parox- ysms of cough, great frequency of pulse, lividity or leaden hue of the countenance, by the dark tinge of the lips and tongue, cold clammy per- spirations, somnolency, and all the characters of asthenic Bronchitis (§ 37.). When the bronchial affection does not appear until during convalescence, it is more slight, unless the causes have been energetic, and it presents more of the usual characters and states of that disease. The consecutive occurrence of either pneumonia or any of the forms of bronchitis should be carefully inquired after, by observing the symptoms, and examining the chest by auscultation.—6. Exten- sion of disease to the sub-mucous and follicular structures, occasioning inflammation and ulcer- ation of these tissues, with symptoms of laryngeal or tracheal consumption upon the subsidence of croup, is a much more rare occurrence than the preceding ; but, when it takes place, a muco- puriform expectoration accompanies and follows the characteristic discharge and signs of croup, with pain and irritation in the larynx and trachea, recurring exacerbations of suffocating cough, and difficulty of breathing, chiefly of a spasmodic description, particularly when the inflammatory irritation is seated in the larynx or epiglottis, and the usual symptoms of hectic. The very marked tendency, also, of the disease to relapse, is in a great measure owing to the persistence of a slight degree of inflammatory action in the large bronchi, or in the trachea and larynx, for some time after the membranous exudation on the diseased surface has been thrown off; the dis- order being readily aggravated upon exposure.to the exciting causes. Tin's disposition of the dis- ease to return diminishes with the length of time that has elapsed from the subsidence of the ori- ginal attack, but does not altogether disappear for many weeks, or even for months, especially in some constitutions, and in the last and first montlis of the year; and even more than one relapse may take place in weak, irritable, and 456 CROUP—Diagnosis. nervous frames, but generally in a more spasmodic form—c. Besides producing these, it may occa- sion, although very rarely, abscess in the vicinity of the larynx or trachea. I believe that dilata- tion of the bronchi is a much more frequent re- sult.—d. Of the more indirect terminations and consequences of this disease, congestions of the encephalon, giving rise to convulsions and effusion of serum in the ventricles, or between the mem- branes, are the most important. In many cases, particularly in delicate and nervous children, the convulsive movements seem to commence with the spasmodic actions of the laryngeal muscles, and the strangulation thereby occasioned ; the head and neck being thrown back, and all the limbs convulsed. Life is in some cases thus ter- minated by asphyxy. Jurine, ViEussEux,and myself, have met with cases of hydrocephalus following the disease ; but they are not common. 22. C. Danger is to be dreaded, when fever is very high early in the disease, and when respir- ation is permanently audible, cooing, and labori- ous', or as described above (§ 7.). When the disease goes on to the third stage, notwithstand- ing the treatment; when it presents any of the complications (§ 16.) and consecutive affections (§ 21.) already noticed: when the discharge of the characteristic exudation does not take place, or when the expectoration of fragments of it is not followed by any relief; when the counte- nance becomes livid or leaden, the eyes sunk, the lips and tongue dark, and the pulse very fre- quent, small, weak, and irregular ; and the other symptoms of vital exhaustion appear; great dan- ger exists. A fatal issue is to be expected when the patient presents the appearances described as characterising the third stage, particularly those noticed as marking its close (§ 8.). 23. III. Diagnosis.—The hoarseness, and the loud, sonorous, and ringing cough ; the forcible and difficult inspirations ; flushed face ; injected and watery eyes ; the frequent and hard pulse, with thirst and inflammatory fever, the hei.ving of the thorax and motion of the trachea, in the developed stage; and the husky choking cough, the whispering voice, and wheezing respiration, &c. of the third stage ; sufficiently distinguish this disease from any other. When it is uncom- plicated, nothing beyond a slight redness is ever observed in the throat ; and there is little or no pain upon deglutition, unless the larynx be much affected.—a. Croup can scarcely ever be mistaken for Cynanche maligna, or C. Pharyngea, or any other form of sore throat, as long as these affec- tions do not extend to the larynx ; as the great difficulty of deglutition, and the but little disturbed state of respiration, independently of the obvious affection ofthe throat, &c, are sufficient to distin- guish between them. When, however, portions of the concreted exudations in these affections irritate the glottis, they occasion a short, tickling, dry cough; and even excite, in some cases, stran- gulating spasms of the larynx, nearly resembling croup, particularly when it is complicated with these maladies. If, however, it be thus associat- ed, the croupal characters, in addition to the ap- pearances in the throat and pharynx, will be too evident to be misunderstood ; the descriptions already given of these complications being suffi- cient to point them out.—6. During the eruptive fever of measles, the tracheal affection is often so great as to simulate croup ; and in many cases it even amounts, as already stated, to a slighter form of the complaint, which usually disappears as the eruption becomes matured : but attention to the symptoms will readily show the nature of the disorder, and how far the affection of the larynx and trachea should be viewed as a symptom, or as an important complication of the exanthema- tous disease.—c. (-roup may readily be distin- guished from bronchitis, by its sudden and severe attack ; its occurrence in the evening and at night ; its remissions ; the hoarseness, and the ringing, dry, and frequent cough; the difficult in- spirations, and impeded respiration; the altered voice and speech ; the sensations and symptoms referrible to the trachea in the former, and to the sternum and chest in the latter ; and by the ab- sence of expectoration until late in the disease, when it is membranous or tubular, and not mu- cous and muco-puriform as in bronchitis, until after the discharge of the membranous exuda- tions. These characters will also serve to indi- cate the supervention of croup on bronchitis,—an occurrence which is sometimes observed, although much more rarely than that of bronchitis on croup.—d. Laryngitis is with greater difficulty distinguished from croup than the foregoing, and in many respects there is little or no difference. The practical importance of the diagnosis may not appear great, but it is sufficiently so to war- rant an accurate distinction. 1st. True laryngitis occurs in adults; seldom, in children, in any other form than associated with either the simple or complicated states of croup. 2d. It is a purely inflammatory disease, attended by a fixed burning pain in the larynx, increased on pressure and examination ; and, when attacking adults, never gives rise to a false membrane, unless it be su- perinduced in the specific and epidemic forms of cynanche, and then it assumes modified charac- ters. 3d. It more frequently terminates in the manner characterising acute inflammations, viz. ulceration and suppuration, than when the larynx is affected in croup. 4th. It is more acutely and constantly inflammatory, the symptoms are more continued, and it is more benefited by a purely antiphlogistic treatment, than croup. 5th. It much oftener passes into the chronic form, than the latter disease. (See Larvnx— Inflammations of.)—e. Chronic laryngeal and tracheal inflammation — the laryngeal and tra- cheal consumption of some writers — resemble croup, in the hoarse voice, harsh dry cough, and the difficulty of respiration ; but their progress is much slower, and less acute, than croup ; they do riot present the violent paroxysms towards night ; they seldom or never are" observed in children; and ulceration of these parts of the air- passages is always found in fatal cases.—/. Croup may also be confounded with the diffusive inflam- mation which sometimes attacks, either primarily or consecutively, the cellular tissue about the throat, or with abscesses in the same situation; either of which may involve the larynx and mem- branous part of the trachea, or so affect them aa to give rise to croupal symptoms ; but the ex- ternal appearances, the difficult deglutition, the state of the throat, and the history of the case, will at once show the differences existing between them.—g\ Pertussis and croup can hardly be mistaken for each other ; the invasion, charac- CROUP —Causes of. 457 tcrs, and progress of both diseases being so very different The prolonged whoop, the unchanged voice, and the occurrence of the cough in con- vulsive paroxysms after a meal, terminating in vomiting and a copious discharge of a clear and glairy fluid; the complete intermissions, respira- tion, voice and speech remaining unaffected; the almost entire absence of fever, and the much more slight and chronic form, of the latter disease in its uncomplicated state; are sufficient distinc- tions. Croup may, however, occur in the course of hooping cough ; but then its characteristic symptoms will make it apparent to the attentive observer, and point out the nature of the resulting association.—h. The effects following substances that have escaped into the trachea often resemble croup; but may be distinguished from it by the sudden occurrence of pain and suffocation; by the frequent change of the exact seat of uneasi- ness with the change of the situation of the foreign body; the dryness of the cough, and the violence of the strangulation; and by the irregu- larity, the completeness, and sometimes the long continuance, of the intermissions. When a foreign substance passes into the glottis, and is re- tained there, suffocation is generally occasioned either from the size of the substance, or from the spasmodic constriction of the muscles of the larynx occasioned by it.—i. Hysteria may also simulate croup; but the age of the patient, the history of the case, and the local and general symptoms, if attentively observed, will indicate the nature of the affection.—k. The spasmodic states of croup closely approach to convulsive spasm of the larynx; but the absence of cough and fever, the brief fits of strangulation, the com- plete intermissions, the spasm of the thumbs and toes, the purplish countenance, and the general convulsions, will distinguish that affection from any form of croup. (See Larynx—Convulsive Spasm of.) 24. IV. Causes.—A.a. Croup is more fiequent in cold and moist climates than in those which are warm. Rapid and frequent vicissitudes of season, weather, and temperature, have considerable influ- ence in producing it. Hence its prevalence in the valleys of Switzerland and Savoy; in this country, particularly on its eastern side; in the other north- west countries of Europe; and in North America. But the middle, and even the south of Europe, are not exemptfrom it. M. Valentin has shown its frequency in the middle and southern provin- ces of France, Goelis in Vienna, and Ghisi in the north of Italy. Sir James M'Grigor notices its prevalence—probably in a complicated form, from its occurrence also in adults (§ 25.)— at Bombay, in 1800. According to the inform- ation given by Jurine, Lentin, Cheyne, and others, we might be led to infer that it has been more common in very modern times than for- merly: the difference may, however, be owing to its having been mistaken for some other affec- tion. I believe that it has not been so frequent- ly met with during the preceding five years, as it was about twenty or thirty years ago. M. Jurine remarks, that, although the table he has given ofthe number of cases from* 1760 to 1807, shows a nearly progressive increase, yet he has observed, at Geneva, no increase during the last eighteen years preceding the date of his work. The following evidence, nevertheless, would ren- der it evident that, in some countries at least, croup is more prevalent now than formerly. Ac- cording to the information given by Dr. Cookson, a practitioner of forty years' experience in Lan- caster had never seen it until 1760. Dr. Fried- lander (Journ. de Montpellier,No. IX. p. 276.), states, that it has become yearly more prevalent I in Vienna; and that the physician to the Hospi- ! tal for Children, who had treated, from 1774 to 1817, nearly 60,000 children, did not meet with a single case in the three first years of his practice, saw it but rarely during the next six years, and yet treated 1665 cases of it in the last five years of this period. Similar facts are also furnished by Dr. Goelis. Although croup occurs at all seasons of the year, it is most prevalent in those which are cold and moist, or when the alternations of temperature are sudden and remarkable. 1 have observed it more frequently in the months of January, February, March, April, November, and December, especially if east or north east winds prevail after heavy or continued falls of rain. I believe that the above results are nearly in accord- ance with those furnished by Jurine,Craw ford, MicHAeLis, Double, andBRiCHETEAU. 25. b. The great susceptibility of early age, and the narrowness of the larynx previously to puberty, have generally been supposed to favour the occurrence of croup. M. Blaud, however, denies that this latter circumstance has any influ- ence in causing it. This is doubtless the case in respect of the production of the disease, but not as regards its severity and danger, both of which it evidently increases. It is rare to meet with croup until after the child has been weaned: I have, however, seen it in children at the breast, as early as three, four, five, and six months of age; but much more frequently at this age in those who have been brought up by hand; and in a still greater number of instances, at from seven months to upwards of a twelvemonth, in those which have been recently weaned. M. Duges states, that he met with an instance of it in an infant of a few days old. The age at which the disease is most common is, according to my ! experience, from one year to nine. But it not i infrequently occurs at both an earlier and a later I period. Van Bergen states, that it is often ob- | served from the age of two to five years inclusive; Home assigns from fifteen months to twelve years: Crawford mentions some cases from fifteen months to two years, but gives the age of from two to eight as the most common: Cheyne,from sixteen months to twelve years; Salomon, from two to five years inclusive; MicHAeLis,from fif- teen months to ten years: Zobel, from the latter months of suckling to nine years; Vieussf.ux, from seven months to ten years: Bernard, from one to six years ; Barthez, from two to ten ; Ru.mse y, till fourteen; and Caillau, from eight- een months to eleven years. The foregoing ap- plies only to the simple and uncomplicated disease. I When it occurs in a complicated form, or conse- cutively upon anginous affections, particularly up- on inflammation of the pharynx, tonsils, or fauces, or on the exanthematous diseases, it may, and, indeed, occasionally does, occur in adult subjects, and in infants of a more tender age. The cases published by M. Louis, and denominated by him croup in the adult, were instances of the angi- nous complication Although the occurrence of 458 C'ROL'P —Causes of. uncomplicated croup in adults is very rare, cases have been observed by Hosack, Mitchell, Mills, and Latour. 26. c. M. Blaud and Dr. Albers observe, that boys more frequently contract the disease than girls, owing to the greater exposure of the former to its exciting causes. This opinion has been opposed by MM. Double arid Royer- Collard; whilst Dr. Jurine states, that of ninety-one cases he treated up to 1808, fifty-four were boys, and thirty-seven girls; and of twenty- eight cases which occurred in 1808, eighteen were boys, and ten girls. According to his observation, also, the greater number of cases occurred at the age of two, three, and four years; and next at one, five, and seven. This accords with my own experience, which is further supported by that of Goelis, who, from 1797 to 1808, treated 252 cases of the disease, of which number 144 were boys, and 108 girls. 27. d. The nervous and sanguine temperaments, or a mixture of the two—the spasmodic charac- ters predominating in the former, the inflammato- ry in the latter—with a tendency to a fulness of habit, seem to predispose to croup. That it will, however, often come on independently of ple- thora, cannot be disputed. I have seen it in in- fants of about four montlis old, brought up by hand; and even in these, soon after having lost much blood in the treatment of other diseases, especially when cold easterly winds occur in the spring or autumn, after heavy falls of rain. Cheyne, and some others, conceive that an hereditary tendency exists in croup. But this is not made out: for, as M. Desruelles has judic- iously remarked, the only proof that can be brought in support of it, is the circumstance of two or more children being seized with it in the same family; an occurrence which may be explained by the susceptibility of age and temperament, being often necessarily the same in several of them; and by their being exposed to the same agents, and placed under similar circumstances. 28. e. The localities in which this disease seems most prevalent are those which are low and moist, near the sea, on the banks of large rivers or lakes, or near marshes, in the depths of low valleys, or at the bases of precipitous mountains. Hence the endemic character, which some writers have im- posed on it, but which is not strictly applicable; for, although it is more frequently observed in the above situations, yet it is also often met with in places very oppositely circumstanced ; and it cannot, therefore, strictly be said to be an endemic disease. 29. /. The epidemic prevalence of croup has been contended for, and denied, by writers. Some consider it as entirely sporadic and accidental; others suppose that it, may become epidemic con- secutively upon catarrhal epidemics, and that it has no other claims to such a character; whilst many believe that it occasionally appears in an epidemic form. That it has so occurred in former times ap- pears evident. Baillou manifestly observed it in an epidemic form, in Paris, in 1576; Ghisi, at Cremona, in 1747; Starr, in Cornwall, in 1748; RosENSTEiN,inUpsal,&c.,inl762; Van Ber- gen, in Frankfort, in 1764 ; Walhbom and Baeck, in some parts of Sweden, in 1768 and 1772; Barker and Must, in some places in the United States; Autenreith, at Stutgardt, in 1807; Albers and others, in parts of Saxony, in 1807 and 1S08; Schmidtmann, in 1811; and various other writers dining the last fifty years. My own observation would lead me to infer, that, , although croup is generally a sporadic disease, oc- I curring occasionally at all seasons, yet it sometimes assumes epidemic features, both in respect of its simple state, and its complications with other spe- j cies of angina, particularly at periods when they or catarrhal affections prevail—the seasons fa vour- i able to the production of these diseases most fre- quently occasioning this malady also. This opin- ion derives support from the numerous facts fur- nished by Rumsev, Pinel, Jurine, Goelis, I Albers, Royer-Collaro, Bricheteau, Bretonnf.au, and other writers referred to at the end of this article. 30. g-. Several authors, particularly Wichmann, Bo ehmer, Field, Ros en,Goe lis, Lobstein, Guersent, Louis, Shultz, and G.Gregory, have adduced facts to show that the disease may occasionally prove infectious. The two earlv Swedish writers contemporary with Home, name- ly, Halen and Wahlbom, assert its infectious nature. On the other hand, this property is denied by Chalmers, Mich AeLis, Thilenius, Dou- ble, and Albers. It has most indubitably man- ifested this property when it has prevailed epidem- ically, and when associated with cynanche maliona, and some other exanthematous or anginous affec- tions. On several occasions, however, of its oc- currence within a short time, in two or more mem- bers of the same family, it has evidently proceeded from the same causes acting upon similar states of susceptibility and disposition. But even the simple form of the disease has appeared in children who have slept in the same bed with another affected by it. Two or three such cases have occurred un- der my own observation; and others are recorded by Goelis, and some other authors now mention- ed. Whether or not it was produced in these cases by inhaling the air respired by the affected child, or by the causes above stated, may be disputed. Yet it is probable that the air which has been re- spired by the affected may sometimes be a con- j current or determining cause of it in others. 31. B. Although the foregoing may be consid- ered as predisposing causes merely, yet they are very commonly the only exciting causes which can be detected. There is no doubt, however, that the causes which occasion common catarrh and bronchitis sometimes also give rise to croup. It is also not infrequently excited by, or at least con- secutive of, bronchitis, hooping cough, the various j forms of cynanche, measles, erysipelas, and scarlet fever; and it occasionally also appears durinc ad- | vanced convalescence from these, especially the latter; and, indeed, from other acute diseases. Also running against the wind, crying, and exer- tions of the voice; cold acting in any manner, or upon any part of the body, particularly upon 'the neck and throat; having the hair cut short during cold or windy weather ; habitual exposure, and the laying aside the accustomed covering of the neck and chest; and even accidental attempts at swrallowing substances of an acrid nature, or of a very high temperature; have sometimes produced croup. The retrocession of the above eruptive diseases, and the suppression of other eruptions or of discharges, secretions, and excretions, are amongst its most frequent causes. 32. V. Pathology of Croup.—i. Lesions CROUP —Pathology of. 459 observed in fatal cases. A precise idea of the organic changes which take place in the course ofthe disease is necessary to enable us to devise, at the commencement, appropriate means, both for their prevention, and for their removal when prevention is unattainable. The lesions observed in fatal cases, and present in all, to a greater or less extent, may be referred to two heads.—1st. Inflammation* with tumefaction, redness, injec- tion of the blood-vessels, and slight softening of the mucous membrane of the air-passages. 2d. An albuminous exudation in the form of a false membrane, or a thick, glutinous, and stringy mu- cus, or both. (See Bronchi and Air-Passa- ges—Lesions of, § 12.) A. The former of these is usually observed, varying, however, in respect both of intensity, and extent of surface affected. In some cases, they are limited to the upper part of the trachea ; in others, they extend to the larynx, or to both the larynx and first divisions of the bronchi, or to the latter merely ; and, in complicated cases particularly, or when the dis- ease assumes a seemingly epidemic, or even in- fectious character, the inflammatory states now enumerated, with the characteristic secretion, ex- ist also in the pharynx and fauces, and advance downwards to the ramifications of the bronchi. In the most acute forms of the disease, the mu- cous surface of the trachea and larynx assumes the above inflammatory appearances in the course of a few hours. In the second stage of the dis- ease, it becomes streaked or partially covered by an albuminous, and sometimes a sanguinolent exudation; and in the last stage, this exudation has concreted to a more or less complete mem- brane ; the inflammatory states of the surface underneath still remaining, but in a less distinct manner, and occasionally in patches or streaks only. In some cases, the injection of the vessels, and tumefaction of the surface, are but slight, yet the exudation of a thick concrete membrane exists to a considerable extent; in others, it is thin and scanty, or almost entirely consists of a thick tenacious mucus. 33. B. The morbid exudation varies much in consistence, in quantity, and the extent of surface covered by it. In some complicated or consecu- tive cases, already alluded to, a false membrane has formed from the fauces to the last ramifica- tions of the bronchi. MM. Bretonneau and Brichetf.au have observed it without any breach of continuity throughout the whole of this extent. I have never met with an instance where it was so extensive, without interruptions, particularly in the bronchi and about the larynx. In the greater number of the pure uncomplicated cases of the disease, the concretion exists princi- pally in the upper part of the trachea. In the more acutely inflammatory, it extends to the la- rynx and epiglottis; in others, to the first ramifi- cations of the bronchi; and in a few, in both directions. In the complicated cases, and in those of an apparently epidemic and infectious nature, the throat is equally affected, constituting the Diphtherite, or the Inflammation pelliculaire of M. Bretonneau. This false membrane is whitish, greyish white, or passing to a grey- ish yellow. Its thickness varies considerably. MicHAei.is and Bard consider a line and half, or two lines, to be its utmost thickness. I have certainly seen portions quite as thick, but not thicker, and sometimes evidently consisting of two or more distinct layers. It is thickest in the posterior and superior part of the trachea, and thinnest about the larynx and epiglottis, when it extends thither, and in the lowest and anterior part of the trachea. Its consistence and tenacity also vary extremely, not only in different, but also in the same case. It is almost universally softest where it approaches the bronchi, where it gener- ally passes into a thick glutinous mucus. The more consistent and firm it is, the more perfectly is it moulded upon the surface from which it was secreted. But when the consistence is slight, it forms merely membranous shreds, or soft polypous concretions, intermingled with a thick glutinous mucus. The interior of those exudations is gener- ally covered with a whitish tenacious mucus; and their exterior, or the surface which has been in contact with the inflamed mucous membrane, is sometimes dotted with minute specks of blood. In some cases, these concretions are found still adhering to the surface on which they are formed; in others, they are either partially or altogether detached from it by a puriform mucus. 34. The state of the exudation varies with the stage of the disease, the intensity of the inflamma- tion, and the treatment which has been adopted. Thus, when a child dies very early in the malady, instead ofthe albuminous coating above described, a tenacious, or reddish, frothy mucus is only found. In this comparatively rare case, the spasm of the air-passages attending the inflammation, together with the obstruction occasioned by this mucus, has produced asphyxia. It seems that this glutinous exudation becomes more condensed, and moulded into a false membrane, or partially assumes this state, as the disease advances. (See Bronchi AND AlR-PASSAGES.) 35. C. In many cases, instead of a membran- ous exudation, a viscous, muco-puriform matter lines the trachea only, or both the trachea and larynx, as remarked by Frank, Vieusseux, Valentin, Double, Desruelles,Briche- teau, Blaud, and Odier. This substance is whitish, greyish, or yellowish grey, and occasion- ally flocculent. It is not infrequently formed in considerable quantity in the more acutely inflam- matory cases (§ 12.), and particularly in those which terminate fatally in some hours. It seems as if the quantity of thick viscous matter thrown out on the inflamed surface, together with the spasm of the trachea and larynx, occasioned suf- focation before it could be condensed into a membranous substance. Cases of this description have been particularly noticed by M. Royer- Collard, and have occasionally come before me in practice. I have sometimes also observed a thick, stringy, and adhesive matter, of a greyish white colour, in the superior and posterior part of the trachea and larynx, obstructing the passage, the mucous membrane underneath being nearly altogether exempt from redness and tumefaction. In 6ome instances, this matter has presented a muco-puriform character, varying in its shade of colour, but extremely thick and adhesive. A similar appearance has been remarked by Des- RUELLES,DoUBLE,BLAUD,andBRICHETEAU. Owing to the absence of the usual marks of in- flammation in the situation where this accumu- lation has been met with, it may be presum- ed that the inflammatory marks had partly dis- 460 CROUP — Pathology of. appeared after the discharge of this matter ; its secretion promoting the resolution of the inflam- matory action, the remaining signs of which had vanished after death; the accumulated secretion which had been instrumental in occasioning dis- solution alone presenting itself, the powers of life having been insufficient for its excretion. I have suspected, from observing the progress of other cases, that the inflammatory action some- times had commenced in the bronchi, extended upwards along the trachea, and that the secretion now noticed had been chiefly furnished from the larger bronchial ramifications, and had become so thick and adhesive when it arrived at the upper part of the trachea and larynx, as not to have been expelled by the cough, but to have excited spasm of the glottis, and thereby produced suf- focation. In some instances of this description, more decidedly inflammatory appearances were observed in the larger bronchi than in the trachea. It is probable in these, that the secretion found in the latter situation proceeded chiefly from the former, and that the injection of the vessels in the mucous lining of the trachea had disappeared after death. 36. D. Any very remarkable lesion of the tis- sues subjacent to the mucous surface has not been found, unless the disease has terminated in trache- al consumption. It has been a question whether or not the false membrane formed in croup is capable of becoming organized, and united to the surface that has produced it. We have no con- clusive evidence of such an occurrence, although Soemmerring, Albers, and Bricheteau are inclined to believe it possible. The other morbid appearances are chiefly the consequences of the interrupted functions of respiration and cir- culation through the lungs; such as congestion of this organ and of the brain ; hepatisation of parts ofthe lung; emphysema of this viscus; and, in very young children, enlargement of the thy- mus gland. The lesions observed in the compli- cations of the disease, as far as they have not been already noticed, more strictly belong to the par- ticular maladies with which it is occasionally thus associated ; where they are described, and in the article Membrane. 37. ii. Nature of the Disease.—Different opin- ions have been entertained as to its inflammatory nature in all cases, the exact character of the inflammation, and the extent to which spasm of the upper parts of the air-passages may con- tribute to its production. The very slight in- flammatory signs sometimes found in the part covered by the false membrane ; the absence of these, as well as of any fluid or concrete exuda- tion, in other cases ; the circumstances under which the disease has sometimes made its ap- pearance, and the absence of phlogistic symptoms in its course, an albuminous exudation either forming notwithstanding, or not at all; have in- duced several writers to consider it as not merely an inflammation of the upper part of the air- passage, but a disease of a peculiar nature, more or less connected with the state of the system, although principally affecting the trachea, and fre- quently the larynx and large bronchi also. The opinions of Rogery, Harles, Hecker, and many others, amount to this merely; and they seem not far from the truth. I have remarked, that, although croup assumes the more unequivo- cally inflammatory form in strong and plethoric children, it does not most frequently affect them, unless they be of the sanguine or irritable tem- perament ; that it presents every shade or modi- fication from this, to the least phlogistic, and most manifestly spasmodic, form ; that even its most inflammatory state may assume a spasmodic or nervous character after large derations, which, while they diminish, as under every other circum- stance of disease, the phlogistic diathesis and symptoms, increase the nervous and spasmodic ; and that, even when the first seizure has been of the inflammatory form, yet the relapses, or sub- sequent attacks, which are sometimes repeated several times at irregular intervals, have generally possessed more of the spasmodic character. 38. Another fact, which I have uniformly ob- served, appears important, namely, that the quantity of fibrine and crassamentum in the blood taken from the patient, and of albumen in the urine, have been great in proportion to the inflammatory type of the disease, and the dispo- sition to form a false membrane; whilst in the more spasmodic varieties, in which an albumin- ous exudation is seldom found, or at least but sparingly, and the urine is more copious and limpid, and less, or not at all, albuminous, the blood has presented a smaller or less firm crassa- mentum. These facts evidently show, not only that the state of the blood is different in these forms ofthe disease, but that the condition of the organic nervous or vital power, upon which the appearances and constitution of the circulating fluid so closely depend, is also different ; and, moreover, that the manifestations of both the one and the other will vary in the different modifi- cations of croup, conformably with these results. The combined and reciprocative operation of the nervous influence, and the condition of the cir- culating fluid, will give rise, according to the state of the frame, and the nature and combin- ation of the exciting causes, to constitutional as well as local phenomena ; to a state of febrile action, which will be inflammatory in, generally, the majority of cases, nervous in others, and pre- sent more or less of gastric or even of adynamic symptoms in some, particularly when the disease occurs in a complicated or epidemic form. The importance of attending, during the treatment of particular cases, and of their different stages, to the characters of the constitutional disturbance — to the attendant fever, will be evident, as indi- cating not only the means to be adopted, but also the nature of the local mischief. Thus, in the cases attended by inflammatory fever, the exudation is abundant and rapidly formed ; in that manifesting the nervous form, it is either scanty, imperfect, or consists of a little glairy fluid, — the spasmodic character predominating, and cerebral symptoms sometimes supervening; and in that presenting the adynamic and gastric form, it is spreading,—being seldom limited to the trachea and larynx, but often extending to the pha- rynx, fauces, the mouth, and even to the nostrils on the one hand, and down the oesophagus and bronchi on the other. It is in this last form that the disease presents itself when it is epidemic or infectious ; and although the adynamic (or the malignant character, according to J. P. Frank) often manifests itself early, yet the antecedent fe- brile symptoms very evidently evince high action. CROUP —Pathology of. 461 39. There is one important point not sufficiently adverted Jo by authors, viz. the very early period at which the tracheal exudation is often poured out, in the inflammatory states ofthe disease; the symptoms marking the first or premonitory period being those indicating the local developement of the malady. Thus, a healthy child has evinced no disorder for several days, or the disorder has been so slight as to escape observation—it may even be more than usually lively and alert on the day preceding the night on which it is most severe- ly attacked; and yet, if an emetic be that instant exhibited, a large quantity of thick, glairy, san- guineous, and gelatinous matter will be brought away from the air-passages; showing that, in many instances, the early advances of the inflam- matory action is slow and insidious; that the cha- racteristic seizure often does not occur until the exudation has accumulated to a considerable ex- tent in the trachea, or the inflammation has ex- tended to the larynx; and that it is partly owing to the retention of this matter, — which is evi- dently thrown out in a fluid form,—that it con- cretes into a false membrane, each successive dis- charge sometimes forming a distinct layer. MM. Gendrin, Andral, and other pathologists, have remarked, that the inflammatory action which gives rise to the albuminous exudation on the surface of mucous membranes is of a sub- acute, rather than of an acute kind. I believe that this is the case in respect of the inflammation of the trachea and larynx, in croup; and that the formation of a false membrane is the result not so much of the sthenic or acute character of the local action, as ofthe abundance of albumen and fibrine in the blood,—a circumstance which partly accounts for the frequency of relapses in some chil- dren (§ 41.o.), and justifies Harles,Hecker, and others, in considering the disease to consist of a peculiar form of inflammation. Some writ- ers, however, suppose that the very acute symp- toms, and rapid termination of many cases, mili- tate against these opinions; but it should be recol- lected that, even in the most severe cases, the inflammatory action, when it commences in the trachea, often exists for several days, in the man- ner already noticed, until it has either extended to the larynx, or produced such a quantity of albumi- nous exudation as will obstruct respiration, or induce, by its irritation, spasm ofthe air-passages, —these effects being the chief causes ofthe sever- ity and rapid termination of the disease. This will become more evident, when we consider the consequences of interrupted respiration upon the I frame — whether the interruption proceed from j the mechanical obstruction occasioned by the exudation and false membrane, or the frequent recurrence or continuance of spasm ofthe larynx and trachea; or from inflammatory action, audi its consecutive exudation extending down the bronchi; or from two or all of these combined. These consequences are, in fact, the third stage of the disease; the symptoms of which are the i usual phenomena resulting from obstructed respi- ration, interrupted circulation, and congestion of the lungs; imperfect action of the air upon the blood, and the circulation of this fluid in a nearly venous state, with congestion ofthe cavities ofthe heart, and impeded return of blood from the head. The circulation, moreover, of imperfectly arterial- ised blood to the nervous systems occasions lethar- 39* gy, with sinking of the vital powers, and increases the disposition to spasmodic action of involuntary parts, and to convulsive movements of voluntary organs; all which (the former especially) become so prominent a character of the malady in its advanced stages, and often terminate existence. Thus it will appear manifest, — and the fact is of great practical importance,—that the severity, rapidity, and danger of croup, are not the imme- diate consequences ofthe activity or acuteness of the inflammatory action; but of the exudation to which it gives rise, and of the conformation and functions of the parts which it affects. 40. Duval, Jurine, Albers,andScHMiDT, have considered it worth ascertaining, in how far the disease could be artificially produced in the lower animals; and whether or not, when thus produced, inflammation exists to the extent of accounting for the phenomena, or gives rise to a false membrane. They injected into the trachea of fowls, dogs, cats, sheep, wolves, &c. various irritating substances, as the bichloride or peroxide of mercury (Schmidt) dissolved in spirits of turpentine, and solutions of iodine, and nitrate of silver; they moreover made these animals inhale the fumes of sulphuric and muriatic acids; and the results were just what might have been an- ticipated, viz. that in some cases, inflammation without any exudation was produced; in others, a fluid, or more or less concrete exudation was found in various quantity; and in all, the matter in the air-passages was not sufficient entirely to obstruct the access of air to the lungs; thus confirming the opinion justly contended for by Cullen and oth- ers, that a great part of the phenomena and conse- quences of the disease is to be attributed to spasm of the larynx and trachea. Schmidt succeeded in producing a false membrane only in young ani- mals,—a fact in accordance with the spontaneous occurrence of the disease previously to puberty, and to be referred to the more albuminous state of the blood often observed at this period. It may be of importance to know that croup—identical in its phenomena and organic changes with the disease in the human subject—occurs also in several of the lower animals, especially before they are fully grown. Its occurrence in chickens is well known by the name of "Pip." Dupuy,Rush, Valen- tin, Youatt, and others, have observed it in horses and dogs; Double, in lambs and cats; and Ghisi and Ghohier, in cows. In some of these animals it has even occurred as an epidemic. 41. Pathological Conclusions.—Another point, of greater importance than it may at first seem, is whether or not the matter concreted and moulded on the inflamed mucous surface be exuded by this tissue itself, or secreted by the follicular glands with which it is so abundantly supplied. M. Grim- aud has adopted the latter alternative. From particular attention I have paid to this subject, some of the results of which have been stated in the article B r o n c h i (§ 11. 12.), I would draw the following inferences relative to it, and to the pathology of croup generally:—(a.) That the mucous membrane itself is the seat of the inflam- mation of croup; and that its vessels exude the albuminous or characteristic discharge, which, from its plasticity, and the effects of temperature and the continued passage of air over it, becomes concreted into a false membrane;—(b) That the occasional appearance of blood-vessels in it arises 462 CROUP — Treatment of its common Forms. from the presence of red globules in the fluid when first exuded from the inflamed vessels, as may be ascertained by the exhibition, upon the approach ofthe symptoms, of a powerful emetic, which will bring away this fluid before it has concreted into a membrane; these globules generally attracting each other, and appearing like blood-vessels, as the albuminous matter coagulates on the inflamed surface;—(c) That the membranous substance is detached in the advanced stages of the disease, by the secretion, from the excited mucous follicles, of a more fluid and a less coagulable matter, which is poured out between it and the mucous coat; and, as this secretion of the mucous cryptae be- comes more and more copious, the albuminous membrane is the more fully separated, and ul- timately excreted if the vital powers of the res- piratory organ and of the system be sufficient to accomplish it; — (d) That sub-acute or slight inflammatory action may be inferred as having existed, in connection with an increased propor- tion of fibro-albuminous matter in the blood, whenever we find the croupal productions in the air-passages ; but that these are not the only morbid conditions constituting the disease;—(e) That, in conjunction with the foregoing,—some- times only with the former of these in a slight de- gree,—there is always present, chiefly in the devel- oped and advanced stages, much spasmodic action of the muscles of the larynx, and of the transverse fibres of the membranous part of the trachea, which, whilst it tends to loosen the attachment of the false membrane, diminishes, or momentarily shuts, the canal (ofthe larynx) through which the air presses into the lungs;—(/) That inflamma- tory action may exist in the trachea, and the exud- ation of albuminous matter may be going on, for a considerable time before they are suspected,—the accession of the spasmodic symptoms being often the first intimation of the disease; and these, with the effects of the pre-existing inflammation, give rise to the phenomena characterising the sudden seizure;—(g) That the modifications of croup may be referred to the varying degree and activity of the inflammatory action; the quantity, the fluidity, or plasticity of the exuded matter; the severity of spasmodic action; and to the,pre- dominance of either of these over the others in particular cases, owing to the habit of body, tem- perament, and treatment of the patient, &c;— (h) That the muco-purulent secretion, which often accompanies or follows the detachment and dis- charge of the concrete or membranous matters, is the product of the consecutively excited, and slightly inflamed, state of the mucous follicles, the secretion of which acts so beneficially in de- taching the false membrane;—(i) That a fatal Issue is not caused merely by the quantity of the croupal productions accumulated in the larynx and trachea; but by the spasm, and the necessary resulfs of interrupted respiration, and circulation through the lungs;— (k) That the partial de- tachment of fragments of membrane, particularly when they become entangled in the larynx, may excite severe, dangerous, or even fatal spasm of this part, according to its intensity relatively to the vital powers of the patient; and that this oc- currence is most to be apprehended in the com- plicated states of the malady, where the inflam- matory action, with its characteristic exudation, I spreads from the fauces and pharynx to the ' larynx and trachea; the larynx being often chiefly affected in such cases, and, from its irritability and conformation, giving rise to a more spasmodic and dangerous form ofthe disease;—(/) That the danger attending the complications of croup is to be ascribed not only to this circumstance, but also to the depression of vital power, and the characteristic state of fever accompanying most of them, particularly in their advanced stages;— (m) That irritation from partially detached mem- branous exudations in the pharynx, or in the vicinity of the larynx or epiglottis, may produce croupal symptoms in weak, exhausted, or nervons children, without the larynx or trachea being themselves materially diseased; and that even the sympathetic irritation of teething may occasion the spasmodic form of croup, without much in- flammatory irritation of the air-passages, partic- ularly when the prima via is disordered, and the membranes about the base of the brain are in an excited state; — (n) That the predominance in particular cases of some one of the pathological states noticed above (g,) as constituting the dis- ease, and giving rise to the various modifications it presents, from the most inflammatory to the most spasmodic, may be manifested in the same case, at different stages ofthe malady, particularly in its simple forms, and in the relapses which may subsequently take place; the inflammatory cha- racter predominating in the early stages, and either the mucous or the spasmodic, or an association of both, in the subsequent periods;—(o) That the relapses, which so frequently occur after intervals of various duration, and which sometimes amount to seven or eight, or are even still more numerous, may each present different states or forms of the disease from the others; the first attack being generally the most inflammatory and severe, and the relapses of a slighter and more spasmodic kind; but in some cases this order is not observed, the second or third, or some subsequent seizure, being more severe than the rest, or even fatal, either from the inflammation and extent of ex- udation, or from the intensity and persistence of the spasmodic symptoms,— most frequently from this latter circumstance. The above in- ferences, however minute or trite they may seem, should not be overlooked, as they furnish the safest and most successful indications of cure, and are the beacons by which we are to be guided in the treatment of the disease. 42. VI. Treatment.—i. The curative Treatment of Croup. I shall first state the method of cure on which I would chiefly rely in the different modifications of the disease; and after- wards notice some of the remedies which have been recommended by various writers. Several of these are of great benefit in certain circumstances ofthe disease; but we can seldom depend upon any one of them: it is on a judicious combination and sequence of means that we should chiefly rely; arid upon the adaptation and co-ordination of these in particular cases. Theintentions of aire are—1st, to diminish inflammatory and febrile action, when present; and to prevent, in these cases, the form- ation of a false membrane, or the accumulation of albuminous matters in the air-passages;—2d, when the time for attempting this has passed, or when it cannot be attained, to procure the dis- charge of these matters; — 3d, to subdue spas- modic symptoms as soon as they appear; and, 4th CROUP — Treatment of its common Forms. 463 to support the powers of life in the latter stages, so as to prevent the recurrence of spasms, and to enable the system to throw off the matters exuded in the trachea. 43. A. Treatment of the common and inflam- matory Croup.—a. If the practitioner see the patient in the first stage (§ 6.), particularly if hoarseness, or a rough cough, with other catarrhal symptoms, be present, it will be proper to give an active antimonial emetic, with the view of ful- filling the first ofthe above intentions. This will often bring away a considerable quantity of a thick, glairy, and sometimes slightly sanguineous matter from the trachea, and will give immediate, although generally only temporary, relief. If the matter discharged from the air-passages present the above appearances ; if the child be plethoric, the pulse at all excited, and the countenance flushed; we should not be deceived by the calm following the full operation of the emetic, but should have recourse to blood-letting. In the majority of instances, cupping between the shoul- ders or on the nape of the neck, or the application of leeches on the sternum, to an extent which the age, habit of body, and strength of the patient may warrant, will be preferable to venaesection. Under these circumstances, particularly when the nausea occasioned by the emetic has hardly subsided, the abstraction of little more than an ounce, or an ounce and a half, of blood, for every year that the child may have completed, will be borne. In town practice, the local is pre- ferable to general blood-letting ; but the latter will be adopted, with advantage, in the country, amongst plethoric and robust children. The ad- vantages of depletion and antimonials are attribu- table to their influence in arresting the inflamma- tory action, and, from the consecutively accelerat- ed absorption of fluids into the circulation, to the relative diminution of the albuminous constituents of the blood. 44. Immediately after depletion, and an emetic, the best internal medicine undoubtedly is calomel and James's powder—from three to five grains of the former, and two or three of the latter. This powder may be repeated every second, third, or fourth hour, until two or three doses have been taken. After the first dose, the child should be put in a tepid bath; and be allowed as much tepid diluents as the stomach will bear, in which sub- carbonate of soda may be dissolved, and which may be rendered agreeable with syrup. If the powders, given to the extent how mentioned, have not acted upon the bowels, castor oil, or some other purgative, assisted by an emetic, should be administered. These means will seldom fail of cutting short the disease. If, however, it still proceed, the means to be employed in the next stage should be adopted according to the circum- stance ofthe case. 45. b. The second or developed stage is that in which'medical aid is most frequently resorted to; and at this period, conformably with what has been stated (§ 39.), the disease is actually further advanced than the symptoms indicate. At its commencement, however, the first intention of cure should be attempted; but the most decided means will be now requisite to attain its fulfil- ment. These should be put in practice, even although the treatment already recommended may have been employed in the preceding stage. An active antimonial emetic should be instantly exhibited, so as to produce full vomiting; and im- mediately upon the conclusion of its operation, blood-letting, general or local, must be resorted to. The abstraction of a greater quantity than that indicated above (§ 43.) will seldom be more beneficial ; nor, indeed, will it be borne without producing syncope, which, in children, especially, should be avoided, as favouring the supervention of convulsions or reaction. But it may be requisite, particularly when the patient has not lost any blood during the preceding stage, to repeat the depletion. On this, or on any future occasion of repeating it, local blood-letting, in the situations and mode already mentioned (§ 43.), is now to be preferred. If it have not been prescribed previously, the calomel and James's powder should be given every two or three hours, until three or four doses are taken ; and the adjuvants directed to accompany and to follow this medicine in the first stage, should also be employed in this. 46. Having thus carried depletion as far as seems prudent, and fully evacuated the prima via, and a very obvious improvement have not taken place, or if the suffocating seizures recur I notwithstanding, a blister should be applied be- [ tween the shoulders, on the nape of the neck, or [ on the epigastrium, but never on the throat; and if symptoms of febrile excitement still attend the seizures, a full dose of tartar emetic should be given, so as to excite vomiting again, and be re- peated until it has this effect fully. If the urgent symptoms and fever still continue, vomiting may be excited a third or fourth time, at intervals of two or three hours. The tartar emetic is, upon the whole, the best medicine for the purpose in the early or inflammatory states of the disease, and may be given in doses of half a grain, in simple solution, to a child two or three years old, as advised by Dr. Cheyne, and repeated at about half an hour, or sooner, if vomiting be not induc- ed. M. Guersent prefers ipecacuanha, and advises blood-letting to precede the" exhibition of emetics. Where the inflammatory action is considerable, this method may be adopted ; but where we may expect to bring away the exuded matter by means of an emetic, before it has con- creted into a membrane, it will be as well to ex- hibit one without delay, and to keep up a constant nausea by the same medicines given in frequent and small doses. 47. If the symptoms continue notwithstanding the judicious use of the above means, we should infer the formation of a false membrane, unless the exacerbation be altogether spasmodic — the breathing and voice becoming natural, or nearly so, in the intervals. The measures to be em- ployed now should have reference to the sepa- ration and discharge of the concrete exudation, and the removal of spasmodic symptoms—to the fulfilment of the second and third intentions pro- posed. Bleeding, even if the state of the patient would admit of it, would not promote these inten- tions ; and the exhibition of calomel or mercu- rials, excepting with the view of promoting all the abdominal secretions and excretions, arid thereby to derive from the diseased organ, would not materially assist our views, inasmuch as it is impossible thereby to affect the system of chil- dren so as to prevent the formation of coagulable 464 CROUP — Treatment of its common Forms. lymph. In this case, we should assist the opera- tions of nature in detaching the false membrane. It has been stated, that this is accomplished by the effusion, by the excited follicles, of a fluid matter between the concrete substance and the mucous coat; therefore those medicines which have usually the effect of increasing and render- ing more fluid the mucous secretion of the air- passages, should now be prescribed. But care should be taken not to exhibit these, or any other expectorants, too early, or until depletion has been carried sufficiently far. They are most service- able about the termination of the second, and the commencement ofthe third stage. The medicines best calculated to act as expectorants in this dis- ease are, the preparations of squills, of ammo- niacum, of senega, the sub-carbonates and the sulphurets of the alkalies, and camphor. The oxymel or syrup of squills may be given, either alone, or with some one ofthe sulphurets, or with senega, and generally to the extent of keeping up a slight nausea, unless the exacerbations of cough and suffocation be severe, when full vomiting should be produced by their means. I prefer the emetic effect at this period to be obtained by squills; as antimony lowers too quickly the vital power, which ought now to be supported, so as to enable the diseased organ to throw off the morbid matter formed upon its surface. A mixture, con- sisting of decoction of senega, with jrinum ipeca- cuanha) and oxymel of squills, may also be adopt- ed with equal advantage. When the medicines fail of exciting vomiting, the pharynx should be irritated by a feather. I have seen very much benefit derived from this simple means; and have considered it more beneficial than any other, in the third stage, in promoting the discharge of matters from the trachea. Jurine also places great re- liance on it. When severe exacerbations, with spasm and threatened suffocation, occur, it is al- ways most advantageous to produce instant vom- iting. The sulphate of zinc has been advised by M. Guersent, and the sulphate of copper by Dr. Hoffmann, for this purpose. 48. During this and the preceding stages, the inhalation of watery and medicated vapours may be resorted to. At the commencement of the disease, vapours of an emollient kind are most beneficial; but when we wish to promote ex- pectoration, camphor may be added to the sub- stance used in this way. Home, Crawford, Pearson, Rosen, Pinel, and Goelis, have approved of this practice. When spasmodic symptoms manifest themselves, inhalation, assist- ed by the tepid or warm bath, is often of use; but antispasmodics should also be prescribed with the other medicines, or in enemata. I have never seen any permanent advantage derived from narcotics given by the mouth, except from opium or syrup of poppies, combinedVith antispasmodics; prob- ably owing to their lowering the vital energies, which are always much depressed when nervous symptoms appear. Great care should be always taken in exhibiting opiates in clysters to children: in very young children the practice is attended by much risk. Opiates are given to greatest advan- tage with ipecacuanha, as in Dover's powder, or with camphor or calomel, or with both. I have likewise found camphor, with James's pow- der and hyoscyamus, of much benefit in some cases in which I have prescribed it. The hydro- sulphuret of ammonia may likewise be tried, in both this and the next stage of the disease. 49. In many cases, the judicious use of blood- letting, calomel, antimony, ike. will cut short the disease, even although the patient may not have been treated until this period-has been fur advanc- ed; and in others, the active use of these means may give rise to very alarming depression of the vital energies, even when they may have succeeded in removing the cause of obstruction and irritation in the air-passages. In these, stimulants, antispas- modics, and restoratives must be immediately resorted to, but with great caution, lest the in- flammatory action be reproduced by their means.* * The following case will illustrate the above observation, and may prove instructive to the less experienced reader. I have extracted it verbatim from my note-book, with the re- marks suggested at the time appended to it:— William Hodson, aged five years and a half, was seized, on the 17th of Nov. 1821, with hoarseness, fever, and a ringing, dry cough. The mother opened its bowels with salts, and i;ave it some antimonial wine. The following day, in the evening (18th ) I saw it. There was much fever, with flushed countenance, and a constant, hard, and ringing cough, with a sibilous noise on respiration. Pulse frequent and hard; skin harsh and dry ; great restlessness, tossing, dyspnoea, with hoarseness, and the characteristic breathing of croup. I directed blood-letting from a vein in the arm ; and the blood was allowed to flow in a full stream till ap- proaching syncope was indicated, seven ounces being ab- stracted ; and the following powders were directed to be taken every ten minutes, till full vomiting; and subsequently every three hours :— No. 162. R Hydrarg. Submur. gr. xxx.; Antimon. Tart. gr. iij.; Ipecacuanha; gr. vj. Misce bem?, et divide in Pulv. viij. Karly in the morning of the 19th I again saw the child. The powders had been given, as above, until full vomiting had been produced; and one powder had been taken subse- quently. The sense of suffocation had disappeared after the vomiting. The matters ejected contained much thick, ropy mucus, with membranous shreds of firm coagulated lvmpn floating in it. The cough and croupy symptoms had disap- peared ; the voice was clear, and the respiration easv: but now the child complained of distressing sickness, with fre- quent vomiting and purging the stools were first bilious, offensive, copious, and faeculent; but they had now become watery. The pulse was extremely frequent, so as scarcely to be counted; and so small and thready as hardly to be felt at the wrist. The countenance was pale and sunk ; the skin cool and moist; and all the symptoms of sinking of the powers of life very manifest. The powders were discontin- ued, and the following mixture directed :— No. 163. Ii Aq. Cinnam. ^iijss.; Spirit. Ammon. Arom. 5jss.; Tinct. OpiiTI|xv. ; Syrup. Scillae 5iij. M. Two tcaspoonsful of this were to be taken every ten or fifteen minutes, until a decided effect from it was evident. After four or five doses, the stools and sickness were re- strained, and the child fell into an easy and sound slerp. A blister was now applied to the sternum, which was to be removed at the end of four hours, and poulticed with a hread-and water poultice. The semicupium to be employed afterwards, and at bed-time. Three grains of calomel, with one of James's powder, to be taken at night; and the mist. camphors-, with liq. ammon. acet., vini ipecacuanha?, and syrup, papaveris, every three hours. Linseed tea, or barley water, with sugar-candy or liquorice, for common drink. 20th.—All the symptoms of croup had disappeared; but there was still some cough and fever, with occasional paroxysms of difficult breathing. The bowels had been open this morning; pulse 120, and small. Antimonial wine was added to the mixture; and an injection directed, with assafoetida, spiritus terebinthina?, oleum ricini, a:id camphor. In the evening.—He had had no return of the paroxysms since the injection, which was retained above an hourj and had procured two evacuations. Pulse 116 ; cough less frequent; skin more natural. The blistered surface had risen in some parts, and was inflamed in all. From this time he continued to recover : diaphoretics, de:i ulcents, apcri; uts, and the semicupium, being employ- ed until convalescence was complete. Remarks.—It is by no means unusual to find a recurrence of the inflammatory" and local symptoms, after they have been apparently most completely- subdued by means similar to those employed in the foregoinr case ; and even after the powers of life, and all local inflammation aiid febrile ac- CROUP — Treatment of the Spasmodic Form. 465 50. c. The treatment of the third stage, either when the patient has not been earlier seen, or when previous measures have failed, should be directed with the view of fulfilling the second and third indications of cure, and at the same time with due reference to the fourth—the preserv- ation of the exhausted nervous and vital powers. The chances of recovery are now very few; but these few should not be neglected. Many of the remedies already mentioned, especially expec- torants, should also be exhibited in this stage; and these ought occasionally — particularly when the symptoms become very urgent—to be given so as to exert a speedy emetic action; and be combined with antispasmodics—with either cam- phor, ammonia, aether, musk, valerian, assafoetida, the oxide of zinc or bismuth, the sulphurets ofthe alkalies, &c.; and the same medicines, or the infusion of valerian, may also be prescribed in enemata, especially when spasmodic or nervous symptoms are predominant. When emetics are required in this stage, those substances which are exhibited in smaller doses in the remissions, in order to act as nauseants or expectorants, are amongst the most eligible—particularly squills, senega, the sulphate of zinc. The inhalation of the vapour of ammonia, camphor, or aether, in that of warm water; or of the fumes of warm vin- egar, either alone, or with camphor; is sometimes productive of benefit in this period. Some ad- vantage may also be derived from sternutatories blown into the nostrils, as advised by Lentin aud Thilenius. I have seen, in two or three instances, the sneezing occasioned by them favour remarkably the discharge of the false membranes from the trachea; common Scotch snuff having been used for this purpose. 51. The tepid bath may be resorted to both in this and the preceding stage, once or twice daily, or according to circumstances; and either the sulphuret of potash, or the sub-carbonates of potash or soda, may be put in the water; and, if a tendency to collapse becomes apparent, the bath should be warm, and some mustard may also be added. Blisters between the shoulders, or on the sternum, may likewise be tried; but they always require great discrimination and care, in order to avoid unpleasant consequences from them. They should not, in this stage, re- main on longer than from four to eight hours. Home and Thilenius advise them to be ap- plied to the neck; Lentin and Goelis, to the neck and sternum; and Royer-Collard, be- tween the shoulders oron the arms; Maercker states, that he has derived but little benefit from them. Olbers and Royer-Collard speak fa- vourably of sinapisms placed on the lower extrem- ities. I have, however, seen more advantage ac- crue from rubefacient liniments (F. 299. 304.) or tion, had been equall7 depressed. This recurrence of the acute symptoms seems owing to either an over active use of stimulants, or an injudicious choice of them in the collapse occasionally following the decided use of blood-letting and antimony. Sometimes it aiisi-s from exposure to cold or a current of cold dry air ; and then, generally a distinct chil- liness or rigo is previously felt. Occasionally I have traced it to a too earlv recourse to food or articles of a too stimu- lating and indigestible description. Inattention to the state ofthe hovels will also dispose to it; and even a blister ap- plied too near upon the seat of dis ase ha* evidently produced such an effect especially in thin irritable children. In no case would I permit a blister to be placed upon the throat so finnlv am I persuaded that mischief is occasioned from it in this situation. epithems, applied on the epigastrium and chest, or between the shoulders. During this, as well as the preceding stage, a cathartic action should be exerted upon the bowels, unless the medicines pre- viously exhibited occasion diarrhoea, or dysenteric symptoms. Medicines of this description are beneficial, as active derivatives from the seat of disease, and as evacuants of morbid secretions. Calomel, with jalap, may be given, either alone, with musk, or some other antispasmodic medi- cine; but, in every instance, the occasional exhi- bition of an enema should not be neglected. Ol- bers, ALEERs,and Jurine, strenuously advise large doses of musk to be exhibited; and Kend- rick and Royer-Collard, assafcetida to be administered in clysters. The affusion of cold water on the head has been sometimes resorted to by Harders, Schmidt, and myself, when the preceding means have failed, particularly if con- gestion or other cerebral symptoms have super- vened, and the exacerbations have assumed chief- ly a spasmodic form. 52. B. Treatment of the humid and spas- modic Forms of Croup.—a. In the humid or bronchial form of the disease, the intentions of cure are,—1st, to subdue inflammatory action; 2d, to remove the matters exuded from the air- passages ; 3d, to calm spasmodic action ; and, 4th, to support vital power. These can be at- tained only by bleeding, general or local, as already advised, but never from the throat itself; in the early stages by antimonial emetics, and subsequently by those consisting of ipecacuanha or sulphate of zinc; by calomel, with James's powder, as prescribed above, and afterwards with other purgatives, as scamrnony or jalap; by cathartic enemata; by external derivatives; and, lastly, by antispasmodics and diffusible stimulants. Of these, individually, little need be added to what has been already advanced. More advantage seems to be derived from purg- atives, in this, than in any other form of the disease. I have sometimes seen them bring away a thick, gelatinous, glairy secretion, similar to that discharged from the air-passages in the ad- vanced stages. Their operation should be pro- moted by the administration of purgatives in antispasmodic clysters, as extract of colocynth with assaefcetida, valerian, or camphor; and if spasmodic symptoms become urgent, the sulphu- rets or sub-carbonates of the alkalies, and either ofthe various antispasmodics already mentioned, may also be taken by the mouth, particularly camphor, with James's powder, or Kermes min- eral, or ipecacuanha, with spirits of nitre, aether, or other diaphoretics. The medicated tepid or tnoderately warm bath, blisters, rubefacient lini- ments, the inhalation of simple or medicated va- pours, may also be resorted to in the manner de- tailed above. In the last stage, when the powers of life indicate exhaustion, ammoniacum, senega, oxymel of squills; and camphor, assafoetida, musk, ammonia, the aethers, &c. in full doses; and rubefacient and stimulating frictions, liniments, and baths, with the rest of the treatment already recommended at this period; are the chief means in which we can confide. 53. b. In the spasmodic form of the malady, the indications of cure are very nearly the same as now stated; but the treatment will necessari- ly vary with the extent to which inflammatory 466 CROUP—Treatment of irritation may be supposed to exist either in or i about the larynx, particularly soon after the ap- pearance of the disease; or about the medulla oblongata, in its more advanced course. In that state of constitution in which this form is most frequent, bleeding is seldom required beyond that procured by a few leeches applied to the nape of the neck, when we infer the presence of inflam- matory irritation in the above situations. In this modification, whether occurring primarily, or in relapses, antispasmodics, given both by the mouth and by clysters, are indispensable; but emetics, and afterwards cathartics, medicated tepid or warm baths, and inhalations, blisters, or rubefa- cient frictions and liniments along the spine and over the epigastrium, and the cold affusion on the head, also constitute important parts of the treat- ment. The antispasmodics most to be confided in, ure, the sulphurets and sub-carbonates of the alkalies, valerian, assafoetida, ammonia, camphor, musk, the preparations of aether, the oxides of zinc and bismuth, and the liquor aminoniuj ace- tatis, with excess of ammonia. Mr. Kimbell states, that he has derived most advantage from the internal use of arsenic, or sulphuret of potass, aided by regular attention to the bowels, the shower bath, and by blisters or anodyne frictions on the spine. Of arsenic I have had no experi- ence in this affection; but I have given the pre- arations of bark, and used the other remedies e has mentioned, with advantage. If the above means do not soon remove the disease, irritation about the base of the brain or medulla oblongata should be suspected, and leeches ought to be ap- plied on the neck; and calomel, with aperients, or with musk or camphor, exhibited once or twice daily, injections being also employed : cerebral symptoms should be always enquired after, and energetically treated when detected. 54. C. Treatment of complicated and con- secutive Croup.—The treatment of the various complications of the disease must be direct- ed according to the general principles now sketched; and with strict reference to the nature of the associated malady, to the period of the primary disease at which it appeared, to the characters of the attendant constitutional dis- turbance, and of the prevailing epidemic, and to the well-ascertained fact that local inflammations supervening in the course of continued or eruptive fevers, although they require depletions, do not admit of them to the same extent as those which occur primarily. 55. a. The association of croup with inflam- mation of the throat, and exudation of lymph in tliis situation, whether originating in the pharynx, whiah is rarely the case, or extending thither and to the air-passages from the fauces and tonsils, is one of the most frequent forms in which the disease presents itself, particularly when epidemic or infectious, and is, therefore, deserving of particular notice. But the treat- ment must, in a great measure, depend upon the degree in which either sthenic or asthenic in- flammatory action and fever may be considered to exist. Although great increase of vascular action is present at the onset, in the majority of such cases; yet it is often attended by deficient vital power, and exhaustion soon takes place. Lven in the most sthenic cases, the treatment which would liave been of service at first, is soon its complicated Forms. no longer admissible; whilst in other cases, and in some epidemics, very marked advnaniia is manifested from the commencement. Much depends on the precision with which the exact nature of the case and the state of vital power are ascertained, and on having early recourse to judicious measures. As to the predominance of either of the states of morbid action alluded to, the frequency and tone ofthe pulse, the colour ofthe exudation in the throat, and of the parts sur- rounding it, and the continuance of the disease, are the chief guides. If the inflammation and exudation commence in the tonsils and spread downwards, if the exudation be of a light colour, and the inflamed parts of a lively hue, the pulse being strong, full, and not very quick, depletions, general or local, the use of emetics and nauseants, and the rest of the antiphlogistic treatment, are required ; but the further the disease departs from these characters, the darker and dirtier the exudations appear, the more livid and deeper the colour of the inflamed parts, the quicker, softer, and weaker the pulse, the more should antiphlo- gistic measures be relinquished, unless in some cases to a moderate extent, and at the very com- mencement ofthe complaint; and the more ought we to have recourse to camphor, ammonia, the decoction of senega, ammoniacum, &c. 56. b. The nearer the complicated disease, in its local and constitutional manifestations, approaches to the malignant form, the more extreme is the danger, and the greater necessity is there for the exhibition of tonics and stimulants. In such cases, the decoction of senega, the infusion of serpentaria, or mixture of ammoniacum, may be prescribed, with camphor, and any ofthe compound spirits of ammonia; or the decoction of bark, with liq. am- nion, acetatis and tincture of capsicum; or the sulphate of quinine, with infusion of roses, and the aethers; or either the chlorate of potassa, or the muriate or carbonate of ammonia, with camphor, musk, myrrh, assafcetida, &c. in suitable vehicles. When the paroxysms of suffocation become urgent, senega, preparations of squills, or F. 402., may be given in doses sufficient to produce vomiting, and repeated according to circumstances; and active stimulant and antispasmodic clysters be thrown up. The vapour of camphor and warm vinegar may also be employed, and various stimulating and aromatic fumigations resorted to. The mouth and throat should be frequently gargled, or washed, by means of a sponge fixed to the end of a piece of whalebone, with a solution of the chlorurets, or of the sub-borate of soda in camphor mixture ; or with a weak solution of nitrate of silver, — a scruple to an ounce of distilled water, — as first advised by Mr. Mackenzie; or with Goulard water, as suggested by Dr. Hamilton; or with the chloric acid or chlorine in decoction of bark, or other stimulating detergents; and sinapisms or embrocations with Cayenne pepper, or rubefacient liniments (F. 300. et cet.), may be applied on the nape of the neck, or on the lower part of the chest, and on the epigastrium. In the complications of the disease with angina maligna, observed by Lo- effler and Bretonneau, powdered alum was directed by them to be blown into the throat; and various other astringent and antiseptic powders may be employed in the same manner. When the cha- racteristic eruption of scarlatina accompanies the affection of the throat and air-passages, the treat- CROUP — Remarks on various Remedies employed in. 467 ment must be directed according to the same principles. In all cases of angina, attended with membranous exudation, whether the attendant constitutional disturbance present sthenic or asthe- nic characters, the local treatment advised by Mr. Mackenzie should be adopted upon the appear- ance ofthe exudation on the tonsils or fauces, and a large blister should be applied early, as being the most efficacious means of preventing the ex- tension of this form of inflammation to the pha- rynx, air-passages, or oesophagus. 57. c. The treatment of the complications with aphtha, or with any of the eruptive fevers, will depend, as much as the foregoing, upon the state of vital power characterising the constitutional affection. The appearance of croupal symptoms in the course of sn.all-pox—particularly confluent small-pox — will require nearly the same medi- cines as have now been recommended (§56.); and the washes advised to be applied to the mouth and throat will be equally serviceable in the aphthous, as in the variolous complication. When croup is consequent upon either measles, or hooping cough, vascular depletion is more fre- quently required than in almost any other com- plication, excepting that with inflammation ofthe throat of a sthenic kind, whether attended by albuminous exudation or not. 58. D. The affections consequent upon croup— or the states of disease which it excites, or into which it passes—require not only appropriate rem- edies, but also the application of them with strict reference to the primary malady, and the means by which it was combated. When it runs on to bronchitis, the latter affection commonly assumes the asthenic form, generally terminates fatally, and requires the treatment described in the art. Bron- chitis (§ 70. etseq.). Its passage into pneumonia is attended with similar results; and depletions, unless they have been previously neglected, are not well borne. When diarrhoea or dysenteric symp- toms are produced, in the latter stages, by the means used to remove the disease, we shall gener- ally find the preparations of opium, and the warm bath, as hereafter to be noticed, of much benefit. A considerable number of cases, particularly those complicated with sore throat, terminate in sinking, or exhaustion of vital power, and not by suffoca- tion. This circumstance should be kept in view in the treatment of the last stage ; and its earliest indications be met with suitable stimulants and tonics (§ 56.). In cases presenting imminent suffocation, the question of tracheotomy should be entertained ; but at the same time, with the recollection, that either exhausted vital power, the extension of disease to the bronchi, and the accumulation of viscid or concrete exudations in them, or inflammatory action, or emphysema of the lungs themselves, may tend individually, or in combination, to prevent the success of the ope- ration, independently ofthe immediate contingen- cies to whjch it is liable. (See § 74.)* * I may here adduce a summary of the practice adopted by the most experienced physician in France in this dis- ease— the senior physician to the Hospital for Children in Paris. It will he seen how closely it agrees with my own, in a similar Institution in London:— M. Jadelot considers croup as a kind of angina of the air-passage: presenting more violent symptoms, and hav- ing true paroxysms, separated by well-marked intermis- sions of a special character. He admits diflerent degrees of the disease, without changing its nature. Bleeding by leeches, and emetics, are the agents he most frequently 59. Remarks on various Remedies ad- vised, AND ON THE OPINIONS OF AUTHORS respecting them.—a. Nauseants and emetics. In the first stage of the disease, and in the com- mencement of the second, I have sometimes found that tartar emetic, given so as to produce and pro- long a state of nausea, has so completely relieved the croupal symptoms^ to prevent altogether the necessity of having recourse to blood-letting; and that in other, and more severe cases, the same medicine, exhibited so as to produce vomiting, and to continue the nauseating effect for some time afterwards, and thereby to prevent reaction super- vening upon the emetic operation, has been follow- ed by a similar result. Emetics have been much recommended after blood-letting, and the inhala- tion of vapour, and when the exudation is presumed to begin to loosen, by Home, Lentin, Da rwin, Maercker, Portal, Smith, Hecker,Vi- euss e u x, Rumse y, &c. When the patient has not been visited sufficiently early, this plan is cer- tainly judicious. But when he is seen in the first stage, it will be better to attempt to prevent the for- mation of the false membrane, by exhibiting nau- seants or emetics instantly, as now advised, and, unless the inflammatory symptoms are very severe, before having recourse to'blood-letting. This early exhibition of emetics is sanctioned by Crawford, Cheyne,Pinel, Hosack, Thompson, Hufe- land, Albers, Schwilgue, &c. Dr. Gais- ler prescribes, on the invasion of the disease, tartarised antimony and oxymel of colchicum. Whilst vascular excitement continues, either this combination, or the antimony only, in repeated doses, as suggested by Cheyne and Michailis, is the best emetic; but when we wish to detach the membranous exudation, the preparations of squills, alone, or with ipecacuanha, are preferable. In the more spasmodic form of the disease, ipe- cacuanha, as Goelis remarks, is as suitable an emetic as can be adopted : but when it is found necessary to exhibit such a medicine in the last stage of the disease, or when it is associated with angina maligna, or attended by symptoms of de- pressed vital power, senega, squills, or the sul- phate of zinc, given with stimulants and anti-spas- modics, or F. 402., are to be preferred. Goelis recommends emetics in the first stage of the least inflammatory forms, and generally in the third employs in its treatment. Emetics alone have often suf- ficed to slop the disease, especially in weak, pale, or bloat- ed subjects; but, in opposite cases, he insists on the applica- tion of leeches, and allows the blood to flow until the child becomes pale, and the pulse loses its strength. After the bleeding, he causes vomiting, several times in succession, at intervals of two or three hours: and the practice is attend- ed by the greatest success, relief being very apparent after each vomit. When the croup has arrived at the second period, with- out having been opposed, and the presence of a false mem- brane is suspected, M. J. directs leeches to be applied ; but, the moment they fall off, he hastens to produce vomiting: and it is in this case that he employs, by spoonsful, every ten minutes or quarter of an hour, the mixture called an- ticroupal,* until full vomiting is produced. He insists, also, upon the use of errhines, and of derivatives applied to the skin and intestinal canal. When the disease is very rapid, it has been a question whether or no we should commence by bleeding, or bv an emetic. M. J.'s opinion is, that we should first bleei, II the child be robust, and if it present signs of congestion towards the superior parts : on the contrary, he would com- mence by vomiting, when the subject is pale and exhaust- ed, and there is little heat or fever. (Ratier's Medical Guide, tfC * R Infusi Polygala; g iv.; Syrup. Ipecacuanha; i, j.; Oxymel. Scilla; 3"iij.; Antimon. Tart. gr. jss. Misce. 468 CROUP—Remarks on various Remedies employed in. stage; but he prohibits them in the second or in- I p. 361.) will show the inefficiency and injurious flammatory stage, and when suffocation is threat- effects of excessive depletions. ened towards the close ofthe disease. When, ! 61. y. Calomel und mercurial inunction have however, tartarised antimony is employed, and been most strenuously recommended, the former nausea is kept up in the intervals between the j especially, since it was first prescribed by Rush, emetic operation, as I have recommended above, bleeding being also employed, the reaction dread- ed by this experienced writer will not come on. His objections to an emetic in the paroxysms of suffocation occurring towards the close of the mal- id in larger doses by Stearns, Marcus, AUTENRKITH, A.\ 1) KRSON, J. P. FRANK, NeU- m a n n , M i ch aelis, and others, who gave it every three or four hours. Hamilton directs it, in full doses, every hour or two hours at first, and sub- ady, may be well founded, were antimony or even sequently at longer intervals; Hecker advises it ipecacuanha to be then prescribed; but, when zinc squills, and senega are conjoined with stimulants and antispasmodics, and their operation accelerat- ed by irritating the pharynx, I have seen the air- passages thereby freed from the substances ob- structing them, and the patient saved. 60. it. Bleeding, general or local, or both, al- though indispensably requisite in the great major- ity of cases, is not always of service. Rumsey and Huggens remarked its injurious effects in the complicated cases they treated; and the more nearly the diseiise approaches to the spasmodic, in small doses; and Wig and states that it is of no use. Cheyne prescribes it with James's powder; Ha rle s and others, with the officinal preparations of antimony ;Sch;effer ,with emetics and musk; Schluter, with oxide of zinc and other antispas- modics; MicHAeLis and Neumann, with expec- torants; Archer, Marcus, and Hufeland, with decoction of senega, and mercurial inunction about the neck; and Augustin, with opium. In the stages attended by excitement, it is best con- joined with James's powder or tartarised anti- mony, as prescribed above ; and sometimes with and the febrile symptoms to the adynamic charac- | opium, or Dover's powder, and subsequently, if ter, particularly in the complications, the more j it be given at all, with purgatives ; expectorants, likely is it to be of little benefit, or even injurious, j antispasmodics, &c. being exhibited in the inter- unless the state of action and habit of body, evi- va!s. Goelis conceives that it is useful indimin dently reijuires it. In the more inflammatory states, it should be promptly and fully performed; the use of nauseating medicines generally pre- venting the necessity of having recourse to very large or injurious depletions. Ghisi, Hume, ishing the tenacity of the croupal exudation, and in retarding its formation. He moreover suppos- es, that the daily exhibition of a small dose of this medicine subdues the diathesis, or constitutional disposition to contract the disease ; and when Crawford, Rosen, and others, have preferred j croup has been prevalent, and appeared in one of general blood-letting at the commencement; and j a family, he has given about a grain at bed-time Bayley, Middleton, Balfour, and numerous i daily to each ofthe other children. writers, have recommended the jugular vein to be j 62. 3, Blisters and counter-irritants have been chosen. Treber, Hirschfikld, Werner, I already mentioned ; but there are certain points, Goelis, and Ma li-atti, very experienced physi- j particularly as respects the period and manner in cians in Vienna, employ local depletions, except- I which they ought to be employed, that require ing in the most inflammatory cases; and I agree | to be noticed. There are very few writers who with them, differing only in preferring cupping to j have not recommended blisters in croup, but quite leeches. As to the period at which it should be | as few have done so with the wished for precis- resorted to, I believe, with Goelis, that little j ion. On this subject Goelis is more practically will be gained by resorting to it before inflam- j minute than any other writer ; and in many re- matory action is manifested, or after excitement I spects his experience coincides with my own. I has subsided. A suppressed and apparently weak I believe that most advantage will be derived from pulse, early in the disease, is often rendered full | as early an application of a large blister as is and hard by venaesection, and a repetition of the operation required,—a circumstance evincing the importance of interpreting aright the state of the circulation. Of forty-seven cases treated by Goe- lis, in 1808, seven were blooded from a vein; thirty-four by leeches only; and six were not blooded at all. The average quantity of blood that I have found requisite to take, altogether, as nearly as I can calculate, is about five ounces in children of three years, seven or eight in those of five or six, and about ten ounces in those from ten to twelve. This result relates chiefly to those not seen until the second stage of the more in- flammatory or common forms of croup. I have met with cases in which blood-letting had been chiefly confided in, and been carried to the utmost extent; but it certainly had seldom or ever cured the disease, when thus employed, and even some- times had been evidently injurious. The cele- brated Washington was said to have died of croup. He lost, at the age of sixty-eight, about ninety ounces of blood in twelve hours. An at- tentive perusal of the cases published by Dr. S. Jackson (Amer. Journ. of Med. Sciences,xol. iv. consistent with the previous employment of blood- letting. Directly after the first depletion, there- fore, one should be applied in either of the situations advised (§ 46.); a piece of fine tissue paper being placed between it and the skin. It ought to be removed upon the appearance of redness of the cuticle, and a warm bread and water poultice placed over the part, and fre- quently renewed. If blisters be used in the latter stages, they should be watched with great care, and be allowed to remain for a few hours only, and not a minute after slight redness is produced. I believe that the dangerous effects sometimes occasioned by them are owing to the want of these precautions, and to having recourse to them at a time when the vitality of superficial parts is soon exhausted, owing to vital depression and to deficiency of blood, consequent upon excessive depletion. The liberal use of calomel, particu- larly when it has not been carried off by purg- atives, may also, by increasing the irritability of the tissues, dispose to unfavourable results from blisters. If prescribed at all, they should be of full size^fliey ought never to be applied over the size y/fliey ough APPENDIX OF FORMULAE. In order to prevent repetitions, and to facilitate reference, the following collection of Formulae 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 prescribed by the three British Colleges, as they are already in the hands of every practitioner; although he has always referred to them, and has followed them, particularly those ofthe London College, in extemporaneous prescription — both in such as are prescribed at this place, and in those directed in the course of the work. The preparations and recipes he has given, both here and at other places, consist of a careful selection of those which are most approved, contained in the Phar- macopoeias of various hospitals and foreign countries, and from the writings of a number of eminent practical physicians, as well as of those which the Author has been led chiefly to con- fide in during a practice of twenty years. In order 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. Fold.) R Castorei, Assafoetidae, aa 3 ij- j Galbani g ss. ; Herb. Rutae recentis §j.; Aceti Vini ft ij. Macera bene et cola. Form. 2. Acetum Camphoratum. R Camphorae Pulver. cum Alcoholis pauxillo solutae, 5 ss. ; Sacchari Albi § ijss. ; Aceti Vini J vss. Solve. (5j. contains 3SS- of camphor.) Form. 3. Acetum Camphors et Ammonia. R Camphorae 3j.> teratur in mortario vitreo, cum Alco- holis gultis nx. vel xxx.; Sacchari Albi Jss. trilis adde ; Acidi Acetici Forlioris 3 'j- i Liqooris Ammoniae Acetatis giijss. ; Infusi Cinchona?, vel Aquae Destilla- tas 5 i'jss* Fiat Mist., cujus suinat aeger Cochlear, ij. ampla secunda vel tertia quaque hora. (In the last stage of Febrile Diseases attended with depressed pow ers of life.) Form. 4. Acidum Nitro-muriaticum. R Acidi Nilrici, Acidi Muriatici, singulorum partes (mensu- ra.) aequales. Dosis a minim, vj. ad Ttl xx. bis, ter, saepiusve quotidie, in Hordei Decocti giv., cum Syrupo Simplice. Form. 5. Acidum Nitro-muriaticum Dilutum. R Acidi Nitro-muriatici, Aquae De9tillatae,aa O j. Misce. (The nitro-muriatic acid bath is to consist of three ounces of this diluted acid to every gallon of water.) Form. 6. .Ether Phosphoratus. R Phosphori Puri gr. ij. ; Olei Mentha Piper. 9j.— 3ss. Solve, et adde ./Ether. Sulphur. 5 j. M. Vel. Form. 7. R Phosphori Puri gr. ij.; JEther. Sulph. gj.; Olei Va- lerian. TT) xij. JVI. (In doses of v. to x. drops on su- gar-) Form. 8. Aqua Cosmetica. R Mist. Amygdal. Amar. vel Dul. colati 5 iij. ; Aquas Rosar. et Aquae Flor. Aurantii aa §iv. ; Sub-boracis Soda; 3j. J Tinct. Benzoini, Jij. M. Fiat Lotio. Form. 9. Aqua Styptica. R Ferri Sulphatis, Alumin. Sulphatis, aa giss. ; Aquas 3 xij. Solve et cola ; dein adde Acidi Sulphuric! §j. Form. 10. Aqua Styptica Cupri et Zinci. R Zinci Sulphatis, Cupri Sulphatis, aa3j. J Aquae Rosa; \ viij. Solve. 3 A Form. 11. Aqua Styptica Zinci. R Zinci Sulphatis, Alumina; Sulphat. Calcin., aa 3j-i Aquae Rosas J vj. Solve. Form. 12. Aqua Traumatica Thedenii. R Acidi Aceiici ft iij. ; Alcoholis ft ij.; Acid. Sulphur ft ss. j MellU despumali ftj. Misce. Form. 13. Aqua Vanilla. R Frucl. Vanilla; concis. et cont. § yj- > Potassae Sub- carbon. 3vj.; Aquae Destil. O ij.; Spirit. Vini Ten. O jss. Macera lent cum calore per triduum, et cola. Form. 14. BALNEUM IODURETUM. (LUGOL.) R Solut. Iodinse Rubefac. (Vide Form, inter Solutiones.) Sj—Siv-; Mux 0on5- *j>—'• Form. 15. Balneum Sulphureum. R Magnes. Sulphatis 3 iv- > Potassae Supertart. 9 j.; Sul- phur. Potassae 3 j. : lere siinul, et solve in Cong. j. q. q. Aquae Balnei. Form. 16. Balneum SuLrHURETi Potass*:. R Potassae Sulphureti § j. ad § iv. ; Aquae Communis ft L ad ft cc. Solve. (Nearly the same as the sulphu- reous baths of Bar&ges. In Chronic Affections of the Skin, and in Chronic Visceral Affections.) Form. 17. Balneum Sulphureti Potass* et Gela- tine. (Dupuytren.) R Potassae Sulphureti, § >j- ad 5 'v- > Aquae Communis ft c. ad ft cc. Solve, ct adde Ichlhyocollae ft j. ad ft ij. in Aquae bullientis solutae ft x. Form. 18. Balsamum Astrinoens. R Olei Terebimhinae part. ij. ; adde guttatim Acidi Sul- phurici part, ijss., in vase vitreo, ope balnei arenar. ca- iefacto. Liquori refrigerato, adde gradatim Alcoholis part. viij. Macera per dies septein. (Dosis3ss.— 3j- vehiculo quovis idoneo, in morbis Haemorrhagicis.) Form. 19. Balsamum Astringens. R Olei Terehinthinae, Acidi Murialici Concent., aa pars j.: agita bene, et post diem adde Alcoholis part. viij.; Camphorae part. S3. Form. 20. Balsamum Succinatum. R Balsam. Copaihae, Terebinthinae Venet., Olei Succini, aa. 5 j. Misce. Capiat TT1 xxx. ter quotidie in quovis ve- hiculo idoneo. (In Leucorrhoea, Gleet, Emissions, fee.) 11 APPENDIX OF FORMULAE. —Balsamum —Decoctum. Form. 21. Balsamum Sulphuris, vel Oleum Sul- phuris. R Florum Sulphuris pars j. ; Olei Amygdal. Dulc. part. iij.; Olei Anisi part. ij. Macera per dies sep- tem in balneo arenario. Form. 22. Balsamum Sulphuris Terebinthinatum. R Florum Sulphuris part. iij.; Olei Lini part. vij.; Olei Anisi part. v. Solve in balneo arenario, et adde OleiTerebinthina; part. xx. Misce. Excitant, diuretic, expectorant, &c. Dosis Ttl x.—xxx. (Balsamus Vita Rulanoi.) Form. 23. Balsamum Terebinthinatum. R Olei Oliva; g vj. ; Terehinthinae g ij. ; Cera; Flavae 5 j.; Bals. Peruvian. 3 ij.; Camphora; rasa; 3 jss. Solve Oleum, Terebinth., et Ceram ; dein adde alia. (Nearly the same as the Balsam of Chiron, a long-celebrated medicine.) Form. 24. Bolus Anodynus. R Pulv. Jacobi veri gr. iv.; Camphorae Pulverizat. gr. iij. ; Pulv. Potassa; Nitratis gr. x. ; Extracti Hyos- ciami, gr. vij.; Conserv. Rosar. q. s. utfiat Bolus. H. s. s. (In Cerebral Affections, &c.) Form. 25. Bolus Antispasmodics. R Pulveris Castorei optimi 3 ij.; Pulv. Radicis Vale- riana; g ss. ; Camphor, rasas 3 j- Misce accurate, et adde Syrupi Papaveris satis quantum ut fiant Boli granorumduodecim: invoIvanturpulvereStig- matorum Croci Sativi. Form. 26. Bolus Arkics. R Pulv. Flor. Arnica; Montan., Camphora; raste, aa gr. iv.; Conserv. Rosar. q. s. ut fiat Bolus. Form. 27. Bolus Bismuthi Compositus. R Moschi gr. x.; Bismuthi Subnitratis er. iij.—viij.; Opii Puri gr. ss.—j.; Conserv. Rosar q. s. ut fiat Bolus, p. r. n. sumendus. Form. 28. Bolus Cambogi^, R Cambogia; Gunnni Resina; gr. viij.: tere cum Olei Ju- niperi TT) iij., et adde Potassa; Supertart. gr. xx.; Pulv. Scillie, gr. j.; Syr. Zingiheris q. s. ut fiat Bolus. Form. 29. Bolus Camphors. R Camphoric rasa; etope Alcoholis subactaegr. iij.—x.; Pulv. Flor Arnica; Montana; gr. iij.—vj. ; Con- fect. Rosie Caninie q. s. ut fiat Bolus, quart! vel sextl quaque hora sumendus. Form. 30. Bolus Catechu Thebaiacus. R. Catechu Ext. contrit. gr. xv.; Confectionis Opii gr. viij. ; Pulv. Creta; gr. iv.: Syrupi Aurantii q. s. ut fiat Bolus, bis, ter, saspiusve in die capiendus. Form. 31. Bolus Ferri. R Ferri 3ub-carbon. gr. x.—xx.; Pulv. Aromatici gr. v. ; Syrup. Zingiheris q. s. ut fiat Bolus, bis terve quotidie deglutiendus. Form. 32. Bolus Guaiaci Ammoniati. R Guaiaci Gum. Resinae gr. viij.—xij.; Camphora; ra- sa, Ammonia; Carbon., aa gr. iv. ; Pulv. Acacia; gr. iij.; Confect. Rosa; q. s. ut fiat Bolus, hora som- ni sumendus. Form. 33. Bolus Guaiaci Compositus. R Guaiaci Resin, cont. 9 j.; Ipecacuanha; Rad. Pulv. gr. j. ; Opii Puri gr. j. ; Confectionis Rosa; Canime q. s. ut fiat Bolus, semel, bis, terve quotidie capien- dus. v Form. 34. Bolus Kino Thebaiacus. R Pulv. Kino Compos, gr. v.—x.; Pulv. Creta; Com- positi gr. xv. ; Pulv. Opii ss. ; Syr. Zingib. q. s. ut fiat Bolus, bis, ter, saspiusve in die sumendus. Form. 35. Bolus Moschi Compositus. R Moschi gr. xxiv.; Pulv. Rad. Valeriana; 9 jss.: Camphora; rasa; gr. xv. ; Conserv. Rosar. q. s. ut fiant Boli iij. Capiat unam 4taquaque hora. Form. 36. Bolus Nitro-camphoratus cum Opio. R Camphora; rasa; gr. iij.—vij. ; Potassa; Nitratis gr. x.—xv.; Opii Puri gr. ss.—jss. Conserv. Ros. q. 9. ut fiat Bolus, hora somni sumendus. Form. 37. Bolus Rhei Compositus. R Rhei Pulv. gr. x—xv. ; Pulv. Creta; Comp. gr. vii. • Pulv. Ipecacuanha; Comp. er. iij.—vij.; Syrup Zin- giheris q. s. ut fiat Bolus, hora somni sumendus. Form. 38. Bolui Sedati vus. R Acidi Boracici 9 j— 3 ss.; Conserv. Rosar. et Syr- upi q. s. ut fiat Bolus, p. r. n. sumendus. Form. 39. Bolus Sudorificus. R Camphorae rasas gr. j—iij.; Potassae Nitratis gr. xij.; Pulv. Ipecacuanha;, et Pulv. Opii Puri, aa gr. j. ; Syrup. Zingib. q. s. ut fiat Bolus. Form. 40. Bolus Valeriana cum Ferro. R Ferri Sub-carbon gr. v.—9 j.; Pulv. Valeriana? 3 ss. ; Syrup. Zing. q. s. Fiat Bolus. Form. 41. Cataplasma Ioduretum. R Cataplasm. Farina; Semin. Lini tepid, q. s.; Solut. Iodina; Rubef. q. s. Sit Cataplasma. Form. 42. Cataplasma Sinapeos Fortius. R Pulv. Sinapeos ft ss. ; Pulv. Capsici Annui, Pulv. Zingiheris, aa 3 j- j Acidi Acetici Pyrolignei q. s. ut fiat Catasplasma, dein adde Olei Terebinthinee g ij. Misce. Form. 43. Cataplasma Sinapeos Mitius. R Cataplasmatis Lini 3 iv.; Farina; Sinapeos g ss. M. Form. 44. Confectio Mentha Viridis. R Mentha; Viridis Fol. recent. g iv.; Sacchari Purifi- cati g xij. Folia in mortario lapideo contunde: turn, adjecto Saccharo, itetum contunde, donee corpus sit unum. (Sprague.) Form. 45. Confectio Sennje Composita. R Sulphuris Sublimati, Potassa; Sulphatis, aa g ss. j Confectionis Senna; g ij.; Syrup. Aurantii q. s. Capiat 3 j.— 3 ij.pro dose. Form. 46. Conserva Menthje Sativ.1. R Fol. Mentha; Viridis recentis g j.; Sacchari Purifi- cati 3 iij. Contunde probe simul, fiat Conserva. Form. 47. Decoctum Alth.eje. R Althaea; Radicis exsiccat. incis. gij.; Rad. Glycyrr- hiza; contus. 3 iij.; Aqua; Destillata;, Ojss. Co- que leni igne ad O j., et cola. Form. 48. Decocti Arctii Lapp^;. R Rad. Arctii Lappa; g jss.—gij.; Aqua; g xvi. Coque ad g xij. et cola. Form. 49. Decocti Arctii Lapp.e Compos. R Rad. Arctii Lap. recent, gj.; Lign. Sassafras., Dul- camara;, aa 3 nj. ; Rad. Glycyrrh. 3 jss. ; Aqua! Ojss. Coque ad O j., et exprime. Form. 50. Decoctum et Infusum Beccabung.e. R Herb. Veronica Beccabungae recentis giij.; AquteFer- ventisOj. Macera per horas binas, vel coque per quartam hora; partem et exprime. Capiat g ij. ter quaterve quotidie; vel utatur extern^ pro embroca- tione, super Ulcerationes Strumosas applicata. Form. 51. Decoctum Calumbje Comp. R Rad. Calumbae, Lign. Quassia; ras.,aa 3 ij. ; Corticis Aurantii exsic. 3 j.; Rhei Pulv. 9 j. ; Potassa; Sub- urb. 3 j. ; Aqux- g xx. Coque ad 5 xv., et cola : dein adde Spirit. Lavandul. Comp. 3 j. (Niemann.) Form. 52. Decoctum Cacuminum Pini Compositum. R Cacum. Pini Sylvest. g ij.; Radicis Symphyti Ma- jor, g j.; Aqua; ft ij. Coque per horse partem quartam ; exprime, et cola. Form. 53. Decoctum Cinchona; Aperiens. R Corticis Cinchona; Pulv. g j.; Aqua; ft ij. Coque Per partem hora; quartam, et adjice Fol. Senna; gss.; Rad. Zingiheris cont. 3 j.; Soda; Sulphatis gss.; Muriat. Ammonia; 9 j. Macera per horas bi- nas, ct adde Syrup. Sennas gj. M. Form. 54. Decoctum Cinchonj: Compositum. R Cinchona; Lancifol. Cort. contus. g ss. Coque ex Aqua; Pura; g xvj. ad consumpt. dimid., adjectis sub finem coctionis Serpentaria; Radicis contus. 3 ij. Stent per horam, et colaturae ad misce Spirit. Cinnamom. Comp. g jss.; Acidi Sulphur, dilut. 5jss. M. Sumanturgij. sexta quique hora. APPENDIX OF FORMULA. — Decoctum —Electuarium. Ill Form. 55. Decoctum Cinchona et Rhei. R Corticis Cinchonae Rubrae contuse 3 iij.; Radicis Gentianaeincisaegss.; Radicis Rhei Palmati 3 ijss.; Sub-carbonatis Potassae 3 j.; Aqua; Fontanae s. q. Coque per horam unam ut obtineantur colaturae un- ciae duodecim, etcola. R Hujus Colatiirae g vss.; Tinctura Canellae, Spirit. Anisi, aa3 jss. ; Syrup. Aurantii, g ss. M. Capiat Cochlear, j. vel ij. Form. 56. Decoctum Cinchona et Serpentaria. R Cort. Cinchona? Pulveriz. 3 vj.; Rad. Serpentaria; g ss.; Corticis Aurantii sic. 3 ij.; Aquas ft jss. Co- que adft j., et adde liq. colati Tinct. Cinnamom. g j. Form. 57. Decoctum Cydoni.se Comp. R Semin. Cydon. con. 3 ij. ; Rad. Glycyrrh. contus., Fici Caricae Fruct.,aagj. ; Aquae Bui. Oj. Coque cum igne leni per minut. horse decern, deinde cola. R IIujus Decocti g vjss.; Sub-boracis Sodae 3 j-; Potassae Tart. 3ij.; Spirit. vEther. Nit. 3 ij.; Syrup. Mori vel Sue. Inspiss. Samb. Nig. g ss. M. Fiat Mist., cujus capt. Cochlear, ij. larga secundis vel tertiis horis. (In irritative Inflammation ofthe Mucous Surface of the Digestive Organs, Dropsy, &x.) Form. 58. Decoctum Deobstruens. R Radicis Taraxaci, Herb. Fumariae, Fol. Sisymbrii Nasturt., Fol. Cliaerophylli Sylvest.,aa g j. Omni- bus bene concisis, adde Seri Lactis gxxxij. Coque per minut. hora vj.; et postea macera ad refrigera- tionein, dein cola. Colaturae adde Tartar. Potassae et Sodae g ss.— 3 VJ- > Mellis Optima; g j. M. Capiat cyathum Vin. ij. vel. iij. vel iv. in die. (Van Swietan.) Form. 59. Decoctum Depurans. R Caul. Dulcamara;, Herb. Fumariae Officin., Cort. Ulmi contr., Rad. Arctii Lappae cone, Rad. Ru- micis Patientia; concis., aa g ss.; Aquae Font. ft ijss. ; Coque ad O jss., et cola. Liq. colat. adde Syrup. Sarsaparilla; g ij. M. Capiat gj.— g jss. ter quaterve quotidie. Form. 60. Decoct. Dulcamara. R Stipit. Dulcamaras g j.; Corticis Aurantii 3 U- j Aquae ft jss. Coque ad ft j., et cola. Form. 61. Decoctcm Dulcamara Comp. R Caul. Dulcamara;, Radicis Arctii Lappa;, aa 3 vi. ; Radicis Glycyrrh., Lign. Sassafras ras., Lign. Gua- iaci ras., aa 3 ij.; Aquae Font, ft ij. Coque ad colaturae g xx. (Augustin. Rheumatism, Sy- phylis, Cutaneous Affections, &c.) Form. 62. Decoctum Filicis Compositum. R Radicis Filicis Maris g j.; Rad. Helenii 3 ij.; Fo- lii Absinthii g ss.; Seminum Santonici cont. 3 iij.; Aqua Ojss. Coque adOj.,et cola. Liq. colati adde Syrup. Rhamni g j. M. Form. 63. Decoctum Galla. R Gallarum contusarum gss. ; Aqua; Distillatae O ijss. Decoque ad oct. ij., et liquorem cola. Turn adde Tinctura; Gallae g j. (This decoction, used as a fo- mentation, enema, or injection, is of considerable use in the treatment of Prolapsus Ani, Hemor- rhoids, and in Leucorrhoea.) Form. 64. Decoctum Gentiana Comp. R Radici Gentiana; Luteae incisaegss.; Aquae Fonta- nae ft j. Coque per semihoram, deinde infunde quantum sufficit super Radicis Calami Arom. 3 iij.: cola, et post refrigerationem adde yEtheris Sulph. 3 ij.; Syrupi Aurantii g ss. Misce. Form. 65. Decoctum Guaiaci et Dulcamara Comp. R Rasur. Ligni Guiacigjss. ; Stipit. Dulcamara; g jss.; Rad. Lauri Sassafras, concis., Flor. Arnica;, Rad. Calami Arom., Rad. .Glycyrrh., aa g ss.; Semin. Fceniculi 3 ij.; Aquae ft iij. Coque ad ft iij., et cola. Capiat gj.— giij. ter quaterve quotidie^ Form. 66. Decoct. Helenii Comp. R Rad. Inulae Helenii gj. ; Summit. Hyssopi Officin. 3 iij.; Fol. Heder. Terrest. 3ij.; Aquaeq. s. ut sint Colaturae g xij. Coque per partem hora; quartam, et cola: adde liq. colat. Potassa; Sub-carbon. 3 j. ; Syrup. Tolutan., Syrup. Altha;a;,aagj. M. Capiat gj.— gij. ter quaterve quotidii. (In Chronic Ca- tarrhs, the Pectoral Affections of Debility, Asthma, Chlorosis, Amenorrhoea, Ate.) Form. 67. Decoctum Inula Compositum. R Rad. Inula; Comp. gjss.; Hyssopi Officinal., Flor. Tiliae Europ. aa 3 iij.; Fol. Heder. Terrest. 3 ij. ; Aqua; ft ij. Coque ad ft jss.; exprime, etcola. Co- laturae adde Spirit. ..Ether. Nit. g ss.; Potassa; Ni- tratis3j.; Syrup. Scillae 3ij.j Syrup.AlthiefBgss. M. Form. 68. Decoctum Pectorale Elsneri. R Rad. Glycyrrh., Croci Stig., Rad. Inula; IIeIenii,Rad. Ireos Flor., Semin. Anisi, Hyssopi Officin., aagss.; Aquae ft ij. Coque ad ft jss.: cola et adde Tinct. Bals. Tolutan. g j. ; Syrup. Tolutan. g j.; Mellis gj. M. Capiat gj.— gij., 4tis vel Otis horis. Form. 69. Decoctum Punicje Granati. R Corticis Radicis Punicae Granati recent, et exsic. g ij.; Aquae Com. O ij. Macera sine calore per ho- ras xxiv. ; dein coque ad O j. et cola. (The whole to be taKen in three doses within two hours.) Form. 70. Decoctum Quassia: Comp. R Ligni Quassia; rasa; g ss.; Flor. Anthemid. 3 VJ- j Potassae Sub-carbon. 3 ijss.; Aq. Fontan. ft ij. Coque ad dimidium, et cola. Form. 71. Decoctum Santonici. R Santonici Semin. contus. g ij.; Aqua; Destillata; g xx. Coque lento igne ad Oj., etcola. (In Ascarides.l Form. 72. Decoctum Sarsaparilla Compositum. R Sarsaparilla; Radicis, concisa; et contusae, g jss.; Glycyrrhizae Radicis contusae g ss.; Coriandri Sem- inum contus. 31J.; Liquoris Potassa: 3j- (ve' sine); Aquae Ferventis O j. Macera per horas xxiv. in vase leviter clauso, et cola: liquoris colati sumat partem 3tiam ter quotidhe. (Sprague.) Form. 73. Decoctum Secalis Cornuti. R Secalis Cornuti 3 ij.; Aquae gvij. Decoqueadgiv Ab igne remove, et paulo post e faecibus effunde. Form. 74. Decoctum Senega. R Senegae Radicis cont. 3 vj.; Aquae Oij. Coque ad O j.; et sub finem Coctionis adde Glycyrrh. Rad. contus. g ss. Exprime, et cola. Form. 75. Decoctum Spartii Cacuminum. R Spartii Cacuminum concisi gj. ; Aquae Distillatae O j. Decoque ad octarium dimidium, etcola. Form. 76. Decoctum Taraxaci Co. R Radicis Taraxaci giv.; Supertart. Potassae, Sub-bo- racis Sodae, aagss.; Aq. lb iij. Coque ad ft ij. ; et adde, ut sit occasio, vel Spirit. iEther. Nit., vel Tinct. Scillae, vel Spirit. Juniperi Comp., vel Oxy- mel Scillae. Form. 77. Decoctum Taraxaci Comp. Stollii. R Rad. Taraxaci, Rad. Tritici Rep., aa g ij.; Aq. ftiij. Coque ad ft ij.: cola, et adde colaturae Potas- sae Sulph. gss.; Oxymel. g j. M. (In Visceral Obstructions.) Form. 78. Decoctum Tormentilla. R Tormentilla; Radicis contusae gj.; Aquae Destillata; Ojss. Coque ad octarium, et cola. Form. 79. Electuarium Alcalino-ferratum. R Oxidi Ferri gss. ; Potassae Sub-carbonatis 3j. ; Sub- carbonat. Calcis 3 ij-j Pulvis Zingiheris 3 jss.; Syrup. Aurantii giijss. M. Fiat Elect, cujus capiat Coch. j. minim, mane nocteque. (Chlorosis, Chorea, &c.) Form. 80. Electuarium Anthelminticum. R Pulv. Valerianae, Semin. Santonici contus.,aagss.; Potassae Sulphatis 3 ''.)•> Pulv. Jalap. 9 iv.; Oxymel. Scillae g iv.; Pulv. Glycyrrh. (vel Extr. Glycyrrh.) 3ij. M. ut fiat Electuarium. (Forchil- dren, one to two drachms; and for adults g ss. three or four times daily.) Form 81. Electuarium Antispasmodicum. R Pulv. Cinchona; g j.; Pulv. Valeriana; g ss. ; Con- fect. Ruta;, gj.; Confect. Ros. Gall, g ss.; Confect. Aurantii 3iij. ; Olei CajeputiSss. ; Syrup. Auran- tii g ijss. vel q. s. ut fiat Electuarium molle. Ca- piat 3j.—iij. mane1 nocteque. (In Epilepsy, Cho- rea, Hysteria, Flatulency, &c.) IV APPENDIX OF FORMULAE. —Electuarium —Emplastrum. Form. 82. Electuarium Aferiens. R Magnesia?, Potassae Supertart., Flor. Sulphuris, Pulv. Rad. Rhei, Pulv. Flor. Anthemidis. aa gr. vj. ; Syrup. Aurantii 3 iij. ; Olei Pimentae TTf ij. M. Sit Electuarium pro dose. (Hecker.) Form. 83. Electuarium Aperiens. R Mannae 3 VJ- j Syrup. Sennae 3iij. ; Olei Amygdal. Dulc. 3ij. Tere beni, et adde Aquae Faeniculi 5'j-i Sacchari Albi 3 Jss- Sit Electuarium, cujus capiat infans 3 j.— 3 ij. pro dose. Form. 84. Electuarium Arnica Composit. R Pulv. Flor. Arnicae 3 iij.; Pulv. Cinchona; g ss.; Pulv. Rad. Serpentaria; 3 iij. ; Confect. Aromat. 3 j. ; Syrup. Aurantii g v. Misce. Capiat 3j.— 3 ij. 2dis horis. Form. 85. Elect. Bechicum. R Mannae Optima; g j.: tere cum Aq. Flor. Aurantii q. s., et adde gradatim Pulv. Acaciae gss.; Extr. Glycyrrh. 3 j. ; Syrup. Tolutan. q. s. Sit Electuarium molle, cujus capiat pauxillum urgenti Tussi. Inlerdum ad- de Pulv. Ipecacuanha;, Extract. Conii, vel Extr. Lactuca;. Form. 86. Electuarium Cinchona Aperiens. R Cinchona; Lancefol. Cort. in Pulv. g j. ; Valerian. Rad. Pulv. 3 iij- ; Confectionis Sennae g jss.; Con- fect. Aromat. 3 ij. (vel Confect. Piperis Nigri 3 iij.); Syrupi Sennae g ijss. vel q. s. ut fiat Electuarium molle. Cujus devoret Cochlear, j. vel ij. minim. mane meridue, et nocte. (In Ague, diseases of De- bility, &c.) Form. 87. Electuarium Cinchona Compositum. R Cinchona; Cordif. Corticis Pulv. g j.; Confectionis Rosae Gallics g ss. ; Acidi Sulphurici diluti 3 j. ; Syrup. Zingiheris g jss. M. Fiat Electuarium. Dosis 3j.— 3 ij. ter quaterve in die. Form. 88. Electuarium Cinchona cum Ferro. R Cinchona; Corticis pulv. gj.; Ferri Sub-carbon.9 ij. — 3 U- ; ^yrup. Zingiheris q. s. ut fiat Electuarium. Dosis 3 j.— 3ij. his terve quotidie. Form. 89. Electuarium Deorstruens. R Pot.issae Supeitart. gjss.; Sulph. Praecip. gj. ; Sub- boracis Sodae 3 'j^s- i Syrup. Zingiheris q. s. ut fiat Electuar. Cochlear, j. vel ij. minima h. s. Form. 93. Electuarium Ferrifugum. R Pulv. Cinchonae gij.; Pulv. Rad. Serpentar.. Pulv Cort. Canellae, aa. 3 ij.; Camphorae rasts 9 ij.; Opii Puri ar. iv. ; Syrup. Zingiheris, et Syrup*, aa q.s. ut fiat Electuarium, cujus capiat 3 ss.— 3 jss. pro dose. Form. 91. Electuarium Febrifugum Hoffmanni. RPulv. Cinchonne^vj. ; Pulv. Flor. Anthemid. 3 ij.; Caryoph. in Pulv , Ext. Centaurii Min., asi 3ss. (vel Pulv. Centaurii 3jss.); Succi Inspiss. Sambuci Nig. gss.; Syrup. Limonis gjss. M. Capiat gj.4tis horis. Form. 92. Electuarium Febrifugum Trilleri. R Cinrhon.T Pulv. gj. ; Pulv. Flor. Anthem. 3ij-; Pot- assae Nitratis, Ferri Ammoniati, aa 3 j.; Syrup. Aurantii g ijss. M. Fiat Electuarium, cujus capiat Cochlear, j.—ij. min. pro dose. Form. 93. Electuarium Ferri Ammoniati Composi- tum. R Myrrhae Pulv. 3 jss. ; Ferri Ammoniati er. xxxv. : tere simul.et adde Pulv. Radicis Rubi.e 3jss.; Pulv. Castorei 3 ij. ; Syr. Zingiheris gjss. vel q. s. ut fiat Electuarium ; de quo snmatur, bis quotidue, ad My- risticae Nuclei magnitudinem. Form. 94. Electuarium Ferri Tartarizati. R Potassae Supertart. g ij. ; Ferri Tartarizati 3 iij.; Zin- giheris 9j ; Svrup. Aurantii q. s. ut fiat Electua- rium molle, cujus capiat 3j— 5 ij. bis terve in die. Form. 95. Electuarium Nitri Camphoratum. R Camphorae rasae et ope Alcoholis pulverizat. gr. vj — xij. ; Potassae NitratN 3 jss.; Confect. Rosae Gallicte gjss. ; Syrup. Simp. q. s. ut fiat Electuarium. Do- sis, moles Myristicae Nuclei subinde capiatur. Form. 9'i. Electuarium Purgans. R Confectionis Sennae g ij.; Pulver. Jalapae3j • Pot- ass. Supertart. pulv. g ss. ; Syrup. Zingiber 3 j M. Sumat Cochl. j. min. bis vel ter die. Form. 97. Electuarium Scilla Compositum. R Potasses Supertart. contrit. 5 iij.; Juniperi Bac. et Cacumin. pulv. g j. : tere benA simul, et adde te- rendo Pulv. Jalapa; 5 ij.; Oxymel. Scillae gij.; Sy- rup. Zingiheris q. s. ut fiat Electuarium. Dosis 3 j.— 3 iij. bis, ter, quaterve in die. Form. 98. Electuarium Senn.t. Compositum. R Sennae Fol. pulver. g ss.; Potassa; Supertart. pulv. 3vj.; Pulv. Jalapa; Rad.3U-i Sodae Sub-boracis 3j.; Syrup. Zingiheris gij. Misce. Dosis a 3j.— 3 ij- pro re nata. Form. 99. Electuarium Terebinthinjb. R Pulv. Tragacanth. 9 iv.; Aq. Purse f. g j. M. Fiat mucilago; tunc gradatim adde Ol. Terebinth, f. g j.; et contere cum Sacch. Purif. 3U-; Pulv. Cure urns gr. x. ut fiat Electuarium. Form. 100. Electuarium Terebinthinatum. R Olei Terehinthinae gj.; Mellis despumati g ij.; Pulv. Rad. Glycyrrh. q. s. ut fiat Electuarium. Form. 101. Electuarium Valeriana Compositum. R Pulv. Rad. Valerian. Minor. 3j.; Pulv. Sem.Santo- nicae 3 ij. ; Pulv. Rad. Jalap, gr. xxx.—xl.; Oxy- mel. Scillae q. s. ut fiat Electuarium. Form 102. Electuarium Vermikugum. R Sulphatis Potassae cum Sulphure, Pulveris Radicis Jalapa;, Pulveris Radicis Valerianae, aa 3j. ; Oxy- mellis Scillitici, g iv. M. Sumantur adulti gss., quatuor vices de die,et pueri e 3j. ad 3 ij. (Stoerk.) Form. 103. Elixir Aloes Compositum. R Croci Stig. pars j. ; Potassa Acet., Aloes, Fellis Tauri inspiss., aa part. ij. ; Myrrhae, part. ij. ; Spirit Vini (vulgo Brandy diet.) part xxiv. Infunde et macera secundum artem, et cola. 3j.— 3 ijss. pro dose. Form. 104. Elixir Pectoralis Wedellii. R Assafoetida; 3 ij. ; Flor. Benzoes, Opii Purif., Cam- phone, Croci Stig., Rad. Scilla;, Olei Anisi, aa 9 ij.; Bals. Peru v. gss.; Spiiit. Vini Rect. ft ijss. Macera, et cola. Form. 105. Elixir Proprietatis Rhubakbarinum. R Aloes Socotrin. gj. ; Rhei 3 vj. ; Myrrhae 3 iijss. ; Croci Stiemat. 3 iij. ; Sub-carb. Potassae 3 ijss. ; Vini Madeirensis ft j. ; Alcohol, g iij. Macera pec dies Septem, et cola. (In dos. 3j.—3 ij. Vermi- fuge, emmenagogue, &c.) Form. 106. Elixir Tonicus. R Aloes, Myrrhae, 5a 3 ij. ; Summit. Absinthii, Sum. Centaurii Minoris, Cinchonae in Pulv., aa g ss.; Corticis Aurantii Amarae 3 iij. ; Croci 3ij. ; Vini Albi Hispan. ft ij. Macera in sole per horas xlviij.: dein adde Sacchar. Alb. g viij., etcola. Form 107. Emplastrum Ammonia. R Ammoniae Muriatis 3j. ; Saponis Duri 3 ij.; Emplas- tri Plumbi g ss. ; Emplastrum et Saponem simul liqua, et paulo antequam concrescant immisce Sa- lem in pulverem tenuem tritum. Extensum super a!utain parti affectae quamprimum applicatur, et pro re nata repetatur. Form. 108. Emplastrum Anodynum Fortius. (Rich- ter.) R Emplastr. Galban. Comp. (vel Emp. Cumini) g j.; Camphorae 3 j. ; Amnion. Sub-carbon., Opii Puri, aa 3 ss. ; Olei Cajeput. gtt. xl. Fiat Emplastrum secundum artem. Form. 109. Emplastrum Anticolicum. R Gum Ammoniaci, Gum. Galbani, aa g j.: Terebin- thin. Venet. et Terebinthin. Commun. aa 3 x.: len- to mneliquefactis, adjice Assafcetida; gjss. ; Croci Stigm. 3 iij. ; Olei Mentha; Pip., et Olei Rutae, ai 3 ss— 3j. et omnia misce. Form. 110. Emplastrum Antihystericum. R Galhani, Sagapeni.aa g j. ; Assafoetidae g ss. ; Olef Rutae 3 ss.—3j. ; Aceti Vini q. s. ad Gum. Resin. liquefnxienrium : dein adde Terehinthinae Com- mun. gj. ; Cera; Flava; % iij. ; Pulv. Myrrhae gss.; Pulv. Castorei 3 jss. ; Olei Succini 3 ss. Misce. (The Wurlembergand Manheim Pharm.) APPENDIX OF FORMULAE.—Emplastrum—Enema. V Form. 111. Emplastrum Aromaticum Compositum. R Emplast. Arom. (PA. Dub.), vel Emp. Cumini gss.; Sulphuris Sublimat. 3 ij.; Olei macis TT) xxxv. Fiat Emplastrum. Form. 112. Emplastrum Belladonna. R Extr. Belladonna; part. iij.; Ammon. Carbon, pulv. parsj. Misce, et fiat Emplastrum. (To very pain- ful parts.) Form. 113. Emplastrum Camphora. R Olei Olivae g xij.; Minium g viij. Liqua, et massae refrigeratae adjice Camphorae g ijss.: solutae in pauxillo Olei. Misce bene. (Stahl.) Form. 114. Emplast. Defensivum. R Minium g viij.; Aceti g iv.; Olei Olivae ft j. Li- qua, et adde Cerae Flavae g ij.; Camphorae g ss. Misce beni. Form. 115. Emplastrum Deobstruens. R Potassae Sulphureti, Pulv. Conii. aa 3 ijss.; Cam- phora; Pulveris, Terehinthinae, aa 3 iv.; Saponis Albi3ss.j Cerae Flavae gj.; Emplast.Simp, giv. M. Form. 116. Emplastrum Picis. R Picis Abietinas vel Nigra; g vj.; Cerae Flavae g j.; Terehinthinae Vulg. 3 iij.; Liquefac simul, et fiat Emplastrum. Form. 117. Emplastrum Resolvens. R Emplast. Ammoniaci cum Hydrarg., Emplast. Picis Comp., Emplast. Galbani Comp., aa partes aequa- les. Fiat Emplastrum. Form. 118. Emplastrum Roborans. R Emplastr. Picis Comp.,Empl. Galban. Comp., Emp. Cumini, aa partes binas ; Oxidi Ferri Rubri ; Thu- ris, aa partem unam; Olei Pimenta; q. s. ut fiat Emplastrum. Form. 119. Emplastrum Rubefaciens. R Emplast. Aromat. Comp. (F. 111.) gss Forma in Emplast., dein asperge cum Antimonii Tartariza- ti g j. ; Camphorae Pulveriz. 9j.; Sulphur. Subli- mati3ss. in unum admixtis. Form. 120. Emplastrum Stibiatum. R Emplast. Picis Comp. part. xj.; Terebinth. Venet. part. iv.; Antimon. Tartarizat. in Pulv. part. j. Li- quefac Emplastrum et Terebinthinam, etadde An- timonium. (Niemann and Augustin.) Form. 121. Emulsio Amygdalo-Camfhorata. R Amygdal. Dulc. decor, gss.; Amygdal. Amar. N iij.; Aqua; Fontana; gvijss.l. a. Emulsio, in Colaturaad- misce Pulv. Gummi Arabici 3'j-j Camphorae (cum paul. Alcohol, subactas) 9 j. ; Syrup. Papaveris Albi 3 ss. M. Et sit Emulsio, de qua sumat quovis bi- horio Cochleare unum,praegressavitri commotione. Form. 122. Emulsio Anticharrhalis. R Sem. Phelland. Aquat. con. g j.; Gum. Acaciae gj.; Aq. Ferv. g ix. Macera, et cola. Colaturae adde Sy- rup. Althaea; g ss.; Vini Ipecac. 3 ij. M. Capiat Coch. ij. larga 3tiis vel 4tis horis. Form. 123. Emulsio Camphorata. R Olei Amygdal. Dulc. gss.; Gum Acaciaeq.s.; Cam- phorae gr. x.—9 j-: tere bene simul, et adde Aquae Foeniculi et Aquae Laurocerasi g ij.; Syrup. Al- thaea; g ss. M. Fiat Emulsio. Form. 124. Emulsio Camphorata. (Augustin.) R Camphorae Subactae gr. xyj.; Amygdal. Dulc.gss.; Aquas Flor. Sambuci g vj. Sit Emulsio. Form. 125. Emulsio Camphorata Composita. R Camphorae gr. x.—9j.: subige in Alcoholis f. 3 ss. ; et adde terendoMucilag. Acaciae gij.; Olei Amyg- dal. Dulc. gss.; Syrup. Altha;ce g ss.; Aquae Lau- rocerasi, Aquae Foeniculi, aa g ijss. M. Capiat Coch. j. vel ij. 3tiis vel 4tis horis. Interdum adjiciatur vel Vinum Ipecacuanha;, vel Vinum Antimonii, vel Potassae Nitras, vel Syrupus Papaveris Albi. A* Form. 126. Emulsio Nitro-Camphorata. R Camphorae Subactae, Potassae Nitratis, aa 9 j ; Pulv. Gum. Acaciae 3 j. ; Infus. Pectoralis vel Aquae Flor. Aurantii, gvjss.; Syrup. Althaea; gj. M. Fiat Emulsio. Form. 127. Emulsio Pectoralis. R Spermaceti 3 j.; Gum. Acaciae 3 ij. ; Olei Amygdal. Dulc. gj. ; Syrup. Simp., Syrup. Tolutan.,aagss. ; Aq. Foeniculi givss. M. Fiat Emulsio. Form. 128. Emulsio pro Tussi. R Olei Amygdal. Dulc. gjss.; Vitelli Ovi unius; Aquas Flor. Aurantii gv. ; Mucilag. Acaciae gss.; Vini Ipecacuanha; 3jss.; Syrup. Althaea; gss. M. Form. 129. Emulsio Sedativa. R Mist. Amygdal. Dulc.; Mist. Camphora; aa g ijss.; Mucilag. Acaciae g ss.; Morphinae Acetatis gr. j.—ij. ; Syrup. Tolutan. gss. Solve Morph. Ace- tat, in Olei Amygdal. TT) xx.; deinde adde alia. Form. 130. Enema Aloes et Assafcetida Comp. R Extr. Aq. Aloes 3 ss.; Assafcetida; 3 jss.; Camphorae rasae gr. xij.; Olei Olivae gjss.; Decocti Avente gxij. Misce. (In Flatulent Colic, Ascarides, &c.) Form. 131. Enema Antihystericum. R Fol. Rutae,Fol. Sabinae,aagss.; Aquae Fervid, q. a, Coque ad g xvj.; et adde Assafcetid. 5 ij.; Olei Oli- vae 3 'J- Misce. Form. 132. Enema Antispasmodicum. (1.) R Tinct. Opii 3j-; Infus. Valer g x.; Mucilag. Aca- ciae gj. M. Form. 133. Enema Antispasmodicum. (2.) R Tinct. Opii 3 ss.— 3J-j Infus. Cuspariae, Decocti Althasas Off., aagv. M. Pro Decoct. Alth. inter- dum utatur vel DecoctoMalve, vel Decoct. Hordei, vel Infus. Ipecacuanha;. Form. 134. Enema Assafcetida, vel Fcetidum. R Assafcetida; Gummi Resinoe 3 ij.; Decocti Malvae Composit. gx.; Spiritus Ammonia; Compos. 3 jss.; Tincturae Opii 3ss. Misce pro Enemate. Form. 135. Enema Assafostida et Terebinthina. R Assafoetida; 3j.— 3U- > Camphorae rasae gr. xij.: tere cum Decoct. Avenae g viij. ; dein adde Olei Tere- binth, gss. ad gjss. Misce, et fiat Enema. Form. 136. Enema Assafcetida Compositum. R Assafoetida; 3J.— 3U- ! Camphorae rasas gr. x. ; De- cocti Avenae g xij. Misce pro Enemate. Interdum adde Olei Terebinth. 3 i>j -—gjss. In flatulent Colics, Worms, &c. Form. 137. Enema Belladonna. R Fol. Belladonnas exsic. gr. xij. ; Aq. Fervid, g vj. (In retention of the urine from Spasm of the Sphinct. Vesicas, or Spasm of the Rectum.) Form. 138. Enema Camphora Comp. R Camphorae rasa; gr. xij.; Olei Juniperi Angl. 3 ss.; Infus. Valeriana; gx.; Mucilag. Acaciae gj. M. Fiat Enema. Form. 139. Enema Camphoratum. R Acidi Acetici Camphorati (F.2.) gss.—gj ; Infus. Valeriana; g viij. M. (Augustin.) Form. 140. Enema Catharticum. R Decocti Malvae Composit. gx.; Magnesia; Sulphatis gj.; Olei Olivae f. gij. Misce. Fiat Enema. Form. 141. Enema Colocynthidis Compositum. R Colocynthidis Pulpa1 incis. 3j. ; Aqua; gxij. Coque paulisper et cola: dein adde Sodae Muriatis (vel Soda; Sulphatis) gss. ; Syrup. Rhamni Cath. gss. Misce. Form. 142. Enema contra Spasmos. R Camphorae rasae gr. v.—x.; Potassae Nitratis gss. ; Olei Olivae gj. : tere simul, et adde Infusi Valeri- anae, Decocti Malvae Comp., aa g vij. M. Form. 143. Enema Emolliens. R Flor. Anthemidis, Semin. Lini contus., 5a g ss. ; Aquae Fervid, g vj. Macera et cola; dein adde Opii gr. vj.—xvj. M. Fiat Enema. vi APPENDIX OF FORM1 Form. 144. Enema Emollio-Aperiens. R Decoct. Malvae Comp. g xij. ; Sodae Tartariz. gss. ; Olei Olivae gij. M. Fiat Enema. Form. 145. Enema Opiatum. R Tincturae Opii f. Jjj.; Mucil. Amyligvj. Misce. Fiat Eneina, tepid, injiciend. Form. 146. Enema Saponis. R Saponis Mollis g j.; Aquae Ferventis Oj. Solve, et tepidum exhibe. Form. 147. Enema Sedativum. R Seminum Lini contus. g j. ; Aquae Ferventis g viij. Macera per horam : dein cola, et solve in Colat. Sub-boratis Sodae 9 j.; Opii Extr. gr. ij.—iij. M. Fiat Eneina. Vel. Form. 148. Enema Sedativum Camphoratum. R Infus. Lini Comp.gx.; Tinct. Opii3ss.; Sub-bora- tis Sodae 3 ss.; Camphorae rasae gr. x. M. Fiat Eneina, bis terve in die injiciendum. Form. 149. Enema Terebinthinatum. R Camphorae rasae 9j.; Olei Terebinth, gss.— gjss.; Olei Olivas gjss.; Decoct. Avenae g viij. Fiat Enema. Form. 150. Enema Terebinthina. R Terehinthinae Vulgaris g j. (vel Olei Terehinthinae f. gss.); Ovi unius Vitellum. Tere simul, et gra- datim adde Decocti Avenae tepid, g x. Injiciatur pro Enemate semel in die, pro re nata. (When it is required to evacuate the lower bowels, 01. Rici- ni g j. will be found a useful addition.) Form. 151. Enema Terebinthino-Camphoratum. R Olei Terebinth, gj.; Olei Olivae gjss.; Camphorae rasae gr. xv. ; Decoct. Avenae g viij. M. Fiat Enema. Form. 152. Enema Thebaiacum. R Opii Puri gr. j.—iij.; Mucilag. Acaciae gss.; Lactis Tepefact. g vj. Misce pro Enemate. Form. 153. Enema Vermifuoa. R Rad. Valerian., Herb. Ahsinthii, Herb. Tanaceti, Cacum. (vel Sem.) Santonic, aa 3 iij. ; Aq. Fer- vid, g xii. Macera per horas binas, et cola. Liq. colat. adde Salis Commun. gss. Fiat Enema. Form. 154. Extractum Aloes Alkalinum Comp. R Aloes SpicatiExtr. contrit. giij.; Zingiheris Radicis concis. gss.; Myrrhae Pulv., Croci Stigmat.,aa 3 vj. Potassae Sub-carbon, (vel Sodae Sub-carbon.) gss.; Macera per triduum leni cum calore, dein cola. Li- quoram defaecatam consume,donec idoneam habeat crassitudinem. (Dosis gr. x. ad xxx.) Form. 155. Extractum Dulcamara. R Stipit. Dulcamara;, pars j.; Aquae Bullient. part. viij. (Split the shoots of dulcamara longitudinally, and macerate them in the water for twelve hours ; boil for a quarter of an hour, and express the fluid. Af- terwards boil the residue with four parts of water, and finally express. Mix the two liquors, and evap- orate with a gentle heat to a proper consistence.) Form. 156. Extractum Hellebori Niori Backeri. R Radicis Hellebori Nig. exsic. ft ij.; Potassae Sub carbon, ft ss.; Alcohol. (22 grad.) ft viij. Backer directs the above to be digested in a sand- bath for twelve hours, shaking it frequently, and afterwards to be expressed and strained. Eight pounds of white wine are to be poured upon the residue, and digested with it for twenty-four hours in a sand-bath, and afterwards to be expressed and strained. After a few hours both these tinctures are to be mixed together, and evaporated with a gentle heat to the consistence of an extract. This is the best preparation of Hellebore. Dose from 10 to 15 grains.) Form. 157. Fomentum Camphoratum. R Camphorae gss.; Acidi Aceticigij.; Aceti Commun. gx. M. (Augustin.) Form. 158. Garoarisma Acidi Muriatici. R Infus. Cinchona; gvj.; Acidi Muriatici TT) xx.; Mel- lis gss. M. LIE. — Enema — Haustus. Form. 159. Garg. Acidi Muriatici Compositum. R Acid. Muriatici f. g jss.; Decoct. Cinchona;, Infus. Rosae Compos, aa f. g iijss.; Mellis Rosa; f. g j. M. Fiat Gargar. Form. 160. Gargari9ma Antisepticum. R Decocti Cinchona; gvj.; Camphorae gr. xx.: Ammo- niae Muriatis gr. xv. M. Form. 161. Gargarisma Astringens. R Infusus Rhataniae, g vjss. ; Acid Sulph. Dilut. gss.; Syrupi Mori g j. M. Fiat Gargarisma. (For Re- laxation of the Uvula and Fauces.) Form. 162. Gargarisma Astringens Zobellii. R Alumina; Crud., Potassae Nitrat., aag ss.; Potassae Supertart. 9 ij.; Aceti Distil, g ij. Solve, et adde Aquae Rosar. gij. M. Fiat Gargarisma. Form. 163. Garg. Boracis Soda. R Boracis Pulver. 3 ij-; Aquae Rosas f. g vij.; Mellis Despumat., Tincturae Myrrhae, aa f. gss. M. Form. 164. Gargarisma Catechu Thebaiacum. R Infusi Rosae f. g vij.; Tincturae Catechu f. 3 vj.; Aci- di Sulphurici diluti f. 3 j.; Tincturae Opii f. 3 jss. Sit Gargarisma siepe utendum. (A. T. Thomson.) Form. 165. Gargarisma Commune. R Aquas Purae g xxij. -, Sub-boracis Sodae 3 x. ; Tinct. Catechu g j.— g iij.; Tinct. Capsici Annui 3 j.— 3 iij.; Mellis Rosae g jss.— g iij. Interdum adde, loco Boracis Sodas et Tinct. Catechu, Acidum Mu- riaticum, vel Acidum Sulphuricum. Form. 166. Gargarisma Potassa Nitratis. (1.) R Potassae Nitratis 3 jss. ; Mellis Despumat. f. g ij.; Aquae Rosae f. gvj. M. Fiat Gargarisma. Form. 167. Garg. Potassa Nitratis. (2.) R Potassae Nitratis 3 ij.; Decocti Hordei f. gvij.; Oxy- mellis Simplicis f. gj. M. (Brand-e.) Form. 168. Gutta Acetatis Morphina. R Morphina; Acetatis gr. xvj. ; Aquae Destillatae 3 vj.; Acidi Acetici diluti 3ij. M. Form. 169. Gutta jEtheris Terebinthinata. R Olei Terehinthinae pars. j. ; .lEther. Sulphurici (vel ^Ether. Nitrici) part. iij. M. (Nearly the same as that recommended by M. Durande in Jaundice and Biliary Calculi.) Form. 170. Gutta Anodyna Acetatis Morphina. R Morphina- Acetatis gr. xvj. ; Aquae Distillatns g j. ; Acidi Acetici TT) iij- ; Spiiitus Vini 3 jss. M. (Misce. In doses of from five to thirty drops.) Form. 171. Gutta Antiloimica. R Pulv. Camphorae gij. ; Spirit. Rect. gviij.; Liquor. Ammon. gij.; Ol. Lavendul. 3' j - M- Fiant Gutta;, quarum capiat xx. ad 3j. quovis in idoneo vehiculo. Form. 172. Gutta contra Spasmos. R Olei Cajeputae, Tinct. ^Ether. Valerianae (Vide Form.) Spirit. Ammon. Succinat., aagj.jOlei Anisi 3 ij. M. (TT) x. ad xxxv.) Form. 173. Gutta contra Spasmos. (Stoll.) R Liquor Ammoniae Carbon., Tinct. Castorei, Tinct. Succini, Tinct. Assafoetida;, aa 3 iij. M. TT) L. bis terve in die. Form. 174. Gutta Nervina. R Camphorae, Croci, aa 3 jss- i Moschi, Myrrhee, aa 9 iv.: tere ruin Sacchar. Albi gss.; et Spirit. Vini Rectific. 3 ij-: dein adde terendo Olei Lavand., Ol. Juniperi, Ol. Rosmarini, Olei Origani, aa 3iij.; Olei Succini, Olei Cajeputi, aa3 j. ; Olei Limonia gss. ; Olei Terehinthinae gij. ; Sacch. Albi gss. ; Spirit. Vini Rect. 3 ij. Macera et seiva, Bin« colat., in vase bene obturato. Form. 175. Haustus Acidi Nitrici et Opii. R Tinct. Opii TT) xx.—xxx.; Tinct. Oaryoph. (Vide Form.) 3 ij-—g ss-; Acidi Nitrici TT) xx. ; Aquae Pimentae gj. M. Fiat Haustus. APPENDIX OF FORMULA. —Haustus. vii Form. 176. Haustus Acidi Nitrici et Opii. R Acidi Nitrici Diluti 3 j. ; Tinct. Opii3ss. ; Infusiis Calumba; 3 ass. Misce, ft. Haustus ter in die capi- endus. Form. 177. Haustus Anodynus. R Mist. Camphorae 3ix.; Potassa; Nitratis gr. vj.; Spirit .rEtheristiulph. Compos. 3j.; Tinct. OpiiTTJx.—xij.; Syrup. Papaveris 3 ij. Fiat Haustus, hora decubi- tus sumendus. Form. 178. Haustus Anti-emesin. R Infus. Aurantii Comp. 3 x.; Spirit. Mentha; Virid. 3j. ; Liq. Potassa; TT) x. ; Magnes. Carbon. 9 j- j Tinct. Hyosciami 3ss. ; Extract. Humuli gr. viij.; Syrup. Zingib. 3 j. M. Fiat Haustus. Form. 179. Haustus Anti-emeticus. R Magnes. Carbon.9j.; Extr. Humuli gr. vj.; Liq. Pot- assae TT) viij.; Tinct. Hyosciami 3 ss.; Spirit. Men- tha; Virid. 3 j.; Infus. Aurantii Comp. (vel. Infus. Caryoph. Comp.) 3 x. ; Syrup. Zingiheris 3j. M. Form. 180. Haustus Aperiens. R Extract. Rad. Jalapa; gr. xv.: tere cum Amygdal. Dulcis Num. iv.; Aquae Cinnam. g j. Fiat Haustus. Form. 181. Haustus Aperiens ex Jalapa et Aloe. R Pulv. Rad. Jalapae gr. xvj. ; Aloes Socot. gr. x.: tere probe cum Extract. Glycyrrh. 3 ss.; Tinct. Rhaei3j.; Ol. Carui TT) ij.; Aquas Cinnam. gj. M. Fiat Haustus. Form. 182. Haustus Aperiens ex Scammonia. R G. R. Scammon. gr. xij. : tere cum Glycyrrh. Ex- tract, gr. xx.; Tinct. Rhaei 3 ij.; Syrup. Zingiheris 3j.; Aq. Cinnam. gj. M. Fiat Haustus. Form. 183. Haustus Astringens. R Quercus Corticis cont. gss.; Aquae Ferventisgxiij. Macera per horam, et cola. R Hujus Colaturae 3 xj.; Tinct. Catechu 3 ss.; Tinct. Cardamom. Comp. 3 j.; Syrup. Aurantii Cort. 3 j. Fiat Haustus. Form. 184. Haust. Boracicus. R Infus. Lini Co., vel Infus. Althajae Co., g jss.; Sub- boratisSodae9j.; Spirit. ^Ether. Nit. 3ss.; Syrup. Papaveris, Syrup. Aurantii, aa 3 ss. M. Fiat Haus- tus, tertiis vel quartis horis capiendus. Form. 185. Haustus cum Calumba et Ferro. R Infusi Calumba; f. 3 xj.; Tinctura; Ferri Muriatis TT) xv.; Tincturi Calumba; f. 3j. Fiat Haustus, bis die sumendus. Form. 186. Haust. Camphora Comp. R Camphorae g. iij.—vij.; Tinct. Calumb.-e, Spirit. An- isi, aa 3jss.; Aquae Pimentae, Aquas Menth. Virid., aa 3 v. Tere Camphoram cum Tinctura et Spir- itu ; dein adde gradatim Aquas. Fiat Haustus, hora somni, vel urgenti vomitu, sumendus. Si sit occasio, adde Tinct. Opii TT) x.—xx., vel Tinct. Hyosciami TT) xv.—xxv. Form. 187. Haustus Carminativus. R Magnes. Sub-carbon. 3j- j Pulv. Rhaei gr. x.— 3ss.; Olei Anisi TT) iij.; Liq. Potassae TTl xij.; Aquae Am- moniae TT) xx.; Aquae Anethi g ij. M. Fiat Haustus. Form. 188. Haustus Colchici. R Vini Colchici min. xxv.—xxxv.; Magnes. Carbon. 9j.; Aquae Cinnam., Aquae, aa 3yj. M. Form. 189. Haustus cum Colchico. R Potassa; Sulphatis 3 jss. ; Sodae Carbonatis 9 ij. ; Aquae Anethi gjss.; Tinct. Calumba; 3 jss. ; Vini Colchici TT) xxv. Fiat Haustus cum Acidi Tartarici grants quindecem in Aquae semifluid-unciasolutis, in impetu effervescentiae sumendus. Form. 190. Haustus Conii. R Infus. conii (F. 230.) g j.; Liq. Ammon. Acet. 3 ij. — 3 iij. Tinct. Hyoscyami vel Conii, TT) xv.; Syrup. Papaveris 3 ss. M. Fiat Haustus. Form. 191. Haustus Conii et Hyoscyami Comp. R Extracti Conii, Extracti Hyoscyami, aa gr. v.; Mu- cilaginis Acacia; f. 3 'j- Tere simul donee quam optimi misceantur, et deinde adde Liquoris Am- monias Acetatis, Aquae Purae, aa f. g ss. ; Syrupi Rhaeadosf. 3j. ; Fiat Haustus, quarta quaque hora sumendus. (Paris.) Form. 192. Haustus Deobstruens et Tonicus. R Rad. Angelicas contusi 3 ijss.— gss.; Rad Calumba concisi 3 jss. ; Rad. Khaeicont. 3 ij.; Baccarum Capsici cont. gr. xxv.; Aquae Ferventis octarium dimidium. Macera per horas duas, deinde cola. R Hujus Infus. 3 x. ; Tinct. Calumba; 3j.; Potassae Sulphatis gr. xxv.; Syrup. Aurantii 3 j. M. Fiat Haustus, bis quotidii sumendus. Form. 193. Haustus Diaphoreticus. R Tnfus. Serpentaria; Comp. (F. 2C2.)g j.; Liq. Am- mon. Acet. 3 iij. ; Syrup. Aurantii 3 j. M. Fiat Haustus, bis teive in die Sumendus. (Dyspepsia, with dry, harsh skin; languor; and debility of pulse.) Form. 194. Haustus Diurf.ticus. (1.) R Potassa; Acetatis 3j. ; Oxymel. Colchici 3 ij.: tere cum Aquae Foeniculi Dulcis gj.; Spirit. Juniperi Comp. 3 iij. M. Fiat Haustus, bis terve in die su- mendus. Form. 195. Haustus Diureticus. (2.) R Acidi Nitrici Diluti, Spiritus lEtlieris Nitrici, aa 3j.; Infusiis Digitalis 3iij.; Aquae Destillata; 3ix.; Syrupi Zingiheris 3 ij. M. Fiat Haustus, ter in die sumendus. Form. 196. Haustus Diureticus. (3.) R Potassae Acetatis 3 ss.; Infusi Quassias, Aq. Cinna- momi, aaf. 3 vj.; Aceti Scillae, Spiritus ^Etheris Ni- trici, aa f. 3 ss. M. Fiat Haustus, ter in die capien- dus. Form. 197 Haustus Diureticus. (4.) R Tincturae Jalapae f. 3 ij.; Aceti Scillae 3 j. ; Aquae Menthae Viridis f. gjss. Fiat Haustus. Form. 198. Haustus Emeticus excitans. R Pulv. Radicis Ipecacuanha; 3 ss.; Ammonias Sub- carbon. 9 j-j Aquae Mentha; Piper, g ijss.; Tinct. Capsici f-9j.; Olei AnthemidisTT) x. M. Fiat Haus- tus emeticus. (In Poisoning from Narcotics, &c.) Form. 199. Haustus Guaiaci Compositus. R Tincturae Guaiaci f. 3 j-; Mellis 3j.: tere simul, et adde Decoct. Senega; f. gjss.; Ammonias Sub-carbo- natis gr. vj. Fiat Haustus, sexta quaque hora su- mendus. Form. 200. Haustus Infusi Cinchona cum Acido Mur. R Pulveris Cinchonas 5 j. ; Confectionis Rosae g jss. ; Aquas Ferventis O j.: tere bene, et per horam, in vase clauso, infunde. R Liquor. Colati 3 XJ- ; Tinct. Cinchonas 3 J- j Acidi Muriatici Diluti TT| viij. M. Fiat Haustus, ter quotidifi sumendus. Form. 201. Haustus Infusi Cusparia Compositus. R Corticis Cusparia; contus. 3 'j- > Rad. Calumba; con- tus. 3jss.; Rad. Rhaei 3 j-; Sem. Cardam. contrit. 5ss.; Sem. Anisi cont. 3ss.; Aqua; Ferventis gxv. Macera per horas duas, et cola. Hujus Infusionis gj. Tinct. Cinnam. 3 jss. ; Spirit. Amm. Aromat. tn xxv.; Syrup. Aurantii 3 j. Fiat Haustus, ter quotidie sumendus. (In all diseases of Debility, excepting Hectic Fever, and in Relaxation of Mucous Sur- face.) Form. 202. Haustus Infusi TJva Ursi Alkalinus. R Infus. Uvas Ursi gjss.— g ij.; Potassae vel Sodae Sub- carbon, gr. xv. ; Tinct. Hyosciami 3ss. (vel Tinct. Opii Camphor., vel Extr. Conii); Syrup. Papaveris 3ss. Fiat Haustus, ter quaterve quctidie* sumen- dus. (In Affections of the Urinary Organs, and of the Air Passages.) Form. 203. Haustus Infusi Uya Ursi Compositus. R Infus Uvas Ursi (F. 207.) 3 xiv.; Acidi Sulphur. Dil. TT) xx.; Tinct. Digitalis TT) xv.; Syrup. Papaveris veri 3jss. M. Fiat Haustus, ter quaterve quotidii sumendus. (In Laryngitis, Bronchitis, &.c.) Form. 204. Haust. cum Iodina. R Liquor. Potassae Hydriodat. Iodiur. Concent. (F. 328.) IT) vj.—xv.; Aqua; Destillata; g j.; Syrup. Althasae 3U- M. Fiat Haustus. Form. 205. Haustus Laxans. R Potassae Tartratis 3j.; Infus. Sennas Compos., Aquae Pimentae, aa f. 3 vj.; Tinct. Jalapa; f. 3 j. M Fiat Haust. laxans. VII1 APPENDIX OF FORMULAE. —Haustus —Infusum. Form. 206. Haust. cum Plumbi Acetate. R Plumbi Acetatis gr. j. Solve in Aqua; Rosae f. g j. ; el adde Oxymellis Simplicis f. 3 j. ; Tinct. Opii TT) v.; Tinct. Digitalis TT) x. Fiat Haustus, quartis vel sextis horis sumendus. Form. 207. Haustus Quinia et Zinci. R Zinci Sulphatis gr. J.—j.; Quinia; Sulphatis gr. ij.; Infusi Rosa; Compos, f. X x.; Tincturae Aurantii, Syrupi Aurantii, 5a f.3j. M. Fiat Haustus, quarta quaque hora sumendus. Form. 208. Haustus Sedativus. R Extr. Conii, Extr. Hyoscyami, aa gr. iv. ; Mucilag. Acaciae 3ij-: tere simul, deinde adde Liquoris Am- mon. Acet. 3 iij. ; Mist. Camphora; 3 v- j Syrup. Rha;ados3j. M. Fiat Haustus, quarta vel quin- ta quaque hora sumendus. Form. 209. Haustus Sedativus Emolliens. R Infus. Lini Co., vel Infus. Althaea; Co., gjss.; Sub- boratis Soda; 9 j-; Spirit. iEther. Nit. 3ss.; Syrup. Papaveris, Syrup. Aurantii, aa 3 ss. M. Fiat Haus- tus, tertiis vel quartis horis capiendus. Form. 210. Haust. contra Spasmos. (1.) R Aquae Mentha; Virid. gj.; Liq. Ammon. Acet. 3ij.; Spirit. Ammon. Arom., Spirit. ./Ether. Sulph. Co., Spirit. Lavand. Co., aa X ss. ; Tinct. Opii TT) xx. M. Fiat Haustus, statim sumendus, et pro re nata repetendus. Form. 211. Haust. contra Spasmos. (2.) R Infus. Caryophyl. g jss. ; Spirit. Pimenta;, Spirit. Rosmarini, aa3ss.; Tinct. Opii TT) xx.; Olei Caje- puti TT| x. M. Fiat Haustus ut supra sumendus. Form. 212. Haustus contra Spasmos cum Pilula Camphora. R Mist. Camphora g j.; Spirit. Athens Sulphur. Comp., Tinct. Camphorae Comp., aa 3 j.; Tinct. Hyoscyami 3ss.; Syrup. Papaveris 3 jss. M. Fiat Haustus, cum Pilul. sequent, sumendus. R Camphorae rasae gr. j.—iij. ; Ammon. Sub-carbon. gr. iij.—vj.; Mucilag. Acaciae q. s. M. et fiat Pil. j. vel ij. Form. 213. Haustus Stimulans. R Aq. Cinnam. g jss.; Magnes. Carbon. 3 ss.; Spirit. Ammon. Arom. X ss. ; Spirit. ^Ether. Arom. 3 j. ; Olei Rosmarini TT) vij. M. Fiat Haustus statim sumendus. Form. 214. Haustus Stomachicus. R Calumba?. Rad. concisi3j.; Acori Calami Rad. con- tusigss.; Rhaei Rad. contusi 9 jss.; Cardam.Sem. contrita; 3ss.; Aquos-ferventis octarium dimidium. Macera per horam, et cola. Hujus Infusionis 3 xij.; Tinct. Aurantii 3 j. ; Potassae Sub-carbon, (vel Sodae Carbonnt.) gr. xij. Misce. Fiat Haustus, bis terve quotidie' sumendus. Form. 215. Haustus Stomachicus Aperiens. R Sodae Tartarizata; 3 ■ j - > Soda; Carbonatis 9 ij.; Aqua; Anethi gss.; Infus. Antheinidisgj.; Tinct. Calum- ba; ; Tinct. Aurantii Co., 553 j. M. Fiat Haus- tus cum AcidiTartarici, granis quindecim in Aquas semifluid-uncia solutis, in impetu effervescentia; sumendus. Form. 216. Haustus Terebinthinatus Aperiens. R Olei Terebinth. 3ij.—3 v. Olei Ricini Xjss.— gss.; Olei Limonis et Olei Cajeputi aa TT) iv. ad xij.; Magnes. 3ss.; Aquae Menthae Virid. gj.—gij. M. Fiat Haustus, pro re nata capiendus. (In puerpe- ral, infectious, and malignant Fevers.) Form. 217. Haust. cum Uva Ursi. R Pulv. Fol. Uvae Ursi er. xv.—9j.; Potassae Nitratis gr. xij.; Pulv. Tragacanth. Comp. 9 j.; Aq. Anethi gjss. M. Form. 218. Infusum Amarum. R Summit. Absinthii Artem. g j.; Corticis Aurantii gss.; Rhei 9 ij. ; Rad. Gentiana" 3 j. ; Aquae Fer- ventis g xij. Macera per horam, et cola. R Liq. Colutig jss. ; Potassa; Sub-carbon, gr. xij. vel Liq. Potassie TT) xxij. ; Tinct. Aurantii Co. X j.; Spirit. Anisi 3 j.; Syrup. Zingib. 3 ss. M. Fiat Haustus, bis terve quotidie sumendus. Form. 219. Infusum Angelica Compositum. R Fol. vel Rad. Angelicas Arch, gij.; Rad. Serpentar. gss.; Florum Sainbuci Nig. g j. ; Potassae Sub-car- bonat. 3 iij-i Aquae ft ij. Macera per horas tres, et cola. R Liq. Colat. gjss.; Spirit. Juniper. Comp. 5 j.; Tinct. Opii Co. TT) x. Fiat Haustus. (In Atonic Dropsy, &c.) Form. 220. Infusum Anthemidis Compositum. R Flor. Anthemidis g ss. ; Semin. Anisi cont. 3 iij.; Fol. Menth. Virid. gss. ; Caryoph. cont. 3 j.; Au- rantii Cort. sic. 3U-; Aquae Fervid, ft jss. Macera per horam, et cola. Form. 221. Infusum Armoracia Compos. R Sinapeos Semin. contus., Armoraciae Radicis con- cis., aa 3 iij- j Aquae Ferventis O j. Macera per horam, et cola. R Colaturasgvij. ; Spirit. Ammon. Arom. 3jss.; Spir- it. Pimentae 3 iij. M. Capiat Coch. ij. ampla ter quotidie. Form. 222. Infusum Arnica (Ph. Mil. Dan.) R Flor. Arnicas 3 j- > Flor. Anthemid. g ss. ; Herb. Mentha; Piper. 3 0- j Aquae Fervid, g x. Macera, etcola. (Dosisgj.— gjss.) Form. 223. Infusum Arnica Compos. R Arnicae Montan. Herb., Summit. Artemes. Vulg., aa g ss. ; Herb. Centaures Benedict., Rad. Calam. Aromat., aa3ij.; Aquae Fervid, gxvj. Macera per horas binas, et cola. Liq. colat. adde Tinct. Au- rantii, Spirit. Pimenta;, aagss. ; Spirit. Rosmarini 3ij- M- (Dosis gss.— gjss. bis terve in die. Form. 224. Infusum Artemisia Vulgaris Co. R Summit. Artemes. Vulgar. 3 vj.; Herb. Centaureae Bened. 3iij.; Aquae Fervid, gxvj. Macera per ho- ras binas, et cola. Liq. colat. adde Spirit. Juniperi Comp. g j.; Olei Rosmarini TT) xii. M. (In Epi- lepsy from Exhaustion, Chlorosis, &c.) Form. 225. Infusum Barberis. R Barberis Corticis contus. gss.; Aqua; Ferventis Oss. Macera per horas binas in vase leviter clauso, et cola. (Dosis, f. gj. ad g ij.bis ter quotidie^ inter- dum cum Sodae Sub-carbonate, vel Potassae Sub- carbonate, vel Tinct. Calumbae.) Form. 226. Infusum Calami Aromatici. R Calami Radicis contusi 3iij. ; Aquae Ferventis Oss. Macera per horas duas, et cola; dein adde Tinct. Calami gss. Form. 227. Infusum Calami Aromatici Compositum. R Rad. Calami Arom. concis. 3 jss. ; Flor. Anthemid. 3j.; Aurantii Cort. exsic. 3 j.; Caryoph. cont. 3 ss.; Aquae Ferventis O ss. Macera per quartam horae partem, et cola. Liquori colato adde Potassae Sub- carbon. 3j.— 3 ij. Form. 228. Infusum Caryophyl. Comp. R Caryoph. contus. 3 j.; Cort. Aurantii sic. 3 ij.; Semin. Coriandri et Sem. Anisi cont., aa3ss.; Aquae Fer- ventis ft j. Macera per semi-horam, et cola. Form. 229. Infus. Cinchona cum Quinina Sul- phate. R Cinchonas Cordifol. Corticis in Pulv. 3 vj.; Confec- tionis Rosae gjss.; Aquae Ferventis O j. Tere bene, et digire per horas duas in vase clauso ; dein cola. R Liq. Colati gvj.; Sulphatis Quininae gr. viij.; Acid. Sulphur. Diluti TT) xxiv. Fiat Mist, cujus Coch. ij. larga tertiis vel quartis horis sumend. Form. 230. Infusum Conii. R Conii Fol. exsiccat. 3 ij.; Anisi, et Coriandri Semin. contus., aa3 jss. ; Aquae Ferventis O ss. Macera per horas duas, et cola. (Dosis gj. ad g ij. bis, ter, quaterve in die.) Form. 231. Infusum Diosma Crenata. R Fol. Diosma; Crenatae g ss.; Aquae Ferventis O ss. Macera per horas quatuor, et cola. (Dose gj.— gjss. Form. 232. Infusum Gentiana Alcalinum Compos. R Radicis Gentianae concis. 3 ij.; Corticis Aurantii sic. 3j.; Semin. Coriandr. contus 3 j. ; Rosmarini Cacumin.3j.; Potassae Sub-carbon, (vel Sodae Sub- carb.)3j.; Aquae Ferventis gxij. Macera per horas duas, et cola. APPENDIX OF FORMULAE—Infusum. ix Form. 233. Infusum Guaiaci Compositum. R Guaiaci Ligni ras. ft S3.; Glycyrrhiza: Radicis con- tusae g j. ; Sassafras Corticis Vera; concisae g ss. ; Coriandri Seminum contusorum gj.; Liquoris Cal- cis O vj. Infunde per dies tres dein cola ; cujus sumat aeger quatuor sexve uncias pro dose, et bis die repetatur. (Sprague.) Form. 234. Infusum Hedera, yel Glecomce Hede- RACEA, CUM AciDO H YDROC YANICO. R Glecomas Hederaceas vel Hederas Terrestrisg ss.— 3yj- ; Radicis Glycyrrhizas 3iij.; Aquae Ferventis Oj. Macera per horas tres, et cola. R Liq. Colati gjss.; Acidi Hydrocyanici TT) ij.—viij. ; Syrup. Althaea; Officin. 3 jss. M. Fiat Haustus, sexta vel octava quaque hora sumendus. Form. 235. Infusum Juniperi. R Juniperi Baccarum contusaium gij.; Aquae Ferven- tis O j. Macera in vase leviter clauso per horas duas, et cola: dein adde, Spiritus Juniperi Com- posit. f. gj.; et insuper, pro re nata, Potassae Su- pertartaris 3 ijss. (Dosis, fluidunc. ij. ad iv. ter quaterve quotidie.) Form. 236. Infusum et Mistura Juniperi Composit. # R Baccarum Jtinip. contus. 3ijss. ; Semin. Anisi con- tus., Semin. Foeniculi cont., 55 3 jss. ; Aquae Fer- ventis O j. Macera per horas tres, dein cola. R Liq. Colati. g xiij.; Potassae Nitratis 3 jss.; Sodas Sub-carbon. 3 jss.; Tinct. Scillae 3 jss.; Spirit. Ju- nip. Co. 3 ijss.; Tinct. Opii TT) xxv. Fiat Mist. cujus capiat Cyathussubindd. Form. 237. Infusum Marrubii. R Marrubii Herbas exsic. g ss.; Aquae Destillat. Fer- ventis O ss. Macera per horam, et cola. R Liq. Colati g jss. ; Tinct. Camphora; Comp. 3 j. ; Ext. Glycyrrh. gr. x. M. Fiat Haustus, ter in die sumendus. (Chronic Bronchitis, and Catarrh with inordinate Secretion.) Form. 238. Infusum Melissa Compositum. R Melissae Officinalis exsic, Radicis Glycyrrh. con- tus., aa 3 ijss. ; Sem. Anisi cont., Sem. Foeniculi, Pern. Coriand. cont., aa 3 ss. ; Aquae Bullientis ft ij. Infunde per horam, et cola. Form. 239. Infusum Mentha Caryophyllatum. R Folior. Mentha; Virid. sic. 3 iij.; Rosas Gallicae Petal. sic. 3 jss.; Caryophyllorum contus. 3jss.; Aurantii Cort. sic. 3jss.; Aquas Ferventis Oj. Macera per horam, et cola. Form. 240 Infusum Mentha Compositum. (1.) R Fol. Menth. Virid. exsic, Radicis Glycyrrh. concis. et cont., aagss.; Semin. Anisi et Semin. Coriand. contus. aa 3 j.; Aquas Ferventis q. s. ut fiat Colatu- rae O j. (Adde Magnes. et Sacch. Album pro tormin- ibus infantum ; aut interdum Acidi Sulphurici Arom. 3j- pro nausea vel vomitu.) Form. 241. Infusum Mentha Compositum. (2.) R Menthas Viridis exsiccat. contusas g jss.; Rosae Gal- licae Petalorum exsiccatorum 3j. ; Aquas Ferventis Oj.; Acidi Sulphurici Diluti 3 ij.; Sacchari Purifi- cati g jss. Mentha; et Rosae Fetalis superinfunde Aquam cum Acidi dimidio mistam. Macera ; dein Liquorem effunde, et Saccharum et Acidum re- man, adjice. (Dosis a fluidunc. j. ad ij. bis, ter, saepiusve quotidhe.) Form. 242. Infusum Menyanthidis. R Menyanthidis Foliorum g ss. ; Zingiheris Radicis conciste 9 ij.; Aquas Ferventis, O ss. Macera in vase clauso per horas duas, et cola. (In doses of SJ- to g jss., united with Spiritus ^Etheris Nitrici 3j. ad 3 'j->'n Rheumatism, Arthritic Affections, and in Cachectic and Cutaneous Diseases.) Form. 243. Infusum Millefolii Compositum. R Herb. Millefolii 3ij.; Herb. Rosmarini, Herb. Thymi Vulg., aa 3 j-» Semin. Coriand. cont. 3 j-; Aquae Ferventis ft J. Infunde per horam, et cola. R Colaturae gjss.; Spirit. Rosmarini 3ss.; Tinct. Aloes Comp. 3j.— 3 ij. Fiat Haustus, primo mane quoti- die' cap. (In Chlorosis, Amenorrhoea, &c.) Form. 244. Infusum Pectorale. (1.) R Herb. Malvae Off., Herb. Tussilag., Radicis Althaeas, Rad. Glycyrrh., 55 3j. ; Semin. Anisi gss.; Aquas Fervid, quantum velis. Macera. Form. 215. Infusum Pectorale. (2.) R Rad. Alth3eae, Herb. Melissae, Herb. Menth. Sat, Flor. Sambuci, Flor. Arnicas, aagj.; Semin. Anisi gss. M. Sint loco Theas. Form. 246. Infusum Quassia Comp. R Radicis Calumba; concis. 3j. ; Ligni Quassia; 3jss.; Aq. Ferventis q. s. ut sint Colaturae g vijss.: adde Zinci Sulphatis gr. iv.; Acidi Sulphur. Arom-Sj.; Tinct. Aurantii Co. X iij. M. Form. 247. Infusum Quassia cum Ao.ua Calcis. R Ras. Lign. Quassias gss.; Aquae Calcis Vivae g vij.; Stent in digestione per horas xxiv. : cola, et adde Aquae Menth. Virid. gij.; Syrup. Aurantii gss. M. Form. 248. Infusum Rhatania. R Rhatania; Radicis contusa; 3 iij. ; Aquss Ferventis O ss. Macera per horas sex, in vase leviter clauso. et liquorem cola. Form. 249. Infusum Rhei. R Rhei Radicis concisa; 3 jss. ; Aquas Ferventis O ss. Macera Radicem per horas duas in vase leviter clauso, et cola : dein adde Sacchari Albissimi X ij.; Olei Menthas Viridis gtt. viij. solutas in Spiritu Menthas Piperitae gj. Tunc misceantur. Form. 250. Infusum Rhei Alkalinum. R Rhei Rad. concis. et contus. 3ij.; Potassa; Sub-car- bon. 3 j.; Aquas Fervid. O ss. Macera per horaa quatuor: cola, et adde Tinct. Cinnam. gss. Form. 251. Infusum Rhei Alkalinum. R Infus. Rhei g vij. ; Potassa; Sub-carbon. 3 ijss. ; Tinct. Sennas et Syrup. Sennas 55 5 iijss. M. Form. 252. Infusum Rhei Comp. R Rhei Rad. concis. et contus. gss.; Cort. Canellae Al- bas cont. 3 ij. ; Flor. Anthemid., Corticis Aurantii, aaSiij^i Semin. Foeniculi cont., Sem. Coriandri cont., aa 3j.; Aqua; Ferventis ft jss. Macera per horas quatuor, et cola. Liquori colato adde Pot- assas Sub-carbon. X ij ; Tinct. Cinnam. gj. M. Form. 253. Infusum Rosa et Aurantii Comp. R Rosas Gallicas Petal, sic. 3iij'.; Aurantii Cort. exsic. 3jj.; LimonisCort. recent. 3j.; Caryophyl. contus. 3jss.; Aqua; Ferventis Ojss. Macera per horam, et cola. Liquori colato adde Sacchar. Albi g j. Form. 254. Infusum Ruta Comp. R Herb. Rutae, Flor. Anthemid., Radicis Calam, Arom., aa3iij. Macera cum Aquas Foeniculi gx. per horas tres, et cola. Liq. Colat. adde Campho- rae 9 j. ; prius in Mucilag. Acacias q. s. solutie ; Spirit. ^Ether. Nit. g ss. M. Form. 255. Infusum Salvia Compositum. R Herb. Salvias, Semin. Sinapeos, 5agss.; Aquae Fer- vid, ft j. Macera per horam, et cola. Liq. colat. adde Spirit. Armoracia; Comp. g ij. M. Capiat Coch. ij.—iij. ter quaterve in die. Form. 256. Infusum Sambuci cum Antim. Tart. R Flor. Sambuci gj.; Aquae Fervid, q. s. ut sit Colat gvj.: cui adde Oxymel. Simplicis, Oxym. Scilliti- ci, aagj.; Antimonii Tart. gr. ij. M. Capiat Coch. j. omni hora.—(Augustin.) Form. 257. Infusum Santonici Seminum Composi- tum. R Semin. Artem. Santonici cont., Rad.Valeriana; Opt.. aagss. Infunde in vase clauso cum Aq. Fervid. gix.: cola, et adde Aquas Menth. Virid. gij.; Extr. Ruta; 3 j. ; Tincturae Valerianae Ammoniati 3 iij. M. Capiat g ss.— g iss. pro dose. (In Hysteria, Chlorosis, Amenorrhoea, Worms, &c) Form. 258. Infusum Sarsaparilla Alkalinum. R Sarsaparilla; Radicis concisae et contusae giv.; Gly- cyrrhizas Radicis contusae gj.; Liquoris Calcis O iv. Macera per horas xxiv. in vase leviter clauso, saepe agitand. Form. 259. Infusum Senega et Serpentaria Comp. R Rad. Senegas, Rad. Serpentaria;, 55 gss.; Aqua; Fer- vid. O j. Macera in vase clauso per horam, etcola. Liq. colat. adde Camphorae 3 ss.; prius solutae in jEtheris Sulphur. 3 iij. ; Aquas Cinnam. gj. ; Sy- rup. Altheas et Syrup. Papaveris 55 g ss. M. Ca- piat Cochlear, ij. larga 4tis horis. (Hecker.) X APPENDIX OF FORMULAE. —Infusum —Linctus. Form. 2G0. Infusum Senna. R Sennae Foliorum g ss.; Coriandri Seminum contus. 3 j. ; Zingiheris Rad. contus. 3 j.; Extracti Gly- cyrrhiza; 3jss.; Aqua; Ferventis O ss. Maceraper horam in vase leviter clauso, et liquorem cola. Form. 261. Infusum Senna cum Manna. R Mannae gij.; Fol. Sennas gjss.; Potassa; Supertart., Seminum Anisi contus., 55 3 ijss. ; Semin. Cor- iand. Sat. contus. 3jss.; Aquas Ferventis Oij. In- funde per horas quatuor, et cola. Form. 262. Infusum Serpentaria Compositum. R Serpentaria; Radicis, Contrayervae Radicis, singulo- rum contus. 3 ij.; Aquas Ferventis O ss. Post ma- cerationem in vase aperto per horas duas, liquorem cola, et adde Tinct. Serpentaria; gss.velgj.—(Cum Liq. Ammon. Acet. &x.) Form. 263. Infusum et Haustus Spartii Composit. R Spartii Cacum. concis. gj.; Marrubii Vulgar. Fol. g ss.; Aq. Ferventis Ojss. Macera per horam, et cola. R Colaturae X xj.; Spirit. ^Ether. Nit. X ss.; Spirit. Ju- niperi Comp. 3 j. Fiat Haustus, ter quaterve quo- tidie sumendus. Form. 264. Infusum Spigelia Compositum. R Spigelia; Radicis concis. g ss.; Sennae Folior. 3 ij. ; Aurantii Corticis cone, Santonici Seminum con- tus., Foeniculi Semin. contus., 5a3j.; Aqua; Fer- ventis g xij. Macera per horas duas in vase leviter clauso, etcola. (Dosis Cyathus Vinos, singulis au- roris, jejuno ventriculo.—In Lumbrici. Sprague.) Form. 265. Infusum Tilia Compositum. R Florum Tilias Europ. g ss. ; Rad. Althasae Officin. 3 iij.; Flor. Auran. 3 ij.; Aquae Ferventis ft ij. Ma- cera per horam ; exprime et cola. Form. 266. Infusum et Mistura Tonico-Aperiens. R Sennas Foliorum g ijss. ; Gentianae Radicis concis. 3 iij.; Aurantii Corticis excis. 3 ijss.; Limonis Cor- ticis recentis X iijss.; Semin. Coriandri contus. 3 ijss.; Zingiheris Rad. concisa; 3jss. ; Aquae Fer- ventis O ij. [Macera bene in vase clauso per noctern integram (vel per horasocto); exprime bene, etco- la. Liq. colnt. adde Magnesias Sulphatis, Tinct. Cardamom. Comp. aag iij.; Spirit. Vini Rect. 3 iij. M. (Dosisgj.—gjss. pro re nata.) Form. 267. Infusum Uva Ursi. R Uvae Ursi Folior. 3ij.; Aqua; Ferventis O ss. Ma- cera in vase clauso, per horas tres,prope ignem,et cola. (With the Alkaline Carbonates in Nephri- tic Cases, &c ; and with the Mineral Acids, &c in Affections of the Air Passages.) Form. 268. Infusum Valeriana. R Valeriana; Radicis contusae g ss. ; Aquas Ferventis O ss. Macera in vase clauso per horas duas. Li- quori colato, addeSpiritus Lavendulas Composite. Syrupi Aurantii, aa g ss. (Dosis fluidunc. ij. ter quaterve quotidie\ Form. 269. Infusum Valeriana Compositum. R Radicis Valeriana;, Rad. Calami Aromatici, 55 con- cis. et cont. gj.; Flor. Arnica; Montana; X ij.; Aquas *erventisg xij.; Liquor. Potassa; X j. Maceraper horas binas vel tres ; exprime, et adde ^Etheris Sul- phur. 3 „j.; et interdum Spirit. Lavandtil. Comp. 3 HJ-, vel Extr. Rutae vel Extr. Taraxaci X iij. M. (Dosis gss.—gjss. ter quaterve in die.) Form. 270. Infusum Valeriana et Serpentaria Comp. R Rad. Valerian. Rad. Serpentarias, Flor. Sambuci hin^'/pt5,;!;5 AT(3.uae Ffrvid. g ix. Macera per horas binas etcola. Liq. colat. adde Acidi Sulph. Arom. Sjss. , Syrup. Papaveris g ss. M. (Fevers Hys- teria, and other Nervous Affections.) ' y Form. 271. Infusum Zinoiberis. R Zingiberis Radicis concisa; 5jss.; Aquas Ferventis Oss. Macera per horas duas in vase leviter clauso et cola: turn adde Tincturas Zingiberis, Syrupi ejusdem, aa g ss. (This is the best vehicle for giv- ing 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. Camphorae, Aq. Rosar., aa part, ij.—iij.; Tinct. Camphora; Co. part. ss.—j. Form. 273. Injectio Argenti Nitratis. No. 1. No. 2. No. 3. R Argenti Nitratis - - 9 j. 9 ij. 3j. Aquas Destillata) - - giij. giij giij. Solve. Form. 274. Injectio Astringens. R Infus. Quercus, ut supra, giv.; Pulv. Gallarum gr. xxx.; Tinct. Catechu 3'j - Fiat Mist, ex quo inji- citur pauxillum, vel per vaginam vel per anurn, in Sanguinis Fluxu. Form. 275. Injectio Boracica. R Aqua; Rosar. giv.; Aq. Flor. Aurantii gij.; Sub-bo- ratis Sodas 9 ij- > Tinct. Camphora; Comp. 3 'j.— gss. M. Fiat Injectio. Form. 276. Injectio Zinci Acetatis Composita. R Zinci Sulphatis, Plumbi Superacet., 55 3 ss. ; Cam- phora; 3ss.; Opii 9ij. Solve in Aqua; Bullientis Oj.: cola, et fiat Injectio, ter quaterve in die utenda; phiala agitata. Form. 277. Ioduretum Hydrargyri. (Internally, in doses of from one grain to three, and externally in ointments.—(Vide Unguent. Iod. Hydr.) For the best account of the preparations and uses of Iodine, consult Dr. O'Shaughnessy's excellent translation of Lugol on Scrofula.) Form. 278. Ioduretum Plumbi. (Internally, in doses of from half a grain to five grains; and externally.—(Vide Ung. Iod. Plumbi.) Form. 279. Julapum Sedativum. R Camphorae gr. vj.; Spirit. ^Ether. Sulphur. Comp. Sjss.; Potassas Nitratis gr. xij.; Aquae Flor. Auran- tiigiij.; Syrup. Althaeas 3 iij.; Syrup Papaveris 3ij. M. Fiat Mist., cujus capiat tertiam partem omni hora, vel bihoris.—(Pierquin.) Form. 280. Linctus Acidi Muriatici. R Mellis Rosae X x. ; Acidi Muriatici IT) xx.; Syrupi Rhceados 3ij. M. Simul agita, ut fiat Linctus. Form. 281. Linctus Boracicus. R Cetaceigijss.; Pulv. Tragacanth. Comp. Xiij.; Sy- rup. Tolutan. g j. : Sub-boracis Sodae 3ijss.; Con- fect. Rosa; 3 v. ; Syrup. Althaea; 5 j. vel. q. s. Fiat Linctus, de quo lambat saepA. (Sore Throat, CEso- phagitis,&c.) Form. 282. Linctus Camphoraceus. R Camphorae gr. xij.; Pulv. Gum. Acaciae 3j.; Syrup. Altha;a;gij. Misce bene. (Niemann.) Form. 283. Linctus Chlorureti Calcis. R Chlorureti Calcis gr. iij.: solve in Aq. Destil. g j.; et adde Mellis gjss. M. Capiat infans cochleare unum minimum subinde. (In softening of the Di- gestive Mucous Surface.) Form. 284. Linctus Demulcens. (1.) R Olei Amygdal. Dul., Syrup. Althasae, 5agij.; Syrup. Papaveris X xj.; Vini Ipecacuanh. X jss.; Vitelli Ovi unius. M. Fiat Linctus. Form. 285. Linctus Demulcens. (2.) R Cetacei 3 ijss.; Pulv. TragaeaiTth. Comp. X jss.; Sy- rup. Papaveris et Syrup. Tolutan. 55 g ss. ; Potassa: Nitratis 9 ij.; Confect. Rosar. X vj. ; Syrup, simp. q. s. ut fiat Linctus ; de quo lambat pauxillum, pro re nata. Form. 286. Linctus Demulcens et Aperiens. R Syrup. Viola; g ijss. ; Olei Amygd. Dul.gj.; Syrup. Scillae et Syrup. Sennas aa gss. M. Fiat Linctus. (Infantibus.) Form. 287. Linctus Emolliens. (Brendellii.) R Saponis Venet. 9 iv.; solve in Olei Amygdal. Dul- cis gjss.; Mannae Purificat. g ss.; Potassas Super- tart. 3 ij.; Syrup. Althaea; g j. M. Fiat Linctus. APPENDIX OF FORMUL Form. 288. Linctus Myrrha et Ipecacuanha. R Myrrhae G. R. 3j.: Pulv. Ipecacuan. gr. vj.; Oxymel. Scillfe, Mucilag. Acaciae, Syrup. Althaeas, aa 3 vj. Fiat Linctus, de quo lambat pauxillum saepe. Form. 289. Linctus Oleosus. (1.) R Olei Amygdalarum, Syrupi Mori, aa f. g jss.; Con- fectio. Fruct. Rosae Caninae g ij. ; Pulv. Traga- canth. Comp. 3 iij. Misce. Cochlear, minim, sub- indd deglutiatur. Form. 290. Linctus Oleosus. (2.) R Olei Olivae g jss.; Oxymellis Scillae, Syrupi Papaveris, aaf. gj. Dosis, Cochlear, parv. j. urgenti tusse. (In common Catarrhal Cough, attended with abrasion of the Fauces, and thin copious Expectoration.) Form. 291. Linctus Opiatu3. R Syrupi Papaveris f. g ij.; Mucil. Acaciae Ver. gjss.; Conf. Fruct- Rosas Caninae, unc. j. ; Acid. Sulph. Dilut. f. 3 ij. Misce. Dosis, Cochlear, minim. subinde. Form. 292. Linctus Opiatus cum Scilla. R Syrupi Papaveris, f. gj.; Syrup. Mori 3vj.; Syrup. Limonis gss.; Oxymellis Scillae, f. g ss. Misce. Dosis, Cochlear, minim, tusse urgenti. Form. 293. Linctus Pectoralis. R Pulv. Sem. Anisi, Pulv. Sem. Foeniculi, Extr. Gly- cyrrh., 55 gss.; Pulv. Sem. Carui 3ij.j Potassae Ni- tratis 3j.; Ol. Anisi 3ss.; Syrup. Althasas gvss. M. Fiat Linctus. Capiat 3j. pro re nata. Form. 294. Linctus Potassa Nitratis. R Potassas Nitratis Contr. 3 jss.; Mellis Rosaef. g j.; Oxymellis Simplicis f. g jss. M. Capiat Coch. minim, pro re nata. Form. 295. Linimentum Ammonia cum Oleo Ter- ebinthina. R Liquoris Ammonias, f. gss.; Olivae Olei, f. gj.; Olei Terebinthinas, f. gss.; Olei Limonis, 3 ss. Agita simul donee misceantur. Form. 296. Linimentum Ammonia et Terebinthi- na Comp. R Liquoris Ammon. gj.; Olei Olivae gij. Misce bend, et adde Spirit. Camphorae g ij. ; Olei Terebinth. g iij.; Saponis Duri X v. Misce bene. Olei Caje- puti 3 j.; Olei Limonis 3 jss. M. Form. 297. Linimentum Anodynum. (1.) R Opii g j- j Camphorae g ij. : Lig. Ammoniae g iv.; Saponis Duri giv.; Olei Terebinthinas gviij.; Olei Limonis gss.; Spirit. Rosmariniet Spir. Lavandul. Sag xij. Misce. Form. 298. Linimentum Anodynum. (2.) R Linimenti Saponis Comp. gj.; Liquoris Ammonias, 3 iij. ; Olei Caryophylli 3 j.; Tincturae Opii gss. M. Fiat Liniment. Form. 299. Linimentum Camphora Fortius. R Camphors rasas 5 ijss.: solve in Tinct. Cantharidis 3 ij. et Tinct. Capsici Annui 3 jss.; dein adde Lini- ment. Saponis Comp. gss.; et gradatim, miscendo, Liquoris Ammonias 3 vj.; Olei Olivae 3 xj. M. Fiat Linimentum, cum quo illinatur pars affecta bis terve quotidie Form. 300. Linimentum Cantharidum Terebinth. R Tinct. Cantharid. X iij.; Olei Terebinth, g j.; Am- monia; Liq. 3jss.; Saponis Duri 3J-; Olei Cajeputi 3ss. M. Fiat Linimentum. (Altered from Au- gustin.) Form. 301. Linimentum Febrifugum. R Antimonii Tartarizati gr. xxv.: solve in Aquae Des- til. 3 ij. vel q. s. ; deinde tere bene' cum Adipis Prccpar. g j. et fiat Linimentum. (The antimony is partially absorbed without producing any Phlo- gosis. Vide Unguent. Antimon. Tart.) Form. 302. Linimentum Iodini. R Linimenti Saponis Co. g j. j Iodini gr. viij. vel. x. Misce. jM.—Linctus—Liquor. xi Form. 303. Linimentum Phosphoratum. R Olei Olivarum Optimi g viij.; Phosphori excisi gr. xx. Solve cum calore, cola ex frigido, et fiat Lin- imentum. (In Paralyse locale, Marasmo, Rheu- matismo, et Arthritide Chronico.) Form. 304. Linimentum Pyrethri. R Tincturae Pyrethri, X vj.; Linimenti Camphora; 3 iv.; Liquoris Ammonia; 3 ij. Misce ; ft. Linimentum. Form. 305. Linimentum Rubefaciens. R Camphoras 3j.; Olei Olivae et Liq. Ammon. aagj. ; Olei Macis TT) xxxv. Misce. (Externally to parts in deep-seated Inflammation.) Form. 306. Linimentum Saponis et Camphora Comp. R Saponis Med. gj.; Alcoholis Rect. gvj.; Aquae Des- til. et Camphorae 55 gj. Solve leni cum calori, et adde Olei Rosmarini 9 iv.; Olei Thymi 9j.; Li- quor. Ammonia; 3 ij. Misce bene Form. 307. Linimentum contra Spasmos. R Olei Olivae, Obei Terehinthinae, Liquoris Ammo- niae, Tinct. Opii, Liniment. Saponis Composit., aa gss. Fiat Linimentum. Form. 308. Linimentum Stimulans. R Linimenti Camphorae Compositi, Linimenti Saponis Compositi, aa gjss.; Olei Cajeputi, gj. Fiat Lini- mentum stimulans. Form. 309. Linimentum Sulphuro-Saponaceum. (Jadelot.) R Sulphureti Potassas giij.; Saponis Albi, Olei Olivae, aa ft j.; Olei Volat. Thymi 3j. M. Form. 310. Linimentum Tabacci. R Tabacci Foliorum gj.; Axungias Porcinae ft j. Melt together, and simmer until the leaves become fria- ble ; then express. (Amst. Ph.) Form. 311. Linimentum Terebinthina Comp. R Liniment. Saponis Co., Liniment. Camphorae Co., 55 gjss. ; Olei Terebinth, g ij. ; Saponis Duri 3 ij-; Olei Limonis etOl. Cajeputi 3 j.— 3 ij. M. Fiat. Linimentum. Form. 312. Linimentum Terebinthino-Phospho- ratum. R Olei Terebinth, g ij.; Camphorae rasas 3 ij.; Liniment. Ammon. Fort, g ij; Saponis Medicin. g ij. ; Phos- phori Puri gr. x.—xij. Soluti in Olei Cajeputi, vel in Oiei Caryophyl. 3 ij. vel q. s. M. (In Chronic Rheumatism and Epidemic Cholera.) Form. 313. Linimentum Thebaiacum Compositum. R Opii Puri 9 ij- j Camphor., Succini, 55 3ss.; Spir- it. Vini g vj. Misce pro Linimento. Form. 314. Linimentum Volatile. R Olei Oliva; g iv.; Camphorae 5 ij.; Aquas Ammoniae 3 ijss. Misce. Form. 315. Liquor Acetatis Morphina. R Morphinae Acetatis gr. xvj.; Aquas Destillat. f. X vij.; Acidi Acetici TTIv. ; Spirit. Vini Rectif. f. 3 j. Solve. (Dosis a IT) v. ad TT) xx.) Form. 316. Liquor Antimonii Tartarizati. R Antimonii Tartarizati gr. xxxij.; Aqua; Destillata; g.xiv.; Spiritus Rectificat. gij.; Uvarum Passarum, demptis acinis, unc. ij. Macera per hebdomadam, et cola. Form. 317. Liquor Balsamico-Aromaticus.—Bal- samum Vita Hoffmanni. R Balsam. Peruvian. 3 j.; Olei Succin., Olei Ruta;, Olei Rosmarini, Olei Lavand., Olei Caryoph., Olei Pimentos, 55 3 ss. ; Spirit. Vini Rectificat. g xjss. Misce bend. (In doses of from 10 to 30 drops on Sugar, or in a suitable vehicle.) Form. 318. Liquor Boracis Soda Comp. R Sub-boracis Sodae 5 VJ- > Potassa; Supertart. g ss.; Aquae Distil. Oj. (Dosis 3 j.— 3 iij. pro infanti- bus; et g ss.— g iij. ter die pro Adultis. Form. 319. Liquor Calcis Muriatis. (Beddoes.) R Acidi Muriatici, Aquns Destillata;, 5agiv.; Marmo- ris Albi Pulv. q. s. ad saturandum. LjE. — Liquor — Mistura. xii APPENDIX OF FORMU Form. 320. Liquor Camphora ^Etherea. R Camphorae rasas 3j.; ^Etheris Sulphurici gj. Solve. Capiat TT) xx.—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 g ss.; Acidi Nitrosi Fortissimi (per pond.) g ss. Tere probe' simul in mortareo vitreo donee effervescentia peracta ; dein adde gradatim Aquas Destillata; gjss. Afterwards filter the liquor through white paper, placed in a. glass funnel. The dose is from four to ten drops, three or four times a day, in an Infusion of Ginger, or Infusion of Quas- sia and Cloves.—(In Worms, Haemorrhages, &.C.) Form. 322. Liquor Hydrargyri Oxymuriatis. R Hydrargyri Oxymuriatis gr. iv.; Acidi Muriatici TT) vj.; Aquas Destillata;, f. g j.; Spirit. Tenuioris 3yj. ; Tincturae Croci 3 U- Tere probd simul in mortario vitreo ut fiat solutio. Incip. sumendo TT) xx. nocte manequeex haustu Infusus Lini, vel Decocti Glycyrrhizae; posteaque pro re nata augea- tur. (Sprague.) Form. 323. Liquor Hydriodatis Potassa. R Potassae Hydriodatis gr. xxiv.; Aquas Destillata; g j. M. Solve terendo in vase vitreo. (Dosis TT) x. —xxx.) Form. 324. Liquor Hydriodatis Potassa Ioduretus. R Potassas Hydriodatis gr. xxxvj.; Iodini gr. x.; Aquas Destillata;, f. 3 x- Solve terendo in vase vitreo. (In doses of 10 gtt. to 30 ter die.) Form. 325. Liquor Morphina Citratis. R Morphinae Purae gr. xvj.; Acidi Citnci Crystal, gr. viij.; Aquae Destil. f. g j.; Tinct. Cocci q. s. Solve. (Dosis Til v.—xxv.) Form. 326. Liquor Plumbi Acetatis Dilutus. R Liquor Plumbi Acetatis, f. 3 j- ad X ij. ; Acidi Ace- tici Diluti, 3 iij- ; Spirit. Rectificati, g jss. ; Aquas Destillata; g xiv. Misce. Form. 327. Liquor Potassa Chloratis. R Potassas Chloratis 3 j. ; Aquas Destillat. g xij. (In indolent Sores as a lotion, and internally in three times its bulk of vehicle.) Form. 328. Liquor Potassa Hydriodatis Iodureta CONCENTRATUS. (LUGOL.) R Iodinas 9 j.; Potassae Hydriodatis 9 ij.; Aquae Des- tillat. 3 vij. Solve. (This solution contains one twenty-fourth part of Iodine. Dose for an Adult, six drops in sugared water in the morning fasting, and six an hour before dinner ; increasing the dose, every week, two drops, until it reaches to thirty or thirty-six daily.) Form. 329. Liquor Potassa Hydriodatis Iodureta. Dilutus. (Lugol.) No.l. No. 2. No. 3. R Iodinas - - - gr. J gr. j. gr. j. J Potassae Hydriodatis gr. jss. gr. ij. gr. ijss. Aquas Destillata; J viij. gviij. 5 viij. Solve. Form. 330. Liquor Zinci Acetatis. R Zinci Sulphatis Purif. gr. xxiv.; Aqua? Destillata; giv. Solve. R Plumbi Superacetatis gr. xxxij. ; Aquas Destillatas g iv. Solve. Misceantur solutiones; ouiescant paulisper; dein coletur liquor. Form. 331. Lotio Acidi Hydrocyanici. R Acidi Hydrocyanic f. gss. ; Spiritus Rectificati, f. gj.; Aqua; Destillata;, f. g xss. Misce, et fiat Lotio diligenter utenda. Form. 332. Lotio Antiphlogistica. R Liquoris Plumbi Subacetatis 3 vj.; Liquoris Ammo- nia; Acetatis giv.; Aquas Purae ft ij. Misce. Form. 333. Lotio Antipsorica. R Potassas Sulphureti g iv. ; Aqua; Oj.; Acidi Sul- phurici 3 iv. Misce. Fiat Lotio, bis terve quotidie utenda. (Dupuytren.) Form. 334. Lotio Boracica. R Sub-boracis Sodas X j.; Aq. Rosar., Aq. Flor. Auran- tii, aa g iij. M. Fiat Lotio. Form. 335. Lotio Evaporans. R TEtheris Sulphur., Liquor. Ammon. Acet., Spirit. Vini Rert.,aa gjss.; Aquse Rosarum giijss. M. Fiat Lotio. Form. 336. Lotio Evatorans Astringens. R Ammoniae Muriatis 3 ij.; Liquoris Ammoniae Acet. giij.; Aquas Puros gxij. Misce. Form. 337. Lotio Flava. R Hydrargyri Oxymuriatis gr. xv.; Liquoris Calcis ft j. Misce. Form. 338. Lotio Hydrargyri Camphorata. R Hydrargyri X ij.; Acidi Nitrici giv.; Aquae Destil. O x. Treat the Mercury with the Nitric Acid, and add the distilled Water ; afterwards add from gss. togijss. of Camphor. (In Chronic Cutaneous Af- fections, applied twice daily.) Form. 339. Lotio Sedativa. R Acidi Hydrocyanici 3j-—3ij-j Mist.Amydal. Amar. gvijss.; Hydrarg. Oxyinur. gr. iij.—v. Fiat Lotio, ope spongias partibus affectis applicanda. Form. 340. Lotio Terebinthin.32 et Camphora. R Camphorae g iv.; Spirit. Vini Rect., Olei Terebinthi- nas, aa giv. M. Fiat Lotio, in Morbis Cutaneis Chronicis utenda. Form. 341. Lotio Terebinthinata. R Olei Terebinthinas,Alcoholis, 55 giv.; Camphors 3vj. Fiat Lotio. (In Pthiriasis, &c.) Form. 342. Mistura Acetatis Morphina. R Morphinae Acetatis gr. ij.; Acidi Acetici 3ss.; Mist. Camphorae gvss.; Tinct. Humuli 3 iij.; Syrup. To- lutan. 3j. M. Fiat .Mist., cujus capiat Cochlear. unum amplum 3tia vel quarta quaque hora. Form. 343. Mistura Acidi Boracici. R Acidi Boracici 3 j.; Mist. Camphorae g iv.; Syrnp. Aurantiigj. M. Capiat Cochlearia ij. 2davel 3ti4 quaque hora. (In Cerebral Affections. Chaussier.) Form. 344. Mistura Acidi Hydrocyanici Comp. R Acidi Hydrocyanici TT) viij.—xx.; Vini Ipecacuan- hne 3 ij. ; Spirit. jEtheris Sulphurici Comp. X iij.; Mist. Camphora;, Mist. Amygdal. Dulc,5a giijss.; Oxymellis Scillae 3 ij.— gss. M. Capiat Cochlear. j. vel ij. vel iij., ter quaterve quotidie. Form. 345. Mistura Acidi Muriatici. R Acidi Muriatici, f. X j.; Decocti HordeiOj.; Sac- chari Purificati, g ss. Misce. (Dosis 5 fluidunc. ij. ad iv. bis ter, saepiusve quotidie\) Form. 346. Mistura Acidi Nitrici Comp. R Extracti Hyoscyami 3 ss.; Acidi Nitrici Diluti 3 j. ; Aquae Destillata; gvss. Syrupi Zingiberis 3iij. M. ft. Mistura. (Dosis unc. j. secundis horis, durante paroxysmo.) Form 347. Mistura Alkalina Anodyna. R Tincturae Opii 3 ij.; Liquoris Potassa; ^ss.; Spiritus MyristiciSss.; Aquas Pn'ras g xjss. Misce. (Dosis a3j- ad 3ij. bis terve in die.) Form. 348. Mistura Alkalina Cardiaca. R Mist. Camph.g vjss.; Pod. Suh-carhon. 3 jss.; Am- nion. Carbon. 9j.; Tinct. Calumba? g ss. ; Spirit. Anisi, Tinct. Cardamom. Co., 55 g ss. M. Mist. Capiat Cochlear, ij. magna, bis terve quotidhi. Form. 349. Mistura Aloes et Guaiaci Comp. R Tinctura; A'oes Comp., Tinct. Guaiaci, Spirit. Am- monia; Aromat., aagss. ; Tinct. Ferri Ammoniati 3 iij. M. Capiat 3j. vel X ij. ter de die, in vehiculo quovis idoneo. Form. 350. Mistura Ammoniaci Comp. (1.) R Mist. Ammoniaci g vjss.; Potassa; Nitratis 3 j.; Aceti Soillrr; 3 iij. ; Spirit. Junip. Comp. g j. ; Tinct. Opii TT) x:j. Fiat Mist, cujus capiat Cochlear, amplum 3tiis vel 4tis horis. Form. 351. Mistura Ammoniaci Composita. (2.) R Gummi Ammoniaci 3 j. ; Oxymellis Pcillae g j. ; Vini 'pecacuanhae 3,j.; Aquas Flor. Sambuci g ivss.; Syrup. Panaveris 3 ij. M. Capiat aeger qiialibet hora Cochleare unum. (Chronic Pectoral Com- plaints.) APPENDIX OF FORMULAE. — Mistura. xm Form. 352. Mistura Ammonia Muriatis. R Muriatis Ammonia;, Extr. Glycyrrh., 55 3 j.; Decocti Althasas g vj.; Oxymel. Simp, g j. (vel Oxymel. Scillas.) M. (Catarrhal Afiections.) Form. 353. Mistura Anodyna. R Magnes. Carbon. X jss.; Tinct. Humuli 3iij.; Aq. Menth. Virid. g iij.; Infus. Caryophyl. g iijss. M. Fiat Mist., cujus capiat Cochlear, ij. larga pro re nata, vel urgenti nausea. Form. 354. Mistura Anodyna. — (Infantilis.) R Testos Prasparatas 3 ij.; Syrupi Papaveris Alb. g j.; Spiritus Ammon. Foetid. 3j.; Olei Anethi, Olei Fcenicul. Dulc, aa TT) iij.; Aquas Distillatae g iij. Fiat Mistura. Form. 355. Mistura Anodyna Acetosa. R Mist. Camphora? giv.; Liquor. Ammon. Acet giij.; Acid. Acet. 3 ij.; Spirit. .(Ether. Nit. 3 ij.; Vini Ipecacuanhas 5 ij.; Extracti Conii gr. xxx.; Syrup. Tolutan. 3 ij. M. Fiat Mist., cujus capiat Coch- lear, ij. vel iij. larga 4ta vel quinta qu-ique hora. Form. 356. Mistura Anodyna cum Zinco. R Zinci Sulphatis gr. vj.; Mist. Camphora? gvij.; Acidi Sulphur. Arom.f. 3ss.; Tinct. Hyoscyami 3 jss. ; Tinct. Camphora? Comp., 3 iij.; Syrup. Limonis 3 ij. M. Capiat Cochlear, ij. larga ter quaterve quotidie. Form. 357. Mistura Anti-emesin. R Magnes. Carbonat. 3 jss.; Spirit. .(Ether. Sulph. Comp. 5 iij-; Tinct. Cardamon. Co. g ss.; Spirit. Anisi, 3 v. Olei Carui TT) x.; Syrup. Zingiberis 3 ijss. Mist. Camphorae gjss.; Aquas Menthas Vi- ridis g vss. Fiat Mist., cujus sumantur Cochlearia duo ampla urgenti flatu vel nausea. Form. 358. Mistura Antiphlogistica. (1.) R Potassas Nitratis 3ss.; Liquoris Ammoniae Acetatis f. gjss.; Vini Antimonii Tartarizati f. 3iij.; Mistu- ra; Amygdalarum f. g vj. Fiat Mistura, cujus sit dosis Cochlearia tria magna quarta quaque hora. Form. 359. Mistura Antiphlogistica. (2.) R Liquoris Ammonias Acetatis, Aqua? Mentha; Viridis, aa f. gij.; Aqua; Destillata? f. g iijss.; Potassa? Ni- tratis 9 ij.; Vini Antimonii Tartarizati 3 iij. Fiat Mistura, cujus sit dosis Cochlearia tria ampla tenia vel quarta quaque hora. Form. 360. Mistura Antiseptica cum Acido Pyro- ligneo. R Acidi Muriatici, iEtheris Sulphur., aa X ij.; Aquas Pimentae X ivss.; Aqua? Cinnam. g ij. ; Syrup. Au- rantii gj. M. Sumantur Coch. duo omni bihorio. Form. 361. Mistura Aperiens. R Magnesias Sulphatis g v.; Magnesias Sub-carbonatis 3 iijss.; Aquas Destillata; O ij.; Spiritus Cinnamo- mi, Spiritus Anisi, aa X ij. Fiat Mistura. Dosis a 3j.ad gij. Form.362. Mistura Aperiens Salina. R Florum Anthemidis gij.; Radicis Zingiberis concis. gj.; Aqua? Ferventis O ijss.; Macera pernoctem ; exprime, et adde Magnes. Sulphatis g ij.; Soda; Sulphatis gjss. ; Potassae Sulphatis 3 v. M. Ca- piat Cyathum primo mane. (After each dose take an hour's exercise in the open air, and breakfast afterwards.) Form. 363. Mistura Aromatica. R Infus. Caryoph. g iv.; Aquae Cinnain. giij.; Tinct. Cinnam. 3 ij. ; Magnes. Carbon. 3 jss.; Confect. Arom. gr. xij. M. Fiat Mist., cujus sumat Coch. ij. larga. Form. 364. Mistura Arsenicalis. R Liquor. Arsenicalis X jss. ; Tinct. Cardam. Comp. 3v.; Aquae Cinnam. giij.; Aqua? Deslillatas g iv. M. Fiat Mistura. Dosis Cochlear, ij. (f.gj.)3tiis vel 4tis horis. Form. 365. Mistura Arsenicalis cum Opio. R Liquoris. Arsenicalis TT) xl.; Confectionis Opii9iv.; Aqua; Mentha; Viridis giv. M. Fiat Mistura." Ca- piat pars 4la post jentnxulum, prandium, et coenam. (Dr. Cleghorn.) B Form. 366. Mistura Assafcetida. ■i R Assafoetida; 3 j.; Liquoris Amnion. Acet., Aqua Pulegii, 5a g iijss. M. Cap. Cochleare unum vel duo pro dose. Form. 367. Mistura Assafcetida Comp. R Assafoetidas 3j.; tere cum Aquas Menth. Virid. gij.: dein adde Tinct. Castorei 3 iij.; Tinct. Valer. Am- ^ mon. 3 ij.; Oilier. Sulphur. X j. Fiat Mist., cujus capiatur Cochleare unum amplum secundis horis. Form. 368. Mist. Assafcetida et Valeriana Comp. R Tinctura? Assafostidas, Tinct. Gentianie Compos., ? Tinct. Valeriana?, Spiritus Ammonia; Arom., aa f. 1 gss. M. de qua suinatur Cochleare unum mini- mum ex aqua; tostie cyatho. Form. 369. Mistura Balsami Peruvia.ni. R Balsami Peruviani f. 3 ij- vel iij.; Mellis Despuma- ; ti, gj. Simul diligenter tere, et gradatim adde i Aquae Destillata; gvij. Dosis a fluid, gj. ad gij. bis, ter, quaterve quotidie Form. 370. Mist. Balsami Tolutani. R Tinctura; Balsami Tolutani 3 ij.; Mucilaginis Acaciae verm, g j. Misce ; Adde gradatim, Aquae Destilla- ta; g iv. ; Tinctura? Opii Camphorata; prislin., Sy- | rupi Simplicis, aa 3iij-i Ammonia; Sub carbonatfs, > 3.ss. (vel sine.) Misce. Fiat Mistura, cujus ca- piat Coch. ampl. ij. ter in die. Form. 371. Mistura Bechica. R Pulveris Tragacanthas Compos. 3ij.; Aqua; Destilla- ta; gxij.; Syrupi Simplicis 3 vj. Misce. Interdum adde, vel Nitratis Potassa? 9 iv., vel Tinctura; Opii i TT) xl., vel Tincturae Hyoscyami 3j., vel Tinctura; Camphora? Comp. gss., vel Oxymellis Scillae 3 vj., 1 vel alium inedicamentum idoneum. Form. 372. Mistura Camphora. R Camphorae 3j. : tere cum Spirit. Rectificati TT) xx.; 1 Magnesias Sub-carbonatis 9 ij.; et Sacchari Purifi- cati 3 ij.: dein adde gradatim, Aquas Destillata; Ferventis O j. M. Fiat Mistura. Form. 373. Mistura Camphora Composita. R Camphorae rasae gr. xij.; Magnes. 3j.; Gum. Acacias in pulv. 3'j.; Mist. Amygdal. Dulc. gvjss.; Tinct. Opii TTI xxx. (vel Tinct. Hyoscyami 3 j.); Syrup. Papaveris Alb. 3 "j- M. (In Afiections of Mu- cous Surfaces, Sec.) Form. 374. Mistura Camphorata. R Camphora; gr. viij.—xvj.; Alcoholis TT) vj.; Sac- char. Albi, Pulv. Acaciae, Magnes. Albi, aa 9 ij.; Aqua; Purae gvijss. M. Form. 375. Mistura Camphorata. (Ph. Dan.) R Camphorae Pulverizat. 3ss.; Gum. Acacias, Sacchar Albi, 55 3 * j - > Magnes. 3ss.; Decocti Althasas Offi cinalis gvijss. M. (Interdum adde Tinct. Opii, vel Tinct. Hyoscyami, vel Vinum Ipecacuanhas, vel Spirit. ./Ether. Nit., vel iEther Sulphur., vel Extr. Conii. &c &x.) Form. 376. Mistura Carminativa. R Magnesias Sulphatis g jss. ; Magnesias Carbonatis 3ijss.; Tincturas Cardamomi Comp. 3jss.; Tinct- ura; Castorei TT) xl. ; Olei Anisi TT) x.; Aquas Ane- thi gxij. ; Aquas Purasg viij. Misce. Dosis&Sij. ad gss. 4tis vel ttis horis. Form. 377. Mistura Carminativa Deofstruens. R Infus. Menthas Caryophyl. (F. 239.) gvij.; Potassa? Super-sulphatis X ijss.; Acidi Sulphur. Dil. 5 j. ■ Spirit. Pimenta;, Spirit. Carui, 553jss.; Spirit. My- ristica? 3 ij.; Sacchar. Albi 3 ij. Fiat Mist. Capiat Cochlearia duo larga 3tiis vel 4tis horis. Form. 378. Mistura Cathartica. R Olei Cinnamomi TT) viij.; Sacchari Purificati g sg. Misce. Adde gradatim Infus. Senna; g x.; Sods Sulphatis gjss. ; Magnes. Sulphatis gj.; Tincturae Jalapae gj.; Tincturas Senna-, f. gjss. Misce. Fiat Mistura, et per chartam cola. Dosis gjss. ad g ij. Form. 379. Mistura CaThartica Ammoniata. R Olei Mentha; Viridis TT) x.; Olei Mentha? Piperita TT) v.; Sacchari Purificati3iij. Misce; turn adde infus. Senna; gvij.; Soda? Sulphatis gj.; Tincture Senna? 3 v. ; Spiritfis Ammonia; Aromat. 3 iij. Misce. Fiat Mistura; cujus sumat partem 4tam 3tiis horis, donee alvus respondent. XIV APPENDIX OF FORMULAE. —Mistuiu. Form. 380. Mistura Cinchona. R Cinchona; Flavas in pulv. sublit. 3 vj.; Confectionis Opii 3 U- i Pulv. Cinnam. Comp. 3 j.; Ammoniae Carbon, gr. xij.; Vini Rubr. Op. gxij. M. Form. 381. Mistura Cinchona Alkalina. R Myrrhae in pulv. 3jss.; Liquor. Potassae Sub-carbon. 3iij.; Decocti Cinchomeg vss.; Tinct. Cascarilla? 3 iij. Fiat Mist., de qua sura. Cochlear, duo ampla bis de die. Form. 382. Mistura Cinchona Aperiens. R Confectionis Rosas Gallicas g j.: contere cum Decoc- ti Cinchona; Ferventis, g viij.: stent simul per min. hor. decern, et cola. R Liquoris Colati g vij.; Acidi Sulphurici Diluti, f. 3 j.; Magnesias Sulphatis 5 iv. ; .Spiritus Myristicae, f. g ss. M. Fiat Mistura, cujus sumat Coch. ampl. iij. ter in die. Form. 383. Mistura Conii Composite. R Extracti Conii Jss.; Sodae Sub-carbonatis Xss.—j.; Decocti Glycyrrh. gvss.; Spirit. Pimentae 5 iij. M. Dosis gss. ad gij. ter quaterve quotidie1. Form. 381. Mistura Creta Comp. R Creta; Prasparat., Gum. Acacias, Sacchar. Purif., aagss.; Olei Foeniculi IT) viij.; Aquas Pimenta; et Aquas Cinnam. aa g viij.; Tinct. Aurantii g j. M. Form. 385. Mistura Decocti Cinchona Ammoniata. R Decocti Cinchona; giv.; Liq. Ammonias Acet. gjss.; Spirit. Ammonias Aromat. (vel Succinat., vel Foe- tid.) 5 iij.; Spirit. Rosmarini 3 ij. M. Fiat Mistura. Form. 386. Mistura Decocti Cinchona Composi- ta. (1.) R Decocti Cinchonas 3 iv.; Liq. Ammon. Acetatis gij.; Spirit. ./Ether. Nit. gij. M. Fiat Mistura. Form. 387. Mistura Decocti Cinchona Composi- ta. (2.) R Pulv. Cort. Cinchona; 3 vj.; coque cum Aq. Fonta- na; g xvj. ad reman, unciar. octo; et sub finem coc- tionis adde Pulv. Radicis Serpentaria; 3 iij.; Pulv. Radicis Rhei Opt. 3 jss. Cola cum express.; dein- de admisce Liquoris Ammon. Acet. g ij.; Syrup. Cort. Aurantii g j. Misce. Capiat aeger altera quaque hora Cochleare unum. Form. 388. Mistura Decocti Cinchona cum Ace- to Pyroligneo. R Decocti Cinchonas g vjss.; Acidi Acetici Fortior. (vel e Ligno destil.) 3 ij.; Spirit. Rosmarini, Spirit. Pi- menta;, aa 3 ij. M. Fiat Mistura. Form. 389. Mistura Demulcens. R Pulveris Tragacanthi gr. xv.; Sacchari Albi gr. xij. Tere, et paulatim adde Mist. Amygdal. Dulc'. g ij.; Mist. Camphora? g iijss.; Syrup. Althaeas g ss. M. Fiat Mist. Demulcens. Form. 390. Mistura Deobstruens. (1.) R Extr. Taraxaci, Extr. Humuli, 55 3 ij. Tartar. Tar- tarizat. 3j.; Aquae Foeniculi gvss.; Vini Antimo- nialis Huxh. X ij.; Oxymel. Scillae g j. M. Fiat Mist., cujus capiat Coch. j. vel ij. 3tiis vel 4tis horis. Form. 391. Mistura Deobstruens. (2.) R Radicis Rhei g j. ; Fol. Sennae X vj.; Aquas Ferv. g xij. Infunde per horas iij. et cola. R Hujus Infusi g x.; Extract. Taraxaci, Ext. Clielid. 5a3iij.; Ext. Flor. Calendul. 3ij. ; Acet. Potassas Xvj.; Tinct. Calumba; gss.; Spirit. Junip. Co. gj.; jEther. Muriat. 3 jss. Jl. Capiat Cochlear, j. vel ij. larga ter de die. (In Glandular Enlargements, particularly those of the Abdomen.) Form. 392. Mistura Deobstruens. (3.) R Extr. Taraxaci 3 ijss.; Ext. Sarsae, vel Spartii Sco- paru,3ij.; Potassa? Tart. 3jss.; Sub-boracis Sodas 3 ss. ; Aqua? Foeniculi Dul. g vj.; Vini Antimon. 3 ij. ; Oxymel. Scillae g j. M. C iij. 3tiis vel 4tis horis. Form. 394. Mistura Diaphoretica Anodyna. R Liquoris Ammoniae Acetatis 5 iv.; Vini Antimonii Tartarizati, Vini Ipecacuanha, aa 3 ij.; Spiritus /Etheris Nitrici g ss.; Syrupi Papaveris g j.; Extrac- ti Conii gr. xiv.; Aquas Destillata?gxij. Misce. Form. 395. Mistura Digitalis et Colchici Comp. R Infus. Digitalis, Liq. Ammonias, Acetatis, aa g ijss. ; Potassa? Acetatis X ij.; Aceti Colchici 3 ij.; Opii Tincturae TT) vij. Fiat Mist., cujus sumanturCoch ij. larga bis terve in die. Form. 396. Mistura Diosma Crenata. R Infus. Diosma? Crenata; g vjss. (F.231.); Pulv. Tra- gacanth. 9 ij.; Tinct. Diosma? Crenata; g ss. M. (In Rheumatism, and Affections of the Mucous Surfaces, particularly those ofthe Urinary Organs.) Form. 397. Mistura Diuretica. (1.) Capiat Coch. ij__ Form. 393. Mistuha Diaphoretica. R Liquoris Ammoniae Acetatis giv.; Vini Antimonii Tartarizati g ss.; Vini Ipecacuanha; 3 ij.; Syrupi Papaveris gss.; Aquae Destillata? gxv. Misce. Dosis a 5j. ad g j. 3lns, 4tis, vel 6tis horis. Interdum adde vel Spiritum yEtiieris Nitrici, vel Tincturum Opii. -ad L. M. Capiat Coch. j. larg. 2da quaque hora. (Altered from Augustin.) Form. 398. Mistura Diuretica. (2.) R Potassa; Supertart. X ij.; Sub-boracis Sod* X j.; Aquae Funiculi g viij.; Spirit. Junip. Comp. et Spirit. iEther. Nit. aS3iij.; Syrup. Papaveris gss. Form. 399. Mistura Diuretica. (3.) R Baccarum Juniperi contus. 3 vj.; Carui Semin. con- tus. 3 ijss.; Anisi Semin. cont. 3 jss.; Aquae Ferven- tis O j. Macera per horas tres, et cola. R Colaturae f. g xij.; Spiritus Juniperi Compositi f. g ij.; Potassae Nitratis 9 ij-; Syrupi Scillae f. g ss. Fiat Mistura, de qua sumatur Cyathus subindi. Form. 400. Mistura Diuretica. (4.) R Infus. Digitalis, Aquae Anethi, aa g iijss.; Potassae Acetatis 3 ijss.; Scillae Aceti (vel Acet. Colchici) 3 iij.; Tincf. Opii TT) x. Fiat Mist., cujus capiat Cochlear, ij. larga bis terve quotidie\ Form. 401. Mistura Diuretica. (5.) R Gum. Acacia; 3 v ; Saponis Med. 3ss ; Sub-carbonat. Potassa? 3 ij.; Potassas Nitratis 9 ij.; Infus. Juniperi ibij. (In Gout, with double its quantity of Potash, and a stomachic tincture and Tinct. of Colchicum.) Form. 402. Mistura Emetica Excitans. (1.) R Zinci Sulphatis 9 ij.; Aqua; Menth. Pip. f. g ivss. Solve, et adde Vini Ipecacuanha?, Tinct. Serpen- taria;, 55 f. g ss.; Tinct. Capsici f. 9 ij.; Olei An- themidis TT) xii. Misce ; et fiat Mist., cujus capiat partem tertiam vel quartam intervallisbrevibus. Form. 403. Mistura Emetica Excitans. (2.) R Antimon. Tartar, gr. xij.: solve in Aquae Mentha Piper, f. givss.; et adde Vini Ipecacuanhas, Tinct. Serpentaria?, aaf. gss.; Tinct. Capsici f. 9 ij.; Olei Anthemidis TT) xii. M. Capiat partem quartam vel tertiam, intervallis brevibus, ad effectum plenum. Form. 404. Mistura Expectorans. R Mistura; Amygdalae Amarae f. gv.; Vini Ipecacuan- has, Tinctura? Scilla?, aa f. X j. ; Syrupi Tolutani f. 3vj. Misce. Sumat Cochleare magnum urgente tussi. (In Humoral Asthma, and the latter Stage of Catarrh.) Form. 405. Mistura Febrifuga. (1.) R Camphorae 9 j. ; Pulv. Gum. Acaciae X j. ; Mist. Amygdal. Dulc. g iij.; Potassas Nitratis 3 ij.; Aq. Flor. Sambuci Nig. giv.; Syrup. Papav. Alb. (vel Syr. Limonis; g ss. M. g ss— g j. 3tiis vel 4tis horis. Form. 406. Mistura Febrifuga. (2.) R Mistura; Camphorae g xxiij.; Antimonii Tartarizati gr. iij.; Potassas Nitratis 3 vj.; Spiritus ^Etheris Ni- trici gss. ; Syrupi Limonum g ss.; Misce. Inter- dum adde, vel Vinum Ipecacuanhas, vel Tinctu- ram Digitalis, vel Tincturam Opii, vel Syrupum Papaveris. Form. 407. Mistura Febrifuga. (3.) R Ammonia; Muriatis, Succi Glycyrrh. Inspiss aa3i • Aquae Font, g v. Solve, et adde Vini Antimonii 3U-; Oxvmel. Scillae gss. M. (Hecker.) APPENDIX OF FORMULA. — Mistura. XV Form. 408. Mutura Febrifuga. (Peysson.) R Antimonii Tartarizati gr.j.; Gum. Tragacanth.9j.; Aquie Commun.gvij.; Tinct. OpiiTT) xx.; Syrup. Papaveris 3 vij. M. Form. 409. Mistura Febrifuga Nervina. R Camphorae Rasas 9 j.—9ij.; Vitel. Ovor. q.s. Subi- ge, ct adde Decocti Cinchona-g vjss.; Tinct. Opii Comp. (Vide Form.) 3ss.; ^Eth'er. Sulphur.3j. M. Capiat gss—gjss. 5tis vel 6tis horis. Form. 410. Mistura Guaiaci Ammoniata. R Guaiaci Gummi Resinse, Pulveris Acaciae, aa 3 ij. ; Decocti Glycyrrhizae, O ss.; Liquoris Ammonia; Sub-carbonatis 3 ijss. Tere Guaiacum etPulv. Ac- cacia; cum Liquore Ammonias, et gradatim adde Decoctum. Form. 411. Mistura Guaiaci Comp. R Gum. Guaiaci, Gum. Ammoniaci, Gum. Acaciae, aa 3>j.: solve terendo in Aquas Foeniculi g vjss., et ad- de Vini Antimonii Tartar, g ss.; Syrup. Althaeas 3vj. M. Capiat Cochleare unum amplum tertiis vel quartis horis. Form. 412. Mistura cum Hydrargyri Oxymuriatis. R Decocti Glycyrrhiza; g v.; Aquae Cinnamomi g ij.; Liquoris Hydrarsyri Oxymuriatis (Form. 322.), Sy- rupi Aurantii, aagss. Misce. Ft. Mistura, cujus sumat Coch. ampl. ij. vel iij. statim post cibum, bis terve in die. (Sprague.) Form. 413. Mistura Infusi Cusparia Composita. R Cusparia; Corticis contus. gj.; Aurantii Corticis ex- siccati g ss.; Aquas Ferventis Octarium j. Macera per horas quatuor in vase clauso, et cola. R Colati Infusi, f. g vij.; Tinctur. Cinnamomi, Syrup. Aurantiorum, aa f. g ss. ; Creta? Prasparatas 3j. M. Fiat Mistur., de qua sumatur Cyathus (Cochlearia iij.—iv.) ter vel quater quotidie Form. 414. Mistura Infusi Salicis Comp. R Cort. Salicis contus. g iij.; Aquae O ij. Decoque ad octarium j.; dein adde Caryophyl. contus. 3ss., et cola. R Colati Liquoris f. g vij.; Tincturae Aurantii f. 3vj.; Syrupi Aurantii f. 5 ij. M. Sumat quartam par- tem ter die. Form. 415. Mistura Infusi Senega Comp. R Rad. Polyg. Senegas cone, g j.; Rad. Glycyrrhizae gss. Coque cum Aqua Fontan. g xvj. ad rema- nent, unciarum octo. In colat. dissolv. Flor. Salis Ammon. Depur.3ij.; Pulv. Tamarind. 3j. ; Tart. Emeticigr. j.; Syrup. Althasa; gj. M. Capiat a;ger altera quaque hor-a Cochleare unum. Form. 416. Mistura Infusi Serpentaria Comp. (1.) R Olei CinnamomiTT) vj.; Sacchari Purif. 3iij.; teren- turbene% et ad. Infus. Serpentaria; (F.'262.)gvij.; Spirit. iEtheris Muriatici gss.; Tinct. Capsici 3ss. — 3j. M. Fiat Mist., cujus capiat Coch. ij.—iv. teitiis vel quartis horis. Form. 417. Mistura Infusi Serpentaria Comp. (2.) R Infus. Serpentarioe g vj.; Tinct. Opii Camphorata? 3 v.; Spirit. Ammonia; Arom. 3 ijss.; Syrup. Au- rantii gj. M. Capiat partem quartam tertiis vel quartis horis. Form. 418. Mistura Infusi Uva Ursi. R Infusi Uvas Ursi 3 xiv.; Potassa? Carbon, gr. xxv.; Extracti Conii, gr. iij., grad. auget. ad vj.; Extract. Papaveris gr. v. ad x.; Syrupi Zingiberis, 3 ij. M. Fiat Haust. ter in die hauriend. Form. 419. Mistura Infusi Uva Ursi Composita. R Uvae Ursi Fol. 3ijss.; Radicis Rhei concis. et cont. 3j.; Aquas Ferventis gxij. Macera per horas ij. in vase clauso, deinde cola. R Liquoris colat. g vijss. ; Sodas Sub-carbon. 3 jss. ; Tinct. Opii TT) xiv. (vel Hyoscyami 3jss.); Tinct. Camphorae Comp. 3 iij.; Syrup. Tolutan. 3jss. M. Fiat Mist., cujus capiat Cochlearia duo magna quatuor vices in die. Form. 420. Mistura Laxans. R Infus. Rosarum Com. g vjss.; Acidi Sulphur. Dil. TT} xx.; Potassas Sulphatis 3 i i j -; Tinct. Aurantii Comp. g iij. M. Fiat Mist., cujus capiat Cochlear. jj. larga tertiis vel quartis horis. Form. 421. Mistura Mucilaginis Anodyna. R Mucilaginis Tragacanthas g ijss.: Oxymellis Scilla? g ss.; Syrupi Papaveris gj. Misce. Ft. Mistura, cujus capiat Coch. amp. saspius urgenti tusse gra- datim deglutiendum. N. B.—For the sake of expedition, if the mucil- age of Tragacanth should not be at hand, its place may be supplied by Pulvis Tragacanthas Comp. Sjss.; Aquae Destil. g ijss. (Sprague.) Form. 422. Mistura Myrrha. R Myrrha? 3 jss.; Decocti Glycyrrhiza; ferventis f. g vss.; Simul tere, et cola. Dosis f. gj. bis vel ter quotidie". Singulis dosibus interdum adde, Sodae Subcarbon- atis gr. xij., vel Acidi Sulphurici Aromatici minim. xv., vel Tinctura? Opii Camphorata; f. 3ss. Misce. (In the latter stages of Phthisis Pulmonalis, when languor or debility is a very prominent symp- tom, the above mixture, combined according to circumstances, is an excellent medicine.) Form. 423. Mistura Nervina. (I.) R Mistura; Camphorae f. g iij.; Mistura; Assafcetidae f. gij.; Tinct. Valerianae, Spiritus Ammonia? Com- pos., Spiritus iEtheris Compos., aa f. X ij. M. Fiat Mis- tura, cujus sumantur Cochlear, duo ampla subinde. Form. 424. Mistura Nervina. (2.) R Mistura; Camphorae f. g vij.; Spiritus ^Etheris Sul- phurici, Spiritus Ammonias Compos., 55 f. 3 ijss. ; Syrupi Croci f. gss. Fiat Mistura, de qua sumantur Cochlearia duo vel tria magna, urgente agitatione. Form. 425. Mistura Oleosa. R Olei Olivae vel Olei Lini, Aquas Pimenta?, aa Oj.; Potassae Subcarbonatis 3 vj. Misce. Dosis gj. ad gjss. Jlntiphlogista fit addendo Liquoris Antimo- nii Tartarizati, g ss. ad g ij. Anodyna fit addendo Tincturae Opii TT) xx. ad gij. Volatilis fit usu Spir- itus Ammoniae Aromatici loco Potassae Subcarbon- atis. Form. 426. Mistura Pectoralis. (1.) R Rad. Althasa; gjss.; Semin. Anisi Cont. 3 iij.; Aq. Fervent, q. s. ut sit colaturae g xij. Adde Mur. Am- monia? 3 ij.; Succi Insp. Glycyrrh. gss. M. (Aust. Phar.) Form. 427. Mistura Pectoralis. (2.) R Decocti Llohenis g xj.; Vini Ipecacuanhas 3 ij. ; Extr. Conii 9 j.; Olei Anisi TT) xij.; Syrup. Altha?aj et Syrup. Papaveris aa 3 iij. M. Capiat Coch. iij. vel iv. quater in die. Form. 428. Mistura Phosphorata. R Phosphori gr. ij. ; Olei Terebinth. 3 ss.; Olei Olivae 3 ijss. ; Aq. Fervent, q. s.; Gum. Acaciae g ss.; Aquas Anethi giv.; Syrup. Zingiberis gj.; Olei Ca- ryophyl. TT) vj. Form. 429. Mistura Purgans. (1.) R Infus. Senna? f. g ivss.; Magnes. Sulphatis g j. ; Aquas Mentha; Sativ. f. gijss.; Tinctur. Sennas f. gss. M. Sumat Cochlear, iv. primo mane, et repet. post horas tres, si opus sit. Form. 430. Mistura Purgans. (2.) R Fol. Sennae, Conserva; Mentha; Sativas (F. 46.), aa gss.; Sem. Coriand. contus. 9ij.; Aquae Ferventis g viij. Macera per horas duas, et cola. R Infusi suprapraescrip. g vij.; Sodae Sulphatis g j.; Tincturae Sennae 3 vj.; Tinct. Cardam. Co. 3 ij. ; Sp. Ammonias Arom.3ij. M. Ft. Mistura. Capiat partem 4tam secundis horis, donee bend solutus sit alvus, etpro re nata repetendam. Form. 431. Mistura Refrigerans. R Camphora; rasas gr. x.—9 j'-: tere cum Mucilag. Aca- cias3iij; Muriatis Ammon. 3 j.— 3 jss.; Aq. Flor. Aurantiar., Aq. Com., aa g iij.; Syrup. Aurantii gss. M. Form. 432. Mistura Resolvens. R Flor. Arnica; 3 jss.; Aq. Fervid, q. 8. ut sint colatu- rae gvijss. Adde Potassa; Sub-carbon. 3j. ; Spirit. Lavandul. Co. 3 jss. M. (In Engorgements of Glands, &c.) Form. 433. Mistura Rhei Composita. R Rhei Radicis contrita?3ss.; Sodae Sub-carbonatis gj.; Decocti Glycyrrhizae, f. g v. et 3 ij.; Tincturae Au- rantii, 3 vj. Misce. Dosis a f.gss. ad f. gj. seme), bis, vel ter quotidie (This is a pleasant and effi- cacious method of administering small doses of Rhubarb in Dyspepsia.—Sprague.) xvi APPENDIX OF FORMULA. — Mistura — Pilul*. Form. 434. Mistura Rhodii Comp. (1.) R Tincturae Rhodii, 3 iij.; Mucil. Acacias ver. 3 vj. Te- rentur proW simul; adde gradatim, Infusi Cary- ophyllorum g iv.; Syrupi Zingiheris g ss. M. Fiat Mistura. Sumat partem 4tam ter in die urgente fiatu. Form. 449. Oleum Camphora. R Acidi Nitrici quantum velis ; Camphorae q. s. s. ad Acidi satiirandum. Decant, and preserve in a closely stopped bottle, (Fef.) Form. 450. Pilula Aloes cum FeRRO. R Aloes Spicati Extracti 3Jss.; Myrrhae Gummi Resi- nae pulv. 3 ij.; Extnu.ti Gentianae 9 iv.; Ferri Sulphatis 9 ij.; Theriaca; Purificat. q. ». Sjmul contunde, et in Pilulas cxx. divide. Dosis a ij. ad iv. semel vel bis quotidie Form. 463. Pilula Anodyno-Aperientes. (2.) R Pulv. Ipecacuanha? gr. viij.; Extr. Colocynth. Comp 9ijss.; Extr. Hyoscyami 3ss.; Fellis Taur. inspiss. 9j. Contunde simul. et divide inassam in Pilulas xxiv., quarum capiat unam, duas, vel tres pro dose. Form. 435. Mistura Rhodii Comp. (2.) R Tincturae Rhodii g ss.; Mucil. Acacia; ver. 3 vj. Tere bend, et adde gradatim, Infus. Uvas Ursi g vj.; Syrupi Papaveris gvj. M. Fiat Mistura. Dosis partem 4tam ter quaterve in die. (In Asthma, and in Chronic Catarrhs, &c.) Form. 436. Mistura -Salina. R Mist. Camphorae givss.; Liq. Ammon. Acet. giij.; Spirit. iEther. Nit. X iij.; Potassa? Nit. 9ij.; Syrup. Limonis3ij. M. Fiat Mist., cujus capiat Cochle- aria ij. larga quaita quique hora. Form. 437. Mistura Salina Antiseptica. (1.) R Infus. (velDecocti) Cinchona? g vij.; Sodas Muriatis 3ij-—3 'ij- I Potassa? Muriatis 3ss.— 3 J- Solve, et adde Tinct. Serpentaria; gss. M. Form. 438. Mistura Salina Antiseptica. (2.) R Infus. (vel Decocti) Cinchonas, Mist. Camphorae, aa giijss.; Potassae Nitratis, Potassae Muriatis,aa9ij.j Tinct. Serpentaria;gss. M. Form. 439. Mistura Salina Antiseptica. (3.) R Mist. Camphorae gvij.; Potassas Oxymuriatis 3jss.; Sodae Muriatis 3 ij.; Tinct. Serpentaria? gss.;Spirit. Lavand. 3'J- M- Form. 440. Mistura Salina Febrifuga. (1.) R Mist. Camphora; givss.; Liq. Ammon. Acet. 3ijss.; Magnesia; Sulphatis g ss.— g j. ; (vel Potassas Sulph. 3 ijss.;) Spirit. ^Ether. Nit. 3 iij. M. Form. 441. Mistura Salina Febrifuga. (2.) R Mist. Camphora; givss.; Liq. Ammon. Acet. giij.; Soda; Sulphatis (vel Sodae Phosphatis) 3vj.; Spirit. iEther Nitrici 3 iij. M. Form. 442. Mistura Sedativa. R Magnesias Subcarbonatis, Creta; Prasparatas, Pulv. Acacias, 55 3 ij.; Spiritus Ammonias Aromat. 3Jss-i Tinct. Assafoetida; 3iij. ; Syrup. Papaveris g ss. ; Aquae Destillata? Oj. Misce. Dosis a gss. ad gj. 3tiis, vel 4tis, vel 6tis horis. Interdum adde Tinct. Catechu, &c &x. Form. 443. Mistura Strychnina. R Strychnina; Purissima; gr. j.; Sacchar. Purif. 3jss.; Aquas Destil.gij.; Acidi Acetici gtt. ij. M. Capiat Cochlearia minima ij. mane nocteque. Form. 444. Mist. Terebinthina Veneta. (Clos- sius.) R Terebinthinas Venet. 3j-—3 jss.; VitelliOvorum q. s.; et adde Aquae Menthas Piperita; givss. Capiat Cochlear, j. vel ij. pro re nata. (Against Worms and Chronic Affections of the Mucous Surfaces.) Form. 445. Mistura Tonica. (1.) R Infus Cascarilla; (vel Gentiana? Comp.) gvij.; Pot- assas Sub-carb. 3j.— 3Jss.; Tinct. Aurantii Comp., Spirit. Pimentae, 55 3 iij. M. Form. 446. Mistura Tonica. (2.) R Infusi Cascarilla; Ojss. ; Acidi Sulphurici Aromat. 3 ij. Misce. Dosis a Cochlear, ij. parv. ad Cochl. iij. magna bis die. Form. 447. Mistura Vermifuga. R Rad. Valer. Min., Semin. Santon., 55gss. Infunde Aq. Font. Fervid, gviij.: digere per horam, dein cola. Liq. colat. adde Assafoetida? 3 j. in Vitell. Ovi solutae. Fiat Mistura. Form. 448. Mistura Vinosa. R Vini gvj.; Ovorum duorum Vitellos; Sacchari Pu- rificat. gss.; Olei Cinnamom. TT) iv.; Tinct. Cap- sici 9 j- M. Dosis gjss. ter quaterve, autsaepius quotidie", urgentibus Languoribus. Form. 451. Pilula Aloes cum Ferro Compositus. R Massae Pilul. Aloes cum Myrrha, Pilul. Ferri Comp., Pilul. Galban. Comp., aa 9 ij- ; Soda? Sub-carbon. exsic. 9j.; Olei Junip. Sabin. TTJiv. Contunde si- mul, et fiat massa aequalis, in Pilulas xxx. distrib- uenda. Capiat asgra binas, mane nocteque. Form. 452. Pilula Aloes et Ferri. R Ferri Sulphatis, Potassas Subcarbonat., aa 9 j. ; Myrrhae pulver. 3j. ; Aloes pulver. 3ss. M. Et divide in Pilulas xxx.; ij. vel iij. pro dose node maneque. Form. 453. Pilula Aloes et Moschi Composita. R Pilul. Aloes cum Myrrha3j.; Camph. rasas gr. xij.; Moschi gr. xxviij.; Balsam. Peruvian, q. s. M. Fi- ant Pilula; xxiv., quarum capiat binas omni nocte Form. 454. Pilula Aloes et Scammonia Comp. R Aloes Spicat. 9j.; Scammon. gr. xij. ; Extr. Rhei 9ijss. ; Baccar. Capsici pulv. gr. viij.; Olei Cary- oph. TT)vj. M. Fiant Pilulae xviij., quarum su- mantur binas hora decubitus, p. r. n. Form. 455. Pilula Alteratiya. (1.) R Massie Pilul. Hydrarg. Sub-mur. Comp. 9ij.; Sapo- nis Castil. 3ss.; Extr. Sarsas et Ext. Taraxaci aa 5jss. Misce bend, et divide in Pilulas lx. quarum capiat binas vel tres, ter quotidie Form. 456. Pilula Alterativa. (2.) R Scilla? Radicis exsic. gr. vj. ; Fol. Digitalis gr. xij.; Hydrarg. Sub-mur. gr. vj.; Myrrha; pulv. 9j- Teie simul, et adde Assafcetid. 3ss.; Extr. Gentianae q. s. Fiat massa aequalis, et divide in Pil. xviij., quarum capiat unam mand, meridid, et nocte. Form. 457. Pilula Ammoniaci Composita. R Gunnni Ammoniaci 3j.; Saponis Castil., Fellis Bov. inspissat., Pilulae Hydrarg., Pulv. Folii Conii., Ex tracti Conii, aa 3 ss. ; Extr. Taraxaci 3 ij.; Sul- phur. Antimonii Aurat. 9j.; Theriaca; Purif. q. 9. Contunde in massam asqualem,et divide in Pilulas Ixxx.; quarum capiat binas vel tres, ter quotidie (Deobstruent, dissolvent, &e) Form. 458. Pilula Ammonia et Anthemidis, R Ammonite Sub-carbonatis Pulver., Extracti Anthe- midis, aa 3ss. Fiat massa in Pilulas xij. dividen- da, quarum sumatur una bis vel ter die. Form. 459. Pilula Ammoniareti Cupri et Zinci. R Ammoniareti Cupri, Oxydi Zinci, aa gr. vj.—xij.; Sacchari Albi, Pulv. Trasacantha?, 5a gr. xij.; Mu- cilag. Acacia; q. s. ut fiant Pilulas xij., quarum capiat unam bis terve quotidie (Epilepsy, Chorea, &.C.) Form. 460. Pilula Anodyna. R Camphora? rasae gr.ij.-vij.; Potassas Nitratis v.-viij.; Extr. Hyoscyami gr. iij.—gr. viij. ; Syr. Papaveris q. 8. Misce. Fiant Pilulae iij.—vj., h. s. sumenda?. Form. 461. Massa Pilularum Anodynarum. R Opii Crarfi in pulv. subtiliss. 3 ss. ; Extracti Hyos- cyami 3 ijss.; Saponis Duri, Iridis Flor. Pulv., aa 3 j. Contunde, ut fiat massa, in Pilulas sexagin- ta aequales distribuenda. N. B. — Ten grains of the mass contain one grain of opium und five of the extract of henbane. Form. 462. Pilula Anodyno-Aperientes. (1.) R Pulv. Ipecacuanha? ar. x. ; Extracti Colocynthidis Comp. 3j.; Extracti Hyosc\ami 3ss.; Pilulae Hy- drarg. 9j. ; Saponis Castil.' gr. x. ; Olei Caryoph. TTJiij. Contundein massam asqualem, et divide in Pilulas xxx., quarum capiat unam, duas, vel tres pro dose. APPENDIX OF FORMULAE. — Pilulje. XVII Form. 464. Pilula Antimonii Alterativa. R Sulphur. Aureat. Antimon. 9 j.; Florum Sulphuris 3 >j- i Camphora? rasas 9 j.; Extracti Taraxaci (vel Extr. Sarsa?) 3 iijss. Fiat massa aequalis, et divide in Pilulas xcv. Capiat binas vel tres ter quotidie. Form. 465. Pilula Antimonii et Guaiaci Compos- ita. R Sulphuret. Aur. Antimonii 9 j.; Florum Sulphur. 3 iij.; Resin. Guaiaci, Extr. Conii, aa 3ij.; Syrup. Althaea; q. s. Fiat massa aequalis, et divide in Pi- lulas cxx. Capiat binas vel tres ter die. Form. 466. Pilula Antimonii Sulphureti Comp. (1.) R Antimonii Sulphur. Prascip. gr. v.; Pilul. Hydrar- gyr., Extract. Hyoscyami, 5a 9 j- Misce ut fiat massa aequalis in Pilulas decern dividenda,quarum sumatur una ter die. Form. 467. Pilula Antimonii Sulphureti Comp. (2.) R Sulphureti Antimonii Pracipitati, Hydrargyri Sub- muriatis, aa gr. ss.; Extracti Conii gr. iv. Fiat Pilula ter die sumenda. Form. 468. Pilula Antispasmodica. R Gum. Ammoniaci 3j.; Benzoini, Pulv. Myrrhae, aa 9 ij.; Assafoetida; 3 ss.; Camphora; 9 j.; Tinct. Opii TT) xij. Misce. Divide in Pilulas lx., quarum capiat asger, omni trihorio, pilulas duas vel tres. Form. 469. Pilula Antispasmodica Pierq.uinii. R Camphora? Potassa? Nitratis, Digitalis Purpur., aa 3ss.; Pulv. Cinchona Flav. 3 j.; Extract. Genti- ana? 3 ij.; Syrup. Simp. q. s. M. Fiant Pilulae lx. Form. 470. Pilula Aperientes Comp. R Pilul. Hydrarg., Pilul. Aloes cum Myrrha, aa 9 j.; Pilul. Cambog. Comp. gr. xvj.; Pulv. Mastiches gr. vj. ; Olei Caryophil. TT) ij. M. Fiat Massa aequalis, et divide in Pilulas xxiv., quarum capiat binas hora somni quotidie Form. 471. Pilula Aperientes Alteratiyje. R Pilul. Hydrarg. 9 j- ; Antimonii Tartarizati gr.jss.; Extr. Jalapae 5 jss. ; Fellis Tauri inspissati 3 ss. ; Saponis Castil. gr. xv. Contunde in massam aequa- lem, et divide in Pilulas xl.; quarum capiat binas vel tres omni nocte. Form. 472. Pil. Argenti Nitratis et Belladonna. R Argenti Nitratis pulv. gr. ij.; Pulv. Radicis Bella- donnas 9 j- ; Extr. Glycyrrh. 3 j. Misce bene, et divide in Pilulas xxxvj.; quarum capiat unam ad tres bis terve quotidie (In Pertussis and Epilep- sy. M. Bories.) Form. 473. Pilula Argenti Nitratis Composita. R Nitratis Argenti pulv. gr. v.; Opii Puri gr. x.; Cam- phora? rasas, Nucis Myristicae, aa 9 jss.; Pulv. Aca- ciae 3 ss. ; Syrup. Simp. q. s. M. Divide in Pilulas xxxvj., quarum capiat unam ad tres bis terve quo- tidie Form. 474. PilulaArgenti Nitratis et Gentiana. R Argenti Nitratis gr. ix.; Opii Puri gr. v.; Extr. Gen- tiana;, Extr. Glycyrrh., aa3jss. Divide in Pilulas Iv., quarum unam ad tres vel quatuor, bis terve quotidie. (Niemann.) Form. 475. Pilula Argenti Nitratis Opiata. R Argenti Nitratis pulv. gr. x.; Moschi 3j.; Opii 3 jss.; Camphorae 3ij.; Pulv. Acacias 3ss. ; Syrup. Simp. q. s. Misce bene, et divide in Pilulas lxxx., quarum capiat unam ad quatuor bis terve quotidie (Van Mons, Cadet de Gassicourt, et Ratier.) Form. 476. Pilula Arsenicales. (1.) R Arseniei Albi gr. ij.; Opii Puri gr. viij. ; Saponis Medic, gr. xxxvj. Divide in Pilulas xxiv., quarum capiat j.—iij. pro dose. Form. 477. Pilula Arsenicales. (2.) R Arseniei Albi gr. ij.; Opii gr. xij. ; Ammonias Mur. 3 ss.; Mucilag. Acaciae 9 ij.; Syrup. Simp. q. s. M. Divide In Pilulas xxx., quarum capiat unam vel binas ter die. Form. 478. Pilula ArseniatisFerri. (Biett.) R Proto-Arseniatis Ferri gr. iij.; Extr. Humuli X ij.; Pulv. Altha-a'3ss.; Sjrup. Auran.q. s. M. Divide in Pilulas xlviij. quarum capiat unam in die. B* Form. 479. Pilula Assafcetida cum Cinchona. R Assafoetida; Gummi Resinae3j.; Extracti Cinchonas Opt. 3 ij. Saponis Duri,3ss.; Olei Pulegii TT) xij. Theriac Purificat. q. s. ut fiat massa: in Pilulas xlviij. divide ; quarum eapiat iij. vel. iv. nocte maneque. Form. 480. Pilula Assafcetida Composita. R Assafustid., Castore,Valerianae, Succini, aa pulveriz. 3ss.; Camphorae gr.x.; Olei Cajeputi q.s. M. Fiant Pilulae xxxvj.; quarum capiat binas pro dose. Form. 481. Pilula Assafoetida cum Felle. R Assafcetid., Fell. Tauri inspissat.,aa3j.; Pulv. Rhei 9 j.; Syrup, q. s. M. Fiant Pilul. xl. Form. 482. Pilula Assafojtida et Valeriana Comp. R Gum. Assafastidae, Pulv. Valeriana;, aa 3 j.; Extr. Aconiti gr. vj.; Pulv. Scilla; gr. viij.; Castorei 3ss.; Ammonias Subcarbon. gr. xvj.; Syrup. Papaveris q. s. M. Fiant Pilulas xlviij., quarum capiat binas ad quatuor pro dose. (In Spasmodic Affections of the respiratory Organs.—Richter.) Form. 483. Pilula Astringentes. R Extr. Cinchonas, Ferri Ammoniati, Alumina; Sulph., Pulv. Aromat., aa 3 Jss- Olei Caryoph. q. s. M. Fiant Pilulas lxxxiv.; quarum j.—ij. pro dose. Form. 484. Pilula Balsama Comp. R Myrrhae Gummi Resinas pulv. 9 U > Galbani, Assa- fostidas,aa 9j.; Capsici Annui Pulv. gr. xv.; Bal- sami Peruviani 3 j. M. Fiant Pilula? xxx.; equibtis sumantur binae vel tres, bis terve de die. Form. 485. Pilula Balsamica. (1.) R Extr. Aloes 3 ij.; Extr. Rhei 3 j.; Balsam. Peruv. et Benzoini, 55 3 ss.; Croci Stigmat. et Myrrhae, 559j.; Extr. Opiigr. v.; Spirit. Vini et Syrup, q. s.TT)lxxx.; quarum capiat unam ad quatuor pro dose. Form. 486. Pilula Balsamica. (2.) R Terebinthina; Chiensis, Spermaceti, aa Tjij.; Pulv. Myrrha; 3j.; Olibani Pulver. q. s. ut fiat Pilulas Ixx.; quarum capiat unam vel duas omni tenia vel quarta hora. Form. 487. Pilula Balsamica Camphorata. R Acidi Benzoini 3 j.; Camphorae, Croci Stig., Balsam. Peruvian., G. Ammoniaci, aa 9 j.; Mucilag. Aca- ciae q. s. M. Fiat massa aequalis ; divide in Pilu- las xxxvj., quarum capiat binas pro dose. Form. 488. Pilula Belladonna. R Extr. Belladonnas gr. vj.; Pulv. Rad. Glycyrrh. gss.; Succi Inspissat. Sambuci Nig. q. s. ut fiant Piluls xij. Capiat unam ad tres pro dose. Form. 489. Pilula Benzoina et Terebinthina Comp. R Myrrhae, G. Ammoniaci, aa 3 jss. ; Benzoini 3 j.; Extr. Gentiana? 9 ij. ; Terebinth. Venet. 3 jss. ; Pulv. Rhei q. s. Fiat Massa aequalis, et divide in Pilulas gr. iv. pond. (In Hypochondriasis, Habit- ual Constipation, &c.) Form. 490. Pilula Bismuthi. R Bismuthi Sub-nit., Castorei, aa gr. j.—ij. ; Pulv. Glycyrrh. et Mellis q. s. ut fiant Pilula; ij., tertiis vel quartis horis sumenda?. Form. 491. Pilula Brucina. R Brucina? Puras, gr. xii.; Conserv. Rosar. 9ij. Misce bene, et divide in Pilulas xxiv. asquales. Capiat unam ad quatuor pro dose. Form. 492. Pilula Cambogia Composita. R Cambogia; 3J-: solve in Olei Ricinipauxillo,et adde Pilul. Aloe's cum Myrrha, Pilul. Galban. Comp., Pilul. Hydrarg., aa 9"ij. Contunde bene1 simul, et divide in xlviij. Capiat unam ad tres pro dose. Form. 493. Pilula Camphora et Antimonii The- baiaca. R Camphorae rasae gr. iv.; Pulv. Jacobi Veri gr. iij. Opii Puri gr. ss.; Syrup. Simp. q. s. Fiant Pilulas ij. quarta vel sexta quaque hora suniendae. Form. 494. Pilula Camphora Comp. (Brera.) R Camphoras, 9j.; Potassae Nitratis 9ij.; Kermes Mi- neralis gr. vj.; Pulv. Glycyrrh. et Mellis, aa q. s. M. Divide in Pilulas xviij., quarum capiat duas tertia quaque hora. XVIII APPENDIX OF FORMULAE. —Pilulje. Form. 495. Pilula Camphora et Ipecacuanha Comp. R Pulv. Ipecacuanhas Comp. gr. iv.; Camphora; rasas gr. j.—iij. ; Syrup. Papaveris q. g. M. Fiant Pi- lulas iij., quarta quique hora sumenda?. Form. 496. Pilula Camphora et Nitri. R Camphorae Subactae, Potassa? Nitratis, aa gr. ij.—v.; Conserv. Rosar. q. s. M. Fiant Pilulas ij. vel iij. Form. 497. Pilula Castorei Thebaiaca. R Opii gr. ss.; Castorei Rossici gr. vjss.; Pulveris Di- gitalis gr. j.; Syrup, q. s. Fiant Pilulas duas, bis vel ter die sumenda;. (In Spasmodic Asthma, and Dyspnoea.) Form. 498. Pilula Cathartica. (1.) R Hydrarg. Submur. gr. viij.; Extr. Res. Jalap, gr. xvj.; Gum. Guaiaci gr. xxiv.; Mucilag. Acacias q. s. M. Divide in Pilulas xij. Capiat binas vel tres pro re nata. Form. 499. Pilula Cathartica. (2.) R Cambogia? Gum. Sjss.; Scammon. 3j.: solve terendo in pauxillo Olei Junip: dein adde Aloes Socot. Sijss.; Gum. Ammoniaci Sjss.; Potassas Sulphatis 3j- ; Oxymel. Scillae q. s. ut fiat massa aequalis. Capiat pro dose gr. x. ad gr. xxx. Form. 500. Pilula Colocynthidis Composita. R Colocynthidis Pulpae gss.; Aloes Spicatas Extracti Scammonias Gummi Resinas, aagj.; Saponis Duri 3ij.; OleiCaryophylli3j. Aloe, Scammonia, et Co- locynthis pulpa in pulverem redigantur; turn cum Sapone atque Oleo conterantur; denique cum Mu- cilagine Acacias subigantur in massam. Form: 501. Pilula Colocynthidis cum Hydraroyro. R Massa Pil. Colocynth. Composit. 3iv.; Hydrargyri Protochlorid. (Calomel) X j. Simul contunde" in mortario lapideo, donee massa a?qualis sit; et in pilulas Ix. asquales distribuenda. Dosis, ab j. ad iv. pro re nata. Form. 502. Pilula Cupri Sulphatis cum Opio. R Cupri Sulphatis gr. vj.; Opii Puri gr. iv.; Pulv. Tra- gacanth. Comp. 9j.; Mucilag. Acacias q. s. ut fiant Pilulae xij. ; quarum capiat unam ter die, postea quater quotidie, vel tertiis aut quartis horis. (Chro- nic Diarrhoea and Dysentery.) Form. 503. Pilula Deobstruentes. (1.) R Antimonii Tartarizati gr. iv.; Pilul. Hydrarg. 9j.; Saponis Castil., Gum. Ammoniaci, Assafoetida?, Extr. Aloes Purif., aa 3ss. Misce bene, et divide in Pilulas lxxv.; quarum capiat binas ter die. Form. 504. Pilula Deobstruentes. (2.) R Extr. Aquosa? Aloes 3 ij.; Gum. Ammoniaci 9ij.; Myrrha?, Mastiches, Benzoini, Rhei, 55 gr. 9j.; Croci Stigm. gr. xvj.; Potassae Sub-carbon. 9ijss.; Mellis q. s. ut fiat massa aequalis. Capiat gr. x. ad xx. pro re nata. Form. 505. Pilula Deobstruentes. (Barthez.) (3.) R Kermes Mineral, gr. j.; Hydrarg. Submur. gr. ij. ; F.xtr. Fumariae (Extr. Taraxaci) gr. x. Fiant Pilul. iij., pro dose. Form. 506. Pilula Deobstruentes. (Recamier.) (4.) R Saponis Castil. 3ijss.; Gum. Ammoniaci 3j.; Aloes Extr. Purif. gr. xv.; Assafcetida; 3ss.; Pulv. Rhei 3j-; Croci Sativi 3ss. ; Syrup, q. s. M. Fiant Pi- lulae lxxxiv., quarum capiat binas bis quotidie. Form. 507. Pilula Deohstruentes. (5.) R Saponis Hisp. 3iij.; Gum. Ammoniaci 3j. ; Aloe's 3j.; Rhei Pulv. 3j.; Assafcetida;, Croci, 5a 3ss. ■ Syrup, q. s. M. Divide in Pilulas c. Capiat binas ad quatuor bis terve in die. Form. 508. Pilula Deorstruentes. (6.) R Saponis Medicinalis 3iv.; Cum. Ammoniaci 3 ij. • Extracti Conii, Extr. Aconiti Napel., aa 3jss.; Mas- sa; Pilul. Aloes cum Myrrha X j. Contunde in massam asqualem, et divide in Pilulas granarum quatuor. Capiat binas mane nocteque, augendo unam quotidie donee xv. vel xx. sumantur in die. (Dr. Lowassy, in Glandular Tumours and Scir- B rhous Formations.) Form. 509. Pilula Deobstruentes. (Stoll.) (7.) R Antimonii Sulphureti Prmcipitati9j.; Saponis Ve- netii 3 U-! Gummi Acacias 3j.; Mucilag. Gum. Tragacanth. q. s. Fiant Pilula? L. Sumat tres > mane1 et nocte. (For Cutaneous Eruptions, Rheu- matism, &c.) Form. 510. Pilula Deobstruentes. (8.) - R Hydrarg. cum Creta gr. xvj. : Sodas Sub-tarbon. ex- 1 sic. 9j- 5 Extracti Taraxaci 3j- M. Fiant Pilula] 1 xx.; quarum capiat binas vel tres omni nocte. Form. 511. Pilula Deuto-Iodureti Hydrargyri. R Hydrarg. Deuto-Iodureti gr. ij.; Extr. Humuli 9ij.; Pulv. Glycyr. q. s. Misce ben^, et divide in Pilu- ' las xvi.; quarum capiat binas man«5 nocteque, et [ augeat dosin ad tres vel quatuor. Form. 512. Pilula Diaphoretica. R Oxydi Zinci, Extracti Aconiti, aa xij.; Sulphureti Antimonii Aurat. gr. vi.; Extracti Humuli 3j-; ' Syrup. Papaveris q. s. Contunde bene' simul, et di- vide in Pilulas xviij. ; quarum capiat unam secun- da vel tertia quaque hora. (In Chorea, Sciatica, Hysteria, and Rheumatism.) Form. 513. Pilula Diaphoretica Sedatiya. R Kermes Mineral., Extr. Opii, 5a gr. ij.; Potassa? Ni- i tratis gr. v.; Syrup, q. s. Fiant Pilula? ij. pro dose. Form. 514. Pilula Digitalis et Camphora Comp. 1 R Pulveris Digitalis gr. vj.; Camphora? gr. xv.; Ex- tracti Hyoscyami 9 jss. Fiant Pilulae duodecim. Sumat tres omni nocte. (In Maniacal and Spas- modic Affections.) Form. 515. Pilula Digitalis et Myrrha Comp. ' R Myrrhae G. R. gr. ij.—iv., Pulv. Digitalis gr. j. ; 1 Extr. Hyoscyami gr. iij.—v. ; Syrup, q. s. Fiant 1 Pilula; ij., bis terve quotidhe sumenda?. Form. 516. Pilula Diuretica. R Scillae Rad pulver. gr. ij.; Pulv. Foliorum Digitalis gr. j.; Pilulas Hydrargyri gr. vj.; Olihani Pulver. 9ss.; Olei Juniperi TT)iv. Fiat massa in Pilulas qnatuor dividenda, & quibus capiat ij. hora somni, superbibendo haustulum Mistura? Diuretica?, No. 398 vel 399. Form. 517. Pilula Diuretica Alterativa. R Potassa; Supertart. 3 j. ; Sub-boracis Soda; 9 jss. ; Pulv. Rad. Polygala? Senega? X j.; Pulv. Radicis Colchici exsic. 9 'j- ; Pulvl Scilla? gr. xvj. ; Extr. Taraxaci 3 iij. Fiat massa aequalis, et divide in Pilulas c; quarum capiat tres ter quotidie Form. 518. Pilula Dulcamara et Antimonii. R Antimonii Sulphurat. Nig., Pulv. Stip. Dulcamaras, aa 3j.; Extr. Dulcamaras 3 ij. ; Syrup. Tolutan. q. s. M. Fiant Pilulas Ix. (Richter, in Scrofula. Also in Cutaneous Diseases.) Form. 519. Pilula Emmenagoga. R Aloes Socot., Myrrhas, 5a 3jss.; Galhan., Gum. Am- moniac, 55 9 ij.; Sub-boracis Sodae 3 jss.; Ferri Sulphatis 3ss. ; Ferri Oxydi 9j.; Rhei 9j.; Olei Rutae et Olei Sabinae, 5a TT) xij. ; Saponis q. s. Fiat massa aequalis, et divide in Pilulas cxx.; qua- rum capiat binas vel tres bis terve quotidie Form. 520. Pilula Extr. Gentiana et Humuli Comp. R Extracti Gentiana; 3 ij.; Saponis Medicin. gjss.; Fell. Tauri inspiss.; Ext. Aloes Purif. 55 3j.; Ext. Humuli 3jss. Misce, et divide in Pilulas pond. gr. iij.; quarum capiat binas vel tres mane" nocteque. Form. 521. Pilula Ferri Ammoniati. R Ferri Ammoniati 5j.; Extracti Aloes, Extracti Gen- tianae, aa 3ss. Contunde simul, et divide massam in Pilulas triginta ; quarum sumat duas ter quoti- die. (In Dyspepsia, Hysteria, Scrofula, and Me- senteric Obstructions.) Form. 522. Pilula Ferri Ammoniati Composita. R Ferri Ammoniati 3j.; Extr. Gentian, et Extr. Aloes aa 9 ij. Contunde simul, et divide massam in Pil xxxvj.; e quibus binae, bis terve quotidhj sumantur APPENDIX OF FORMULAE. — Piloljs. xix Form. 523. Pilula Ferri Aperientes. (1.) R Ferri Sulphatis, Potassae Sulphatis, 55 5j.; Galhani, Assafustidae, aa 5 jss. ; Ammonias Muriatis 5 ij. ; Massie Pilul. Aloes cum Myrrha X iij.; Theriaca? Purif. q. s. Contunde in massam asqualem, et di- vide in Pilulas cl.j quarum capiat binas bis terve quotidie Form. 524. Pilula Ferri Aperientes. (2.) R Ferri Sulphatis, Potassas Sulphatis,5a 3j.; Galbani, Assafoetida;, aa Sjss.; Extr. Gentiana; 3 ij.; Massa; Pilul. Aloes cum Myrrha 3 iij.; Theriacae Purif. q. s. Contunde in massam asqualem, et divide in Pilulas cl. Form. 525. Pilula Guaiaci Comp. (1.) R Gum. Guaiaci 3ij.; Saponis Venet. 3j.; Calomela- nos, Sulphur. Antimonii Aur., Pulv. Rad. Sene- gas, Camphoras, 55 gr. xvj.; Aceti Scillas q. s. Fiat massa aequalis, et divide in Pilulas Ixxx.; quarum capiat duas vel tres bis terve quotidhs. Form. 526. Pilula Guaiact Comp. (2.) R Gum. Guaiaci 3 ij.; Calomel., Sulph. Antimonii Aur., aa3ss.; Mucilag. Acaciae q. s. M. Fiant Pilulae 1. capiat ij.—iv. pro dose. (Cutaneous Affections.) Form. 527. Pilula Guaiaci Composita. (3.) R Guaiaci Gummi Resinas pulv. 3 ij.; Pulv. Opii Crudi gr. vj.; Hydrariryri Protochlorid. (Calomel) gr. xij.; Antimonii Tartarizati gr. iv.; Tinctura; Myrrhae q. s. ut fiat massa, in Pilulas xxxvj. divid- enda. Dosis, ij. vel iij. nocte mamsque. Form. 528. Pilula Guaiaci et Antimonii Comp. R Pulv. Jacobi Veri 3j.; Resin. Guaiaci in Pulv., Massa; Pilul. Aloe's cum Myrrha, aa 3 jss.; Syrup. Simp. q. s. Fiat massa asqualis, et divide in Pilulas xlviij. Capiat binas ad quatuor pro dose. (Emmena- gogue, Stomachic, Aperient, and Antirheumatic) Form. 529. Pilula Hellebori et Aloes Comp. R Extr. Rad. Hellehor. Nig., Aloes Ext. Purif., Ferri | Ammoniati, aa3j.; Croci Stigmat. 3ss.; Opii Puri gr. v.; Syrup, q. s. M. Fiant Pilulae 1., quarum ca- I piat binas vel tres. Form. 530. Pilula Hydrargyri Anodyna. R Pilul. Hydrargyri, Pulveris Ipecacuanhas Compos., Extract. Hyoscyami, aa gr. v.; Fiat massa in Pilu- las iij. dividenda. Sumantur hora somni. Form. 531. Pilula Hydrargyri Oxymuriatis. R Hydrargyri Oxymuriatis, Ammonias Muriatis, aa gr. v.; Aquas Destillata?, f. 3ss. ; Glycyrrhizae Ra- dicis Pulveris 9iv.; Mellis Opt. 3ss. Cogantur in massam, quain divide in Pil.xl.; i quibus sumatur ' una ter die. Form. 532. Pil. Hydrargyri Phosphatis Composita. R Hydrargyri Phosphatis gr. ix.; Antimonii Tartari- zati gr. j. ; Opii Crud. in pulv. subtiliss. gr. vj. ; Confectionis Fructi Rosas Caninus q. s. ut fiat mas- '• sa, in Pilulas sex asquales distribuenda. Quarum una, hora decubitus sumenda. Form. 533. Pilula Hydrargyri et Scilla. R Sodae Sub-carbon, exsic 3ss.; Saponis Duri 9 ij.; Pilul. Hydrarg. gr. xxiv.; Pulv. Scilla? Rad. exsic gr. xij.; Olei Juniperi q. s. M. Fiant Pilulae xxiv., quarum capiat unam ter die. Form. 534. Pilula Hydrargyri Submuriatis Com- posita, seu Pilula Plummeri. R Hydrargyri Submuriatis 3ss.; Antimonii Sulphureti Prascipitati 3j.; Guaiaci Gummi Resinae contrita? 3ij.; Saponis 3ss.; Olei Juniperi, TT) xxx.; The- riac Punficat. (Treacle) q. s. ut fiat massa, in Pi- lulas sexaginta dividenda. Form. 535. Pilula Hydriodatis Ferri. R Ferri Hydriodatis gr. xxx.; Croci Stigm. pulveriz. 3j.; Sacchari Albi 3 iij.; Mucilag. Tragacanth. q. s. Misce. Contunde in massam asqualem, et divide in Pilulas xc; quarum capiat unam binas vel tres, bis terve quotidie (Chlorosis, Amenorrhoea, Scro- fula, &c.) Form. 536. Pilula Kino Composita. R Kino, 9ij.; Camphora; rasa; et subactae 3ss.; Oxid. Zinci9ss.; Confect. Aromat.9j. M. Divide in Pi- lulasxx. Capiat binas mane' nocteque. (Augustin in Diabetes. Also in Affections of Mucous Surfaces.) Form. 537. Pilula Morphina cum Digitale. R Acetatis Morphinasgr.j.; Pulv. Fol. Digitalis gr. vj.j Camphora? rasa; gr. x.; Pulv. Acacias gr. viij.; Sy- rup. Tolutan. q. s. Fiat massa aequalis. Divide in Pilulas vj., quarum capiat unam tertiis horis. Form. 538. Pilula Myrrha\t Balsami Comp. R Myrrhae 3jss.; Benzoini9ij.; Balsam. Copaibas 3j.; Extr. Glycyrrh. 9iv. Fiant Pilulae xliv. secundum artem. Capiat a?ger binas bis terve quotidie. (Asthma, Chronic Bronchitis.) Form. 539. Pilula Nervina. (Stoll:) R Gummi Ammoniaci, Gummi Assafoetida?, aa 3jss.; Saponis Venet. 3 ss.; Pulv. Castorei, Ammonia; Carbon., aa gr. xxv.; Mucilag. Acaciae q. s. M. Fiant Pilulae lxxx.; & quibus sumantur bins; tertiis vel quartis horis, vel ter die. Form. 540. Pilula Nervina Antimoniata. R Gummi Galbani 3jss. ; Gummi Sagapeni, Saponis Venetian., aa 3j.; Pulv. Rhei 3ss.; Antimon. Tar- tarizat. in aqua font. q. s. sol. gr. vj.—x.; Succi Liquoritia? X j. Misce. Fiant Pilula? gr. iij.: sumat unam ad tres ter quotidhs. Form. 541. Pilula Nucis Vomica. R Extr. Res. Nucis Vomica? 9 ss.; G. R. Assafcetida; gr. 3 jss. Syrup, q. s. Fiat massa asqualis, et di- vide in Pilulas xxx. Capiat unam bis terve in die. (Cardialgia Spasmodica, &c.) Form. 542. Pilula Nucis Vomica Composita. R Morphina; Acetatis gr. j.; Ext. Nucis Vomica; gr. ij.; Olei Olivas gr. x. Solve ; et adde Extr. Rad. Hellebori Nig. (Ed. Ph.) 9 j.; Pulv. Glycyrrh. gr. viij.; Mellis, q. s. Fiat massa asqualis, et divide in Pilulas xij ; quarum capiat unam bis terve in die. (In Chlorosis, Amenorrhoea, &c.) Form. 543. Pilula cum Oleo Crotonis. R Pilul. Aloe's cum Myrrha Sjss.; Saponis Castil9j.; Olei Crotonis Tiglii TTJvj.; Pulv. Glycyrrhiza? q. s. M. Fiant Pilulas xxx. Capiat binas vel tres omni nocte. (In Amenorrhoea.) Form. 544. Pilula Plumbi Acetatis et Digitalis. R Plumbi Acetatis gr. iv.; Pulveris Digitalis gr. vj.; Pulveris Opii gr. iij.; Confectionis Rosas Caninae, q. s. Misce, et divide in Pilulas sex asquales ; qua- rum sumatur una ter in die. Form. 545. Pilula Plumbi Acetatis et CoLCHicr. R Plumbi Acetatis gr. xii.; Pulveris Colchici gr. xxv.; Pulveris Opii gr. iii. ; Mucilaginis Acacias q. s. Misce optimd, et divide in Pilulas asquales duode- cim. (In active Hasmorrhages, in Phthisis, &c) Form. 546. Pilula Plumbi Superacetatis. R Plumbi Superacetatis gr. viij.; Opii Crudi pulver. gr. iv.; Confect. Fruct. Rosas Caninae q. s. In Pilulas viij. divide. Dosis, j. ij. vel iij. semel, bissaepiusve in die. Form. 547. Pilula Purgantes. Fel. Tauri inspissat.; Aloe's Extr. Purificat., aaSj., Extr. Colocynth. Comp., Saponis Castil., aa9j. M. Fiant Pilula; xxxvj. Form. 548. Pilula Rhei Resolyentes. Pulv. Rhei, Sodas Acetatis, Fellis Tauri inspiss. aa 3ij.; Pulv. Gum. Acaciae q. s. Fiat massa Pilular- is. {Ph. Dan.) Form. 549. Pilula Rhei Balsamica. Pulv. Rhei, Pulv. Gum. Acacias, aa partes equales; Balsam. Copaibse q. s. ut fiat massa pilularis. Form. 550. Pilula Scammonia. G. R. Scammon. gr. xv.; Sacchar. Albi gr. x. Tere probe ; deinde adde Ol. Carui TTJiv. Fiant Pilulas vj., quarum sumat ij. omni hora. XX APPENDIX OF FORMULAE—Pilule. Form. 551. Pilula Scilla Composita. R Rad. Scilla; recent. 3ss.; Gum. Ammoniaci, Succi Glycyrrh., aa 3j.; Sulphur. Antimonii Aur., Pulv. Nucis Mynstici, aa 9 j. ; Syrup. Papaveris q. s. M. Fiant Pilulae 1., quarum capiat binas ad tres ter quaterve in die. Form. 552. Pilula Scilla cum I^cacuanha. R Scillae Radicis Pulveris, Zingiberis Radicis Pulveris, aa 3j.; Ipecacuanhas Radicis Pulv. 3ss.; Saponis Duri, 3 jss. ; Olei Juniperi, TT) xxx. Contunde, ut fiat massa, in Pilulas lx. dividenda. Form. 553. Pilula Sedativa. (1.) R Extr. Opii gr. j.; Nitratis Potassas gr. vj.; Campho- rae rasas gr. v.; Syrup. Papa ver. q. s. ut fiant Pilu- lae iij. pro dose. Form. 554. Pilula Sedativa. (2.) R Camphorae Subactae 9 j. ; Potassa; Nitratis 3 ss. ; Extr. Hyoscyami, Extr. Anthemidis, aa 9 ij. ; Sy- rup Papaveris q. s. M. Fiant Pilula? xxxvj., qua- rum capiat binas 4tis vel 6tis horis. Form. 555. Pilula Sedativa. (3.) R Camphora; rasa? et subactae gr. x.; Extr. Hyoscyami 9j.; Extr. Papaveris Alb. gr. xij. M. Divide in Pi- lulas xij., quarum capiat binas vel tres hora somni. Form. 556. Pil. Soda Carbonatis cum Hyoscyamo. R Camphorae 3ss.; (Sp. Rect. q. s. ft. terendo pulv.) Sodae Carbonatis3jss. ; Extracti Hyoscyami,9ij.; Saponis Duri 3j.; Olei Juniperi TT)xxx.; Pulveris Irid. Flor. q. s. ut ft. massa, in Pil. xxx. aequales distribuenda; quarum sumat iij. nocte man&jue, cum Infus. Lini vel Decoct. Althaeas, propotu com- muni. Form. 557. Pilula Stahlii. R Peroxid. Antimonii, Aloes Socot., Resin. Guaiaci, aaSj.; Croci Stig., Myrrhas, 3ss.; Bals.Peruv. q. s. ut fiat massa aequalis. Divide in 1. Form. 558. Pilula Stomachica. (1.) (Frank's Grains of Health .- — Grana Vita Mesue.) R AloesSiij.; Mastiches, Petal. Ros. Rub.,5a 3j.; Fel- lis Tauri inspissat. 3 jss. Misce bene'; divide in Pi- lulas c.; quarum capiat ij. vel iij. antd prandiuin. Form. 559. Pilula Stomachica. (2.) R Extr. Gentiana; 3 ij. ; Fellis Bovina? inspiss. Sjss.; Scammonia? 3j. Contunde in massam asqualem, et divide in Pilulas lxxx.; quarum capiat binas quo- tidie, vel primo mane, vel ante prandium. Form. 560. Pilula Stomachica. (3.) R Limat. Ferri 3 ij-; Pulv. Canellae X j.; Fellis Bov. insp. gss.; Syrup, q. s. M. Fiat massa Pilularis. (Chlorosis. &c.) Form. 561. Pilula Stomachica. (4.) R Limatura; Ferri X j.; Pulv. Rhei, Extr. Gentianae, Fellis Tauri insp. aa 3 iij. M. Fiat massa Pilularis. Form. 562. Pilula Stomachica. (5.) R Fellis Tauri inspissat., Extr. Aloes purif., Extr, Gentianas, Saponis Venet., 55 3ss. M. Fiant Pi- lulae xxx., quarum capiat binas bis in die. Form. 563. Pilula Stomachica Aperientes. R Ext. Fumarias Officinalis, Extr. Jalapa?, aa 3j.; Pulv. Capsici Annui, gr. xvj.; Soda? Sub-carbon. exsic. 3ss. Misce secundum artem, et divide in Pilulas xxxvj.; quarum capiat duas vel tres hora et semisse antd prandium. Form. 564. Pilula Stramonii. R Extracti Stramonii3j. ; Saponis DuriSij.; Acacia; Gummi pulv.9j.; Glycyrrhizae Radicis pulv.jjij.; Mucilag. Tragacanth. q. s. ut ft. massa, in Piiulas lx. dividenda. Dosis, j. nocte mandque, vel ter die. Form. 565. Pilula Strychnina. R Strychnina? Purif. gr. ij.; Conserv. Rosarum X j. Misce bend, et divide in Pilulas xxiv. Form. 566. Pilula Styracis Composita. R Styracis 3jss.; Olibani, Benzoini, Croci, Extr. Gly- cyrrh., Mastiches, 553 ss.; Opii Puri 9ij.; Myrrha; 9ij.; Balsam. Tolutan.9j. Tere bene simul, ut sit massa aequalis. Divide in Pilulas lxxx., quarum capiat unam binas vel tres pro dose. (Each pill contains half a grain of opium.) Form. 567. Pilula Sudoriftca. (1.) R Hydrargyri Protochlorid. (Calomel) gr. xij.; Anti- monii Tartarizati gr. jss. ad gr. iij.; Opii Crudi in pulv. subtiliss. gr. vj. Misce ; rum adde Confect. Fruct. Rosa? Canina; q. s. utlt. inassa. In Pilulas vj. asquales divide, quarum capiat j. hora somni. Form. 568. Pilula Sudorifica. (Dumeril.) (2.) R Kermes Mineral. (F. 636), Sulphur. Aurat. Antimo- nii, aa 9 j- i Extr. Opii gr. xij.; Extr. Hyoscyami 3 U- Divide in Pilulas lx. Capiat j.—ij. bis terve in die. Form. 569. Pilula Sulphatis Strychnina. R Strychnina? Sulphatis gr. ij. ; Confect. Rosar. 3j. ; Misce probe\ et divide in Pilulas xxiv. asquales. Capiat unam pro dose. Form.570. Pilula Terebinthinata. R Gum. Guaiaci 3j.; Terebinthinas Vulg. 3jss.; Pulv. Glycyrrh. q. s. ut fiant Pilulas xxxvj., quarum ca- piat binas vel tres ter quotidie Form. 571. Pilula Terebinthina et Camphora cum Opio. R Extr. Opii 9j.; Pulv Rad. Glycyrrh. 3jss.: tere cum aqua? pauxillo, et adde Terebinth. Venet gij.; Cam- phora? rasas gr. xv.; Croci Stigmata 9j.;*Mastiches gr. x.; Pulv. Acacias gr. x.; Olei Juniperi q. s. Tere beni simul, et fiat massa asqualis. Divide in Pilulas lx.; quarum capiat binas ad tres bis terve quotidie. Form. 572. Pilula Tonica Aperientes. (1.) R Qninina; Sulphatis X ss.—3 j. ; Potassa? Sulphatis Sjss. ; Gum. Galbani 9 iv.; Extr. Gentianas, vel Anthemidis, 3j. ; Massa; Pilul. Aloe's cum Myrrha 5iij.; Theriaca; Purif. q. s. Contunde in massam asqualem, et divide in Pilulas cxx.; quarum su- mantur bins; vel tres, bis terve quotidie Form. 573. Pilula Tonico-Aperientes. (2.) R ftuinina; Sulphatis 9 j.; Aloes Extr. purif. Sss.j Extr. Gentianae 3j. M. Fiant Pilulae xxiv., quarum sumat unam vel binas omni meridie. Form. 574. Pilula Tonica Aperientes. (3.) R Ferri Sulphatis 3j.; Extracti Absinthii (vel Gen- tianae), Extr. Aloes Purif., 5a 3 jss.; Syrup. Croci q. s. M. Divide in Pilulas lxxxv., quarum capiat binas, tres, quaterve pro dose. Form. 575. Pilula Tonico-Aperientes. (4.) R Quinina; Sulphatis, Extr. Aloes Purif., aa 9ij.; Extr. Gentianas, aa Sjss.; Syrup. Simp. q. s. "Divide in Pilulas xlviij.; quarum capiat duas vel tresprodose. Form. 576. Pilula Tonico-Aperientes. (5.) R Quininae Sulphatis 9(.; Massa? Pilul. Aloes cum Myrrha 9ij.; Extr. Gentianas 3j. M. Fiant Pilu- las xxx., quarum capiat binas bis quotidie Form, 577. Pilula Tonica cum Cupro. R Cupri Sulphatis gr.x.; Pulv. Rhei 3j.; Extr. Anthe- midis 3 ij.; Syrup. Simp. q. s. M. Fiant Pilulas xl., quarum capiat j. ad iij. (In Leucorrhasa, &c. by Augustin ; and in Gleet, Chorea, &c The Am- moniated Copper is substituted for the Sulphate in Chorea by Niemann.) Form. 578. Pilula Tonica cum Sulphate Zinci. R Zinci Sulphatis 9j.; Extracti Gentians 9iv.; Extr. Anthemidis 9jj. Contunde massam, et divide in Pilulas xl. ; quarum sumantur dua; bis die, cum Haustu infra praescripto. R Infus. Gentianas Composit. 3 x.; Acidi Sulphurici Aromat. TTJxij.; Tincturae Zingiberis 3j. M. Fiat Haustus. Form. 579. Pilula Tonico-Emmekagoga. R Quinine Sulphatis, Massa; Pilul. Galban. Comp., 55 3ss. ; Massa? Pilul. Aloe's cum Myrrha3j.; Olei Junip. Sabina? q. s. M. Divide massam in Pilulas xxx., quarum capiat binas mand nocteque. Form. 580. Pilula Uya Ursi et Rhei. R Pulv. Uva? Ursi, Pulv. Rhei, aa Sss.; Saponis Castil. gr. xxv. ; Mucilag. Acacias q. a. M. Fiant Pilulas xx.; capiat binas bis quotidie Form. 581. Pilula Uya Ursi et Soda. R Pulv. Fol. Uva? Ursi, Sodae Sub-carbon exsic, Sapo- nis Duri, aa 3j- ; Mucilag. Acacia; q. s. M. Fiant Pilulas xl., quarum capiat binas bis teive quotidie APPENDIX OF FORMULAE. —Pilule—Pulvis. XXI Form. 582. Pilula Valeriana Composita. R Pulv. Valerianae gr. xxx. ; Castorei gr. xx. ; Oxidi Zinci gr. xx.; Syrup Simp. q. s. M. Fiant Pilulas xviij., quarum capiat tres ter quotidie. (Dupuy- tren.) Form. 583. Pilula Valeriana et Zinci. R Pulv. Valeriana; 9'j.'> Castorei gr. xv.; Oxid. Zinci 9j.; Olei Cajeputi TT)v. ; Syrup. Simp. q. s. Di- vide in Pilulas xviij., quarum capiat tres quater in die. (Nearly the same as those used by Dupuy- tren.) Form. 584. Pilula Zinci et Myrrha. R Zinci Sulphatis gr. xij.; Myrrhas in pulverem tritae 3 jss. ; Confect. Rosa? q. s. ut fiant Pilula; xxiv. ; i quibus sumantur binas bis quotidie Form. 585. Pil. Zinci cum Myrrha et Ipecacuanha. R Zinci Sulphalis gr. xij.; Myrrha; in pulv. trit. 3j.; Pulv. Ipecacuanhas gr. xvj. ; Extr. Hyoscyami 9j- Syrup. Papaveris q. s. M. Fiant Pilulas xxiv.; e quibus sumatur una ter quaterve quotidhj. Form. 586. Pilula Zinci Sulphatis Composita. (1.) R Zinci Sulphatis gr. xij.; Moschi 3 jss.; Camphorae 3 ss. M. et divide in Pilulas xxxvj., quarum su- mantur dus bis vel ter in die. Form. 587. Pilula Zinci Sulphatis Composita. (2.) R Zinci Sulphatis gr. xij.; Pulv. Ipecacuanhas gr. vj.; Pulv. Myrrha; 9ij.; Extr. Lactuca? 9'jss.; Syrup. Tolutan. q. s. Contunde in massam asqualem, et divive in Pilulas xxiv. Form. 588. Potus Antiphlog. Diureticus. R Decocti Asparagi Officin. ft ij.; Potassa? Nit. 3 ij. ; Spirit. jEther. Nit. 3iij-; Oxymel. Scilla gss. Sit pro Potu communi. Form. 589. Potus Decocti Sarsa Comp. (Tisane de Feltz.) R Antimonii Sulphureti g iv.; Aqua? Com. ft xij.; Rad. Sarsaparillas giij.; Radicis Chinas Orientalis, Corticis Lig. Buxi, Ichthyocollas, aa gjss.; Oxymu- riatis Hydrarg. gr. iij. (Enclose the Antimony in a muslin bag ; and boil the whole, excepting the Corrosive Sublimate, until the water is reduced to one half: strain the decoction, and add the Subli- mate. The properties of this decoction will not be materially affected by omitting the Radix China; and Cort. Buxi; or Sassafras or Guaiacum may be substituted, and Extractum Taraxaci added.) Form. 590. Potus Diureticus. (1.) R DecoctiTriticiRepen. ftijss.; Potassas Acetat. gjss.; Spirit. iEther. Nit. giij.; Aceti Colchici gss.; Vini Xeres gvj.; Oxymel. Scillas gjss. Fit pro Potu communi. Form. 591. Potus Diureticus. (2.) R Decocti Tritici Repentis O ijss. ; Potassae Supertart. gj.; Potassas Nit. 3iij.; Sodas Sub-boracis 3ij.; Sac- char. 3 iv. Sit pro Potu ordinario. Form. 592. Potus Febrifugus. (1.) R Potassas Nitratis3iij.; Seri Lactis O iij.; Succi Li- monis g ijss. M. Sumat pro Potu ordinario. Form. 593. Potus Febrifugus. (Stoll.) (2.) R Pulpa? Tamarindorum gss. vel 3vj.; Potassas Nitra- tis 3 ij. vel 3 iij.; Seri Lactis O ijss. M. Omni bi- horio vasculum coffasanum. Form. 594. Potus Manna et Tamarindorum. R Mannae, Conserv. Tamarind. Indie, 5a gjss.; Seri Lactis ft jss. Digere et cola. Capiat cyathum gubinde Form. 595. Potus Refrigerans. R Acidi Muriatici 3j.; Spirit. ./Ether. Nit. Siiijss.; De- cocti Hordei Comp. g xxiv. M. Capiat cvathuin pro re nata. (In Febrile Affections.) Form. 596. Pulvis Acidi Benzoini et Camphora. R Acidi Benzoici gr. vj.; Camphora; gr. ij.; Sacchari Albi 9 j. M. Fiat Pulvis. Dispens. tales doses tres. Capiat asger altera quaque hora unum. Form. 597. Pulvis Alumina et Ouinina. R Alumina; Sulphatis gr. viij.—xij.; Quininas Sulphatis gr. j.—iij.; Gum. Arab., Sacchar. Albi, aa gr. xij. Fiat Pulvis. Dispens. tales duodecim. Capiat a;ger tertia quaque hoi-a pulverem unum. (In Adynamic Fevers, Haematemesis, Passive Haemorrhages, &c) Form. 598. Pulvis Ammoniareti Cupri cum Zinco. R Cupri Ammoniareti, Oxydi Zinci, 55 gr. ss.—j.; Sacchari Albi gr. x. M. Fiat Pulvis. (Epilepsy and Chorea.) Form. 599. Pulvis Antihydropicus. R Potassa? Supertart. gj.; Potassas Nitratis, Sub-boracis Sodae, 5a 3 ij.; Puiv. Fol. Digitalis 9 j. Tere bene simul, et divide in Cartulas xij.; quarum capiat unam bis terve quotidhs, in quovis decocto vel in- fuso. Form. 600. Pulvis Antimonii et Camphora. R Sulph. Aurat. Antim., Radicis Ipecacuanha?, 55 gr. j.; Camphorae rasas gr. j.—iij.; Sacchari Albi 3j- M. Pulv. Dispen. tales dose$ sex : sumat asger al- tera quaque hora Pulverem unum. (In Chronic Inflammations of the Respiratory Organs.) Form. 601. Pulvis Antimonialis Compositus. R Pulveris Antimonialis 3 v.; Antimonii Sulphureti prascipit. 3j- M. Dosis gr. v. proaetate adulta. Form. 602. Pulvis Antiphlogisticus. R Potassas Nitratis g iij.; Potassas Tartratis g ivss.; Acidi Boracici g j. Tere in Pulv. subtiliss. (In doses of 3ss. in Cutaneous Affections, &c.) Form. 603. Pulvis Antispasmodics. (Stahlh.) R Kermes Mineral, gr. j.; Potassas Nitratis, Potassae Sulphatis, 55 gr. x. Misce bend. Form. 604. Pulvis Aperiens. R Pulveris Jalapae giij.; Submuriatis Hydrargyri gj.; Pulveris Zingiberis 3 ij. Misce. Dosis, a gr. iv. ad gr. xx. Form. 605. Pulvis Asari Compositus. R Asari Folior. exsiccat, g iij.; Origani Folior exsiccat., Lavandula; Florum exsiccat., 5a gj. Simul teren- tur, et fiat Pulvis. (In Chronic Ophthalmia and Toothache, as a sternutatory, &e; to produce a se- cretion from the Schneiderean membrane.) Form. 606. Pulvis Belladonna. R Pulv. Rad. Belladonnas gr. iv.; Pulv. Rad. Glycyrrh et Sacchar. Albi, 5a gr. xxviij. Tere bene simul Dosis gr. iv.—xx., bis in die. Form. 607. Pulvis Belladonna Compositus. R Pulv. Rad. Belladonnas gr. vj.; Pulv. Ipecacuanhas gr. vj.; Pulv. Rad. Glycyrrh., Pulv. Sacchar. Albi, 5a3ss.; Sulphur. Prascipit. 9'j-! Olei Anisi,Olei Succini, 5a TT) iij. Misce. In dosis gr. v.—xx. Form. 608. Pulvis Belladonna Compositus. (Hecker.) R Pulv. Fol. Belladonnas gr. j.—iij.; Moschi, Campho- rae^ gr. v.; Sacchar. Albi 3ss. Tere bend, et divide in Cartulas viij. (Antispasmodic. Pertussis, &c.) Form. 609. Pulvis Bismuthi. R Bismuthi Sub-nit. gr. j. ; Magnes. Calcinat., Sac- char. Albi, 55 gr. x. M. Fiat Pulvis; tertia vel quarta quaque hoi! sumendus. (Odier.) Form. 610. Pulvis Bismuthi Compositus. R Bismuthi Sub-nitrat., Moschi, 5a gr. j.; Extr. Hyos- cyami gr. ss.; Magnes. Sub-carbon, gr. v. M. Fiat Pulvis, tertia quaque hora sumendus. (Marcus.) Form. 611. Pulvis Boracis etSabina. R Putveris Foliorum Sabinas, Pulv. Zingiberis, aa gr. vij.; Sods Boracis 9j- Fiat Pulvis, bis die su- mendus. (In Amenorrhoea with a languid pulse.) Form. 612. Pulvis Calomelanos cum Digitale. R Hydrargyri Submuriatis, Sacchari Albi, 55 gj.; Pul- veris Digitalis gss. Misce. Dosis, a gr. j. ad gr. v. Form. 613. P:ilyis Calumba Compositus. R Pulveris Calumbtegj.; Pulv. Rhei gss.; Sodae Sub- cnrhonatis3iijss. Misce. Dosis, a gr. vj. ad 3 ss. bis de die. XXII APPENDIX OF FORMULAE. —Pulvis. Form. 614. Pulvis Camphora. R Camphors; 3ss.; Sp. Rectif. q. s. Ft. terendo pulv.; dein adde, Sacchari Purificat. x j.; puiv. Acacias 3JS8. M. Fiat Pulvis, et in cart. x. asqualis dis- tribuendus. Form. 615. Pulvis Camphora et Zinci. R Camphora? rasas 9j.; Zinci Oxidi gr. xv. M. In Car- tulas iv. distribue; quarum sumat unam hora somni. (In Epilepsy supervening about pubertv, and con- nected with venereal desires and indulgences.) Form. 616. Pulvis Carminativus. (1.) R Magnes. gr. viij.; Seminum Anisi contus., Seminum Foeniculi cont.,aa gr. ij.; Croci gr. j.; Sacchari Al- bi gr. vij. Contunde bene simul, etsit pulvis. Ca- piat dimidium statim, etalterum post horam. (For the Tennina of Infants, kc.) Form. 617. Pulvis Carminativus. (2.) R Magnes., Sacch. Albi, aa3j.; Pulv. Corticis Canel- las, Semin. Foeniculi cont. gr. xx. ; Olei Anisi TT) viij. Tere bene simul,et divide in Cartulas xij.; quarum capiat unam bis terve quotidie, vel urgent. torminibus. Form. 618. Pulvis Carminativus. (3.) R Sem. Anisi, Sem. Carui, Sem. Coriand., Sem. Foeni- culi, aa g j.; Cort. Auran., Rad. Zingib., aa 3vj.; Creta? Praspar. g jss.; Magnes. g ss. ; Macis Sjss.; Sacchar. Alb. gij.: tere bene simul. Dose, 3j___3 ij. Form. 619. Pulvis Catharticus. R Submuriatis Hydrargyri, Pulveris Cambogias, Pulv. Jalapae, Pulv. Rhei, Pulv. Cinnamomi, aa X ij. Misce. Dosis, a gr. v. ad 9j. Form. 620. Pulvis Cinchona Compositus. R Pulv. Cinchonas gjss. ; Pulv. Mosch. gr. xv.; Cam- phone 9j.; Ammonias Carbon, gr. xxv.; Olei Suc- cini et Olei Menthas aa TTJvj. Misce probe", et di- vide in Pulv. viij. Form. 621. Pulvis Cinchona cum Soda. R Pulveris Cinchonas, Sodae Subcarbonatis, 55 partes asquales. Dosis, a gr. v. ad 9ss. bis terve in die. Form. 622. Pulvis Corticis Cusparia CoMr. R Pulv. Cort. Cusparia? gr. x.; Cinnam. Comp. gr. vj.; Olei Pimenta? TT)j. M. Fiat Pulvis, ter de die capiendus. Form. 623. Pulvis Creta et Rhei Compositus. R Creta; Praspar. gss.; Saponis Amygdal., Pnlv. Rhei, fa 3 j- ; Hydrarg. cum Creta 9 j.; Olei Foeniculi TTJvnj. ; Sacchar. Albi 5ij.: tere bene simul. Ca- piat gr. vj. ad 3 ss. pro dose bis vel ter die. (Pro Infantum Diarrhoea.) Form. 624. Pulvis Cretaceus. R Creta; Preparatae, Acacias Gummi Ver. pulv., aa g iv.; Sacchari Purificati contriti, g iij. Misce. Ft. Pulvis. Form. 625. Pulvis Cyanureti Zinci. R Zinci Cyanureti gr. vj.; Magnesias Calcinatas gr. iv.; Pulvis Cinnamomi, gr. iv. M. Fiat Pulvis quarta quaque hora sumendus. (In Gastrodynia! Dysmenorrhoea, Dyspepsia.) Form. 626. Pulvis Deobstruens. R Gum. Guaiaci 3 ij.; Flor. Sulphur. 3 jss.; Calomela- nos 9j.; Radicis Ireos Flor., Semin. Foeniculi, aa 3jss.; Opii Extr. gr. ij.; Sacchar. Albi gss. Tere ben«i simul, et divide in Pulv. vj. Form. 627. Pulvis Diureticus. (1.) R Potassae Nit., Potassae Supertart., aa 9 iv.; Pulv Scillae gr. viij.; Pulv. Zing. gr. xvj. Misce bene, ei divide in Cartulas viij. Form. 628. Pulvis Diureticus. (2.) R Potassas Supertart. Sjss.; Pulv. Scilla; exsic gr ij • Pulv. Digitalis gr. j. ; Pulv. Zingiberis gr. v. Fiat Pulvis, ter quaterve quotidie sumendus ex theriaci. (Form. 629. Pulvis Eccoproticus R Potassas Supertart. gj.; Magnes. Sub-carbon., Flor. Sulphur., aagss.; Potassa? Nit. 3 ij. Misce, et di- vide in Cart. vj. (In Hmmorrhoids, &x.) Form. 630. Pulvis Ecphracticus. (1.) R Potassas Supertart.gss.; Sodas Sub-boratis, Magne- sia; Sub-carbon., aa 3ij.; Pulv. Flor. Anthemidis, Pulv. Semin. Foeniculi, 5a 3 ij.; Sacchari Albi gss.; Olei Juniperi, et Ol. Anisi, aa TT) xv. Tere bend simul. Capiat 3j.— 3 ij. bis terve quotidie Form. 631. Pulvis Ecphracticus. (Sellii.) (2.) R Magnes. Sub-carbon., Potassas Supertart., Sulphur. Sublimati,Pulv. Rhei, Pulv. Flor. Anthemid., Pulv. Seminum Foeniculi (vel potius Sacchari AlbiSss.; Olei Foeniculi Dul. TT)xxiv.), aa gss.; Olei Junipe- ri TT) xviij. Tere benA simul. Capiat 3j.— 3 ij. bis terve quotidie' ex vehiculo quovis idoneo. (In Obstructions, Jaundice, Piles, &c) Form. 632. Pulvis Excitans. R Boracis Soda; gr. xv.—9j. ; Pulv. Fabinae gr. vj. ; Pulv. Castorei, Pulv. Rad. Zingib. 55 gr. x. M. Fiat Pulvis. Sumat asgra de die Pulveres binos in vino vel cum melle. (Stimulans et emmenagogus in Menstruorum defectu ex Leucophlegmasia. Hartmann.) Form. 633. Pulvis Infantilis. R Rhei Radicis Pulveris3ij.; Magnesia? Suh-carbona- tisSx.; Zingiberis Rad. Pulv. Sss. M. Fiatpulvis. Capiat gr. vij. ad 3ss. pro dose. Form. 634. Pulvis Ipecacuanha cum Calomelane. R Hydrargyri Sub-muriatis 3 j.; Pulv. Ipecacuanhas 3ij.; Pulv. Cinnamomi 3 jss.; Sacchari Albi 3ijss. M. Dosis, a gr. ij. ad gr. x. Form. 635. Pulvis Jalapa Compositus. R Jalapa; Radicis Pulveris gj.; Potassae Super-tartratis gij.; CapsiciBaccarumPulv.gr. xij. Omnia, scor. sim trita, permisce. Dosis a 3ss. ad 5j. mane Form. 636. Pulvis Jalapa et Calomelanos. R Pulv. Rad. Jalapa? gr. xv.—xx.; Hydrarg. Submur. gr. ij.: tere probe1 cum Sacchar. Alb. 3 ss.; et adde Pulv. Acacia? 9j.; 01. Carui TT)ij. M. Fiat Pulvis, statim sumendus. Form. 637. Pulvis Kermes Mineralis. (Hydro-Svl- phuret of Antimony. Berzelius.) R Aquas Pluvial, part. 280; Sub-carbon. Sodas part. 128 ; Sulphureti Antimonii pulver. part. 6. Dissolve the Soda in the water whilst boiling; and boil the Sulphuret in the solution for half an hour, stirring it frequently. Filter the boiling liquor in a vessel containing warm water which had been previously boiled. Decant the water after it is cooled. Wash the precipitate which is formed, first with cold wa- ter, afterwards with warm water, until it passes off quite insipid. Lastly, press it, and dry it in the shade. (Stimulant, Emetic, Diaphoretic. Al- terative, Becchic, Expectorant. Dose j.—iv. gr.) Form. 638. PulvisKermes Minerahs et Camphora. R Kermes Mineral, gr. ij.; Camphora? Subact. in Pulv. gr. iij.; Potassa; Nit. gr. v.—xij. M. Form. 639. Pulvis Kermes Mineralis Camphoratus. R Kermes Mineral, gr. iij.; Camphora? Pulverizat. gr. viij.; Potassae Nitratis gr. xxiv.; Sacchar. Albi3ss. Tere bene, et divide in Pulv. iv. Capiat unam, quater in die. Form. 640. Pulvis Lenitiyus Hypochondriacus. (Klein.) R Flavedinis Cort. Aurant., Radicis Rhei, Potassa Tartratis,aa3ss.; Olei Cajeput. TT) iij. M. Ft. Pul- vis pro una dose. Form. 641. Pulvis Lientericus. R Pulveris Tragacanth. Comp., Pulv. Rhei, aa 3 iij.- Pulv. Ipecacuanha; comp. 3j.; Hydrargyri cumCre^ tasj. Misce. Dosis,a gr. v. ad 3ss. 3tiis, 4tis, vel 6tis horis. Interdum adde Extract. Catechu, &.c. Form. 642. Pulvis Nitro-Opiatus Ipecacuanha, vel Pulvis Doveri. R Ipecacuanha; Radicis contrita? X j.; Opii Crudi contri- ti gr. xiv.; Potassas Nitratis 5 viij. et gr. xv. Tere APPENDIX OF FORMULAE. —Pulvis —Solutio. XXIU simul, et fiat pulvis. (A scruple of this powder contains one grain and a half of opium, two grains of ipecacuan, and sixteen grains and a half of ni- trate of potass.) Form. 643. Pulvis Purgans. R Hydrarg. Sub-mur., Cambog. G. R. pulveriz., Pulv. Zingiberis, aiSss.; Sacchar. Purif. 9j. Tere bend simul; et adde Olei Foeniculi Dulcis TT)xx. Dosis gr. v. ad xv. l Form. 644. Pulvis Refrigerans. (1.) R Acidi Boracici gss.; Potassas Nitratis gj.; Potassa? Supertart. gij. Misce bene Capiat 9j.—5j. pro dose. Form. 645. Pulvis Refrigerans. (2.) R Potassa; Supertartratis pulverizati uncias duas ; Ni- tratis drachmas tres. Misce, et divide in partes xij. asquales. Fprm. 646. Pulvis Resolvens, vel Deobstruens. R Potassae Supertartratis pulverizati g ivss.; Sodas Sub- boracis gjss.; Antimonii Tartarizati gr. iij. Misce probd, et divide in partes asquales viginti. Form. 647. Pulyis Rhei Compositus. R Pulvis Rhei 3 iijss.; Hydrargyri cum Creta 3 j.; Pot- assa? Suhcarbon. 3 jss.; Pulv. Cinnamomi 3 ss. Misce. Dosis, a gr. v. ad 9j. bis vel ter die. Form. 648. Pulvis Rhei et Magnesia. R Pulv. Rhei 9 j.— 3ss.; Magn. Sub-c.arb. gr. xvj.— 3ss.; Semin. Freniculi, Sacchari Albi, 5a gr. x. ; Olei Cassias Cinnam. TTJj. M. Fiat Pulvis. Form. <>49. Pulvis Rhei et Sulph. Potass.*:. R Pulv. Rhei gr. vj.—x.; Potassas Sulphatis gr. x.— 9j- ; Pulv. Sem. Anisi gr. vj.; Olei Foeniculi XI)}. M. Fiat Pulvis, bis terve quotidie sumendus. Form. 650. Pulvis Scammonia cum Calomel. (1.) R Scammon. Gum. Resinas pulv. 3ij.; Hydrarg. Sub- mur. (Calomel), Sacchari Purificati, 55 3 j. M. Fiat Pulvis. Dosis gr. x. ad gr. xx. mane Form. C5I. Pulvis Scammonia cum Calomel. (2.) R Scammon. Gummi Resinas pulv., Hydrarg. Proto- chlorid. (Calomel), Potassa- Supertart., aa 3 ij. Misce bene simul, et sit Pulvis. Form. 652. Pulvis Scammoni *: et Jalapa. R G. R. Scammoneas gr. xij. ; Pulv. Rad. Jalapa? gr. xviij.; Potassae Supertart. gr. xxv. Tere probe in pulverem tenuissimum; dein adde Pulv. Zingi- beris gr. viij.: divide in partes tres asquales, quarum sumat j. secunda vel tertia q. q. hora, donee plene dejecerit alvus. Form. 653. Pulvis Sedativus. R Hydrarg. cum Creta3j.; Pulv. Ipecacuanhas Comp. 9ij.; Magnes. Carbon 3 ss. Tere bend simul. Do- sis gr. iv.—xij., pro Infantibus. Form. 654. Pulvis Senega et Camphora. R Pulv. Rad. Senegas, Sacch. Alb., aa gr. xij.; Cam- phora? rasa? gr. ij. M. Fiat Pulvis. Dispensentur tales doses tres. Capiat asger, interjectis duabus horis, pulverem unum. (In Chronic Affections of the Chest.) Form. 655. Pulvis Soda Compositus. R Sodas Sub-carbon, exsiccat. 3vj.; Hydrargyri Sub- muriatis 3j.; Pulv. Creta; comp. gj. Misce. Dosis, a gr. v. ad 9j. Form. 656. Pulvis Soda cum Hydrargyro. R Sodas Sub-carbon, exsic. giv.; Hydrarg. cum Creta 3 ij. Misce bene Dosis, gr. vj.—ad gr. xij. pro infantibus bis quotidie Form. 657. Pulvis Specificus Stomachicus. (Po- terii.) R Protoxid. Ferri, Antimon. Crud., aa partes asquales vel unam ; Potassas Nitr. part. vj. Detona seu de- flagra, et lava. Form. 658. Pulyis Sulphatis Potassa et Ferri. R Ferri Sulphatis3vj.; Potassas Sulphatis gxij. Tere bene simul, et adde Acidi Sulphurici TT)xxxvj. M. Dosis 9j.— 3 jss. bis, ter, quaterve in die Form.659. Pulvis Sulphatis Quinina Antimoniati. R Quinina? Sulphatis gr. xij.; Antimonii Tartarizat. gr. ij. Misce bene, et divide in partes vj. asquales Capiat unam 2dis vel 3tiis horas inter paroxysmos Form. 660. Pulyis Sulphatis Ouinina et Morphia. R Quinina; Sulphatis gr. iv.—xij. ; Morphina; Sulpha- tis, gr. j—ij. Misce, et divide in dos. iv. vel vj. Form. 661. Pulvis Sulphuret. Aureat. Antimonii, vel Deuto-Sulphuret. Antim. (Berzelius.) R Liquoris restantis post prascipitat. Mineralis Kermes diet, quantum velis; infunde Acid. Acetici quan- tum sufficiat, vel donee nil amplius prascipitationis appareat Lave bene materiam prascip. et exsicca. (N. B. the Precipitated Sulphuret of Antimony of the Lond. Ph. is an admixture of Kermes Min.and the Golden Sulph.) Form. 602. Pulyis Tonicus. R Ferri Sulphatis exsiccati 3iij.; Potassae Sulphatis gij.; Pulveris Cascarilla; giijss. Misce. Dosis,at gr. iij. ad gr. x. bis terve in die. Form. 663. Pulyeres Tonica. R Pulv. Cinchona;, Extr. Glycyrrh., aa 3iij. ;. Pulv. Rad. Valerian. 9U-; Sacchar. Albi3ss. Tere bene: simul, et divide in Cartulas ix. Capiat unam ter quotidie. (Heller and Niemann.) Form. 664. Pulyeres Tonico-Aperientes. R Pulv. Cinchona; gj. ; Pulv. Rhei 3ijss. ; Ammonias Muriatis 3 jss. Misce bene, et divide in Cartulas xij. (Bang et Jadelot.) Form. 665. Pulvis Valeriana et Zinct. R Valeriana? Pulv. gj.; Oxid. Zinci 9j.j Mosehi,Sac~ chari Purif., 55 gr. x.; Orei Cajeputi TT|xii. Tere simul, et divide in Cartulas vj.: quarum. capiat unam ter die. Form. 666. Pulvis Zinci Ottdi Compositus. R Oxydi Zinci gr. xij.; Magnes. Calcinates 3ss.; Pulv. Calumba? 5 j. Tere bend simul, et divide in Cartu- las xij.; quarum capiat unam ter quaterve in die. (DeHaen.) Form. 667. Pulv. Zinci Sulphatis Comp. R Myrrha? G. R. 3 j.; Pulv. Ipecac, gr. vj.; Zinci Swf- phatis gr. vj.; Pulv. Glycyrrh., Sacchar. Albi, 52 3 jss.; Tere optime simul ut fiat Pulvis. Divide in Cartulas ix., quarum capiat unam ter quaterve in die ex theriaca. Form. 668. Sapo Olei Crotonis Tiglii. R Olei Crotonis Tiglii partes ij.; LixiviiSaponariipara j. Contere, et fiat Sapo. Dosis gr. ij. vel iij. Form.669. Sapo Terebinthina. R Potassas Causticas gj.; Liquefac lento igne,et adjice Olei Terebinthinas g iij. Misce ben<5 donee refrix- erat. (Used both externally and internally.) Form. 670. Sapo Terebinthinata. R Saponis Castil. gj.; Olei Terebinthinas g ijss.: adde Solutioni Potassa? Sub-carbon, gij. ; Camphorae rasas9ij. Misce bend. (Used externally and in- ternally.) Form. 671. Solutio Iodina. (Lugol.) No. 1. No. 2. No. 3. R Iodinas - - - - gr. ij. gr. iij. gr. iv. Potassae Hydriodat. - gr. iv. gr. vj. gr. viij. Aquae Destil. - - - ftj. ftj. ftj. Solve. (Chiefly for external use; for injections in Scrofulous Fistulas, &c Form. 672. Solutio Iodina Caustica. (Lugol.) R Iodina; g j. ; Potassas Hydriodatis g j.; Aquas Dei. sti I lata? gij. Solve. Form. 673. Solutio Iodina RurefaCiens. (Luool.) R Iodina? 3iv.; Potassas Hydriodatis gj.; Aquas De- stillata; gvj. Solve. XXIV APPENDIX OF FORMULAE. —Solutio—Tinctura. Form. 674. Solutionis Muriatis Morphina. R Muriatis Morphinae gr. x.; Aq. Destillat. Calid. TT) 1000. ^olve. (Dose twenty-five ininiiue—equal to J of the Muriate.) Form. 675. Solutio Sulphatis Morphina. R Sulphatis Morphinae Ver. gr. iv.; Aqua? Destillata; gj.; Solve. (Ofthe same strength as Laudanum.) Form. 676. Spiritus ^Etheris Muriatici. (Olim, Spiritus Febrifug. Cluttoni.) R Acidi Sulphurici, ftj. gxij. (per pond.); Acidi Mu- riatici ftj. (per pond.); Spiritus Rectificati cong. j. Distilletur liquor, secundum artem. Form. 677. Spiritus Ammonia Anisatus. (PA. Cont. Omn.) R Olei Anisi 3iij.; Spirit. Ammoniae gvj. Solve. Form. 678. Spiritus Castorei Ammoniati. R Castorei contr. giij. ; Croci Stigm. gj.; Herb. Ar- temisia g vj.; Potassa? Sub-carbon. 3 ij. ; Spirit. Tenuior. g xxx. Macera per dies vj. et cola. Dein adde Spirit. Ammonias, Liquoris Ammonias, aa gvj. M. Dosis 3 j.— 3ij. Form. 679. Spiritus Castorei Comp. R Castorei contr. giij.; Croci Stigm. gj.; Herb. Ar- temisia? gvj.; Spirit. Tenuior. ft ijss. Maceraper dies sexi et cola. Deinde adde Olei Anisi, Olei Ju- niperi, Olei Rutas, aa 3 j. M. Dosis 3 ss.—3 jss. 3tiis vel 4tis horis. Form. 680. SpiritusTerebinthinatus. R Olei Terebinthinas g jss.; Spirit. Vini Rect. g vj. Distilla leni cum calore. Dosis in TTJvj.—xx. (In Jaundice.) Form. 681. Spiritus Terebinthinatus Comp. R Saponis Albi g ij. ; Opii g ss.; Spirit. Vini Junip. (vulgo Hollandii) gxijss.; Spirit. Terebinth. Rect. giv.; Camphora? 3 vj. Macera beni, et cola. (Ex- ternally as a Liniment; and internally in Colics and Nephritic Complaints, in doses of from 10 to 20 drops, and in Dropsies.) Form. 682. Suppositorium Opiatum. R Opii Puri gr. ij. ; Saponis Duri Hisp gr. iv. Simul contunde, et fiat massa pro Suppositorio. Form. 683. Suppositorium Plumbi Compositum. R Emplastrum Plumbi part. viij. ; Abietis Resinae cont. part. ij. ; Opii Puri pulveriz. part, ss.—j. Solve emplastrum et resinam; deinde adde Opium, et forma in Supposit. Form. 684. Syrupus Belladonna. R Fol. Belladonna? 3ij.; Rad. Bellad. 3 j.; Sacchar. Albi ftj. Aquae q. s. ut sit decocti ftj. Form. 685. Syrupus Morphina Acetatis. R Morphina Acetatis gr. iv.; Syrupi Clarificati gxvj. Misce ut fiat Syrupus. (In doses of from two tea- spoonsful to a table-spoonful every three hours, or only at bed-time.) Form. 686. Syrupus Morphina Sulphatis. R Morphina; Sulphatis gr. iv.; Syrupi Clarificati gxvj. Misce. (In the same doses as the Acetate. May be given alternately with the Acetate.) Form. 687. Syrupus Papaveris. R Extracti Papaveris Veri (in vacuo praep.)'gj. Solve in Aqua?.Destillata? Ferventis Oj. ; cola, et adde Sacchari Purificati ft ijss. Form. 688. Syrupus Potassa Sulphureti. R Sulphureti Potassae 3j.; Aquas Hysopi vel Fasnicnli g ij. Solve, et adde Sacchar. Albi g iv.; et mace- ra in Bain. Aren. Form. 689. Syrupus Ouinina. R Syrupi Simplicis g viij.; Quininn- Sulphatis pr. xxxij. Capiat Cochlear, ij. minima, bis terve de die. Form. 690. Syrupus Rhei Compositus. R Rad. Rhei concis. et contus. giij.; Fol. Senna-gij.; Canellas Corticis cont. gss.; Semin. Foeniculi cont. gj.; Potassa? ^ub-carhnn. 3ij.; Rad. Zing, concis. 3j.; Aquae Ferventis ftij. Maceraper horas viginti quatuor loco in calido, et cola. Liq. colati adde Mannas giij.; Sacch. Purif. ft iijss. Fiat Syrupus. Form. 691. Syrupus Senna et Manna. R Fol. Senna? giv.; Semin. Foeniculi cont. gjss.; Sera. Anisi cont 3iij.; Radicis Zingiberis 3 jss.; Aquas Ferventis O iij. Digere per horas quatuor; expri- me et cola. Dein colaturae adde Mannas Optima; gvj.; Sacchari Albigxxij.; et fiat Syrupus. Form. 692. Syrupus Sulphureti Soda. R Sodas Purae (cum Alcoh. praep.) 3j-; Aq. Destillat. 3 v.; Liquefac leni igne, et adde Sulphur. Puri quantum solveri potest. R Liquoris gj.; Synip. Communis g xxxj. Misce bene in vase bene obturf- to. (Doses of 3 j.—3 ij. for infant^ gj.—giij. for adults.) Form. 693. Tinctura Acetatis Ferri C«mp. R Acetatis Plumbi g ss.; Ferri Sulph. 3 iij.; Aeeti, Alcoholis, 55 gij.; Aq. Rosar. 3 vju Solve Acet. Plumbi in aceto cum leno igne ; dein adde Sulph. Ferri in Pulv., cujus, post solutionem, infunde Al- cohol, cum Aq. Rosar. permistum. Form. 694. Tinctuba Acetatis MoBParNA C«M- vosjta. R Morphina; Acetatis gr. xvj.: solve in Aqnae DestiT. 3 iij.; Acidi Acetici TT)v.; Spirit. Lavanduf. Co. f. 3 vj. ; Spirit. Myristica?, vel Tinet. Cinnoanem>. Comp. Svij. M. Dosis IT)x.—3j. Form. 695. Tinctura ^Etherea Vajieriana. R Radicis Valerian, pulver. gj. ; LEtlierici Sulphurici non-rectificat. g vj.; Alcohol, rectif. g j. Macera per triduum et cola. Form. 696. Tinct. Aloetica Alkalina. (Saxon Ph.) R Croci Stigmnt. in pulv. pars j. ; Aloes Socot. inpulvr. part, jss.; Myrrhtp pulv. part, ij.; Sub-carb. Potassas part. iv. Misce, et pone in locnm humidum- rrt de- liquescat ; dein infunde Aqua; Ferventis part. xij. Macera per horas duodeeim, et adde Alcoholis Concent, part, duodeeim. Digere leni cum calore per dies tres, et cola. In dos. 3ss— 3J8S- Form. 697. Tinctura Alkalina Potassjb. R Potassas Causticas g ss.; Alcoholis Concent. g iv. Macera per dies septem in balneo arenario. Form. 698. Tinctura Alkalim Stibiata. R Antimonii Crudi gj.; Potassa; Sub-carbon, g ij. Melt in a crucible, and reduce them to yellowish scoria; ; then powder them immediately in a hot iron mortar, and pour upon them rectified Alcohol gvj. Macerate for three days, and filter. Form. 699. Tinctura Amara. R Aloe's Socot. giv. vel v.; Gum. Myrrha;, Mastiches, Benzoes, Rad. Calumba? concis. aa gij.; Rad. Gen- tiana? gjss.; Croci Stigm. gj.; Spirit. Vini Gallics (Brandy) ft ix.; Spirit. Vini Hollandias (Hollands) ft iij. Macera per mensem, et cola. (The celebrat- ed " Drogue Ame>e" of the Jesuits, and an excel- lent tonic and aperient.) Form. 700. Tinctura Ammoniaci Alkalina. R Gummi Ammoniaci giij.; Liq. Potassae Sub-carbon. g ijss.; Myrrhae g j.; Alcoholis Oj. Maceraper dies septem, et cola. Dosis 3ss.— 3JSS- Form. 701. Tinctura Balsamica. (1.) R Olei Terehinthinae gj.; Tinct. Myrrhasgij. ; Tinct. Benzoini Comp. g iv. Macera in loco calido. (In- ternally, and to Indolent Sores, &c.) Form. 702. Tinctura Balsamica. (2.) R Balsam. Tolutan. gss.: Balsam. Peruvian., Styracis Balsam., Flor. Benzoes, Myrrha-, 55 5 iij. ; Croci Stigmat. 3 ij.; Spirit. Vini rect. g xx. Macera per dies tres, et cola. ( Wirtemburgh Ph. nearly.) APPENDIX OF FORMULAE. —Tinctura. XXV Form. 703. Tinctura Balsami Tolutani. R Balsami Tolutan. gj.; Semin. Anisi cont. gj.; Flor. Benzoes gss.: Spirit. Rectificat. O j. Digere, do- nee solvatur Balsamum ; dein cola. Form. 704. Tinctura Belladonna. R Belladonna? Foliorum exsiccatorum g ij.; SpiritQs Tenuioris O j. Macera per dies quatuordecim, et cola. Form. 705. Tinctura Benzoica Anodyna. R Camphora? rasas Sjss.; Ipecacuanha?, Balsam. Tolu- tan. aa g ss.; Acidi Benzoini 55 3 ij.; Opii Puri, Croci Stig., 3 ijss.; Olei Anisi 3j.; Spirit. Vini Ten. ft ij. Macera ben^, et cola. Dosis TT) vj.—xxx. (The Tinct. Opii Benzoica Compos, of the Aust. Phar. and Tinct. Anodyno-Sudonfic. of various for- eign Pharmacopoeias.) Form. 706. Tinctura Brucina. R Brucina? Purae gr. xij. ; Alcoholis (s. g. 837) f. g j. Solve. ( 3 j. contains gr. jss. of Brucine. Dose 3ss.—gij.) Form. 707. Tinctura Calami. R Calami Radicis contusi g iv.; Spiritus Tenuioris O ij. Macera per dies quatuordecim, et per chartam cola. Form. 708. Tinctura Camphora Thebaica. R Opii Pulveriz. 3iij. ; Camphora? 3yj.; Corticis Ca- nellas contus., Croci Stigmat., aa 3 ij ; Caryophyl- lorum, Pulv. Capsici, 5a 3 jss. ; Potassae Sub-car- bon. 3 ij.; Olei Anisi 3jss. ; Spirit. Vini Tenuior. (vel Sp. Vini Gallicae, vel Sp. Vini Hollandias), O ij. Macera leni cum calore per dies viij. ad xij.; dein exprime et cola. Form. 709. Tinctura Caryophyllorum. R Caryophyllorum contus. giij.; Spirit. Vini Tenuior. O ij. Macera bene, et cola. Form. 710. Tinctura Cascarilla Alkalina. R Corticis Cascarilla? cont. giv.; Potassas Sub-carbon. gss.; Spirit. Tenuior. ft ij. Macera bene,et cola. Dosis 3 j -— 3 iij. Form. 711. Tinctura Castorei Alkalina. R Castorei contus. giij.; Potassas Sub-carbon. 3iij. ; Croci Stigm. 3 ij.; Spirit. Rosmarini ft ij. Macera per triduum, et cola. M. Dosis3ss.— 31J. Form. 712 Tinctura Centaurii Cacuminum. R Centaurii Cacumin. (flowering tops of Centaury), g iij.; Spiritus Tenuioris O ij. Digere per dies quatuordecim, et cola. Form. 713. Tinctura Cinchonina Sulphatis. R Cinchonina? Sulphatis gr. xxxvj. ; Alcoholis Rect. giij.; Solve. Dosis 3j.— 3iij. Form. 714. Tinctura Conii. R Conii Foliorum exsiccatorum gij.; Cardamomi Sem- inum coiitusorum 3 iij.; Spiritus Tenuioris Oj. Digere per dies septem, et per chartain cola. Form. 715. Tinctura Digitalis jEtherea. R Fol. Digitalis exsic. et pulv. part. j.; .(Ether. Sul- phur, part. iv. Macera per triduum, et cola. (Do- sis, TTJ xx.—xxx. ter die. (Several continental Pharmacopoeias.) Form. 716. Tinctura Diosma Crenata. RFoI. Diosmas Crenata; 3 ij -; Spirit. Tenuioris Oj. Ma- cera per dies septem, et cola. (Dose 3 j.— 3 iij.) Form. 717. Tinctura Diuretica. R Olei Juniperi 3ss.; ^Etheris Nitrici, Tinctura; Digi- talis jEthereae, 5a X iij. M. (Dosis 3 ss.—3j. ter quaterve in die. Hufeland.) Form. 718. Tinctura Ferri ./Etheraa. R Acidi Muriatici gij.; Acidi Nitrici dilut. gjss.; Ferri Rimaturae. q. s. Dissolve the iron in the acids, evaporate to dryness ; afterwards deliquesce the residue by exposure to the air, and mix the deli- quesced liquor with double its weight of Sulphuric ./Ether; asitating the mixture frequently until it assumes a golden yellow color: then decant, and add double the quantity of rei-tified Alrohnl. This Tincture may he used previously to the addition of the Alcohol, or subsequently. In the state of Tether the dose is from IH to 21 drop- . in that of /Ethe- real Tincture, from 21 to 31 drops ; in diseases of Debility,and Spasmodic XflTections. Form. 719. Ti nctura Fructus Vanilla. R FructGs Vanilla? concis. et contus. pars j.; Alcoho- lis part. vj. Macera leni cum calore per dies octo etcola (Nervine, Analeptic,Excitant,&c. Pfaff.) Form. 720. Tinctura Galbani Composita. R Galbani Gummi Resinas g jss.; Pimento; Baccarum contus. gj.; Cardamomi Semin. contus. gss.; Spir- it. Rectif. O j.; Aquas Destil. O ss. Macera dies quatuordecim, et cola. Form. 721. Tinctura Galla. R Gallarum contus. g ij. ; Spirit. Tenuioris O ij, Ma- cera per dies octo, et per chartam cola. Form. 722. Tinctura Iodina ForTior. R Iodinas 9ij. ; Spirit. Rectificat. gj. Solve, terendo in vase vitreo. 3j. contains five grains of Iodine. Dose II|vj.—xxiv. Form. 723. Tinctura Iodina Mitior. R Iodina; gr. xxiv.; Spirit. Rectif. f. gj. Solve, teren- do in vase vitreo. M ": — J:: Form. 724. M- 5J-gr. iij. Tinctura Lobelia Inflai R Herb. Lobelias Inflatas exsic. g ij.; Spirit. Vini Ten. Oj. Digere per dies decern, etcola. (Emetic in dos^ es of3j.to 3 ij.; Antispasmodic in doses of TT)xx. to 3ss.; and Diuretic in smaller quantities.) Form. 725. Tinctura Myrrha Alkalina. R Myrrha? gj.; Potassae Sub-carb. 3 vj.; Aquas Ferven- tisgiij. Tere; dein macera in balneo aren. ad mel- lis crassitud., et adde Spirit. Tenuior. g x. Macera bene, etcola. Capiat 3J-—3'j- ex Infus. Anthem- idis. (In Scrofula, &c.) Form. 726. Tinctura Nervosa. (Riemerii.) R Spirit. Cornu Cervi Rect. part. iv.: adde eradatim Alcohol. Rect. part, xvj.; Camphorae part.~ij.; Olei Junip. pars j. Solve. Form. 727. Tinctura Nucis Vomica. R Extracti Nucis Vomica? exsic. gr. iv.; Alcoholis (3681 f. gj. Solve. ( 3j. Tinctura? ad gr. ss. Extracti.) Form. 728. Tinctura Opii Camphorata. (Sive Elix- ir Paregoricum Pharm Pristin.) R Camphora? 9ij,; Opii Crud. in pulv., Acidi Benzoici aa3j.; Olei Anisi Xss., Potass. Sub-carbon. 3j. Om- nia in mortario simul optime terentur; paulatimaf- funde Spiritus Tenuioris Oij. : stent in digestione per dies decern : turn adde Radicis Glycyrrhizae in- cisas giv.; digere iterum per dies septem, et cola. Form. 729. Tinctura Opii Composita. (Vel Lauda- num Liquidum Verum Sydenhamii.) R Opii Puri contrit. gij.; Croci gj.; Cort. Canellae, Caryophyllorum, a5 3jss. ; Spirit. Vini Rect. giv.- Vini Hispan. ftj. Macera cum leni calore per dies xvj.; dein exprime et cola. (TTJxv. equal to 1 grain of pure Opium.) Form.730. Tinctura Phellandrii. (Marcus.) R Semin. Phellandrii Aq. gss.; Alcoholis gvj. Macera per horas xxiv., et adde Vini Burgundiaegvj. Ma- cera per dies tres, et cola. Capiat lT|x.—lx. (In chronic Bronchial, and Pulmonary Affections.) Form. 731. Tinctura Quinina Sulphatis. R Qninina? Sulphatis gr. viij.; Spiritus Vini5i. M Fiat Tinctura. OJ Form. 732. Tinctura Quinina Sulphatis Acid. R Quinina? Sulphatis gr. xlviij. ; Tinctura Aurantii Comp. gvss.; Acidi Sulphurici Dilut.3ij. M. Fiat Tinctura. (Dosisgss. ad 3ij.) Form. 733. Tinctura Rhatania. (Sprague.) R Rhatania? Radicis contus. g iij. ; Spiritus Tenuioris SJ!" „Plgere per dies oct0' et Per chartam cola. This Tincture is strongly impregnated with the medicinal virtues of the root. It is a very grate- ful tonic, when given according to the following formula Infus. Rosa? g x . Acid. Sulph. Aromat. TT)xv. ; linct. Rhatania;, Syrup. Rhceados,553j. M. Fiat haustus, ter in die hauriendus. XXVI APPENDIX OF FORMULAE. —Tinctura —Unguentum. Form. 734. Tinctura Rhatania Aromatica. (Sprague.) R Rhatania; Radicis contusas g iij.; Canella? Corticis contusasgij.; Spiritus Tenuioris O ij. Digere per dies decern, et per chartam cola. The following is an agreeable method of exhibitingthis tincture:— R Infus. Aurantii Compositi gvj.; Tinctura; Rhatania; Aromat., Syrup. Zingiberis, 55 g j. Misce. Fiat mistura; cujus sumat coch. ampl. iij. ter in die, urgente languore vel flatu. Form. 735 Tinctura Rhei Anisata. R Radicis Rhei concis., Radicis Glycyrrhiza; concis., 55 g ij.; Seminum Anisi contus., Sacchari Purif. 5a gj.; Spiritus Tenuioris octarios ij. Macera per dies quatuordecim, et cola. Form. 736. Tinctura Rhodii. R Rhodii Ligni ras. giv.; Spiritus Rectificati Oj. Ma- cera per dies quatuordecim, et per chartam cola. Form. 737. Tinctura Sabina Alkalina. R Olei Essent. Sabina? 5ij.; Tinct. Alkalina; gvij.et 3ij. (F. 696.) Solve. Dosis TT)xx.—xxx. Form. 738. Tinctura Senna Amara. R Fol. Sennas part, vj.; Radicis Gentianas concis. part. iv.; Corticis Aurantii exsic. part. ij. ; Cardamom. Semin. contus. part.j. ; Spirit. Vini Ten. partes xiv. Macera per dies quatuordecim, et cola. Form. 739. Tinctura Stramonii. R Daturas Stramonii Seminum contus. gij.; Spiritus Tenuioris O j. Macera per dies quatuordecim, et cola. Form. 740. Tinctura Strychnina. R Strychnina; Purae gr. ij.; Alcoholis (sp. gr. 838.) f gj. Solve. Dosis TT) viij. ad xxx. Form. 741. Tinctura Tabacci. R Fol. Nicot. Tabacci gij.; Alcohol. Rect. Oj. Mace- ra per dies septem ; exprime et cola. Form. 742. Tinctura Tabacci Composita. R Tabacci Foliorum concis. g ss.; Camphorap rasa? 3 ij.; Spirit. Rectif., Aquas Destil., 55 giv. Macera per dies octo, et cola. Form. 743. Trochiscus Catechu Extracti. R Catechu Extract. Pulv. g iij.; Cinnamomi Corticis in pulv. S.jss.; Olei Cinnamomi TT)v.; Sacchari Puri- ficati g xiv. ; Mucil. Tragacanth q. s. Fiat massa in Trochiscos formanda. (Sprague.) Form. 744. Trochiscus Ipecacuanha. R Ipecacuanhas Radicis Pulv. 3 iv.; Sacchari Purifica- ti ftij.; Mucil. Tragacanth. q. s. Misce secundum urteni ut fi.-ft Troch. 480. (Each lozenge contains half a grain of Ipecacuanha. In recent Coughs and in Diarrhoea. Form. 745. Trochiscus Lactuca. R Extract. Lactuca? Concentrat. (Prohart's), Extracti Glycyrrhiza?, Pulv. Acaciae Ver., 5a3iv. Hasc opti- ma terantur simul, et cum aqui fiat massa, in Tro- chiscos formanda. Form. 740. Trochisci Nitro-Camphorati. R Extr. Opii gr. vij.; Camphora; rasas gr. xxyj.; Potas- sae Nitratis gijss.; Sacchar. Purif."3 iij. ; Mucilag. q. s. Misce bene, et divide in Tabulas 1.; quarum capiat vj.—x. pet diem. (Chaussier.) Form. 717. TRocfriseus Potassa Nitratis. R Potassa; Nitratis Pulv. giv.; Sacchari Purificati ftj.; Hasc Optima terantur simul, et cum Mucil. Traga- canth. fiat massa in Trochiscos formanda. Form. 748. Trochiscus Zinci Sulphatis. R Zinci Sulphatis Purif. 3 iv.; Sacchari Purificati ft ij. Hasc optime terantur simul, et cum Mucil. Traga- canth. fiat ma=sa in Trochiscos formanda. (This mass should he equally divided, so that each lo- senge may .cantata gr. \ of the Zinc.) Form. 749. Unguentum Antimonii Tartarizati, vel Febrifugum. (J.) R Antimonii Tartarizati gr. xxv. Solve in Aqua? Des- til. q. s. ; dein adde Antimonii Tartarizati in pulv. suhtiss. redacti 3jss.; Adipis Prasparat. 3x. Misce bene, et fiat Unguentum. (Produces Phlogosis,and its antimony is partially absorbed.) Form. 750. Unguentum Antimonii Tartarizati. (2.) R Antimonii Tartarizati in pulv. 3j.; Adipis Praepar- at. g j. ; Camphora? rasa? et subact. gj. ; Olei Caje- puti IT)xv.; Moschi gr. iij. Misce bend. Form. 751. Unguentum Antimonii Tartarizati. (3.) R Antimonii Tartarizati 3jss.; Adipis Prasparati gj.; Balsami Peruviani TT)xv. M. Form. 752. Unguentum Argenti Nitratis. R Argenti Nitratis Pulv. gr. xl. ; Adipis Praspar. g j. Liq. Plumbi Acet. 3 ij. M. Fiat Unguentum. Form. 753. Unguentum Balsami Peruviani. R Balsami Peruviani, 3j.; Unguenti Elemi Comp. 3 vij. Unguento balneo in aquoso liquefacto ; adjice Bal- samum Peruvianum, et fiat Unguentum. Form. 754. Unguentum Belladonna. (1.) R Belladonna? Fol. recent.; AdipisPrasparata;,55giv. The leaves are to he bruised in a marble mortar; after which the lard is to be added, and the two incorporated by beating. They are then to be gen- tly melted over the fire ; and after being strained through a cloth, and the Belladonna well press- ed, the ointment is to be stirred till quite cold. (Sprague.) Form. 755. Unguentum Belladonna. (Chaussier.) (2.) R Ext. Belladonnas 3ij.; Aquas Destil. gjss. Terecum Unguent. Simp., vel cum Axungia,gijss. M. Form. 756. Unguentum Calomelano3 et Camphora. R Calomelanos, Camphorae, aa 3 j. ; Olei Caryoph. TTJiv.; Unguent. Simp. 3ij. M. Form. 757. Unguentum Calomelanos cum Cam- phora. R Calomelanos 5 ij.; Camphora? 3 j.; Unguent. Simp. (vel Ung. Sambuci Flor.) 3 vj. M. Fiat Unguentum. Form. 758. Unguentum Camphora Compositum. R Saponis Albi rasigjss.; Camphorae rasa; 3 iij. ; Olei Terebinthina? gss. Misce paulatim, et adde Am- monia; 5j. M. Form. 759. Unguentum Comitissjk. R Olei Pimenta?, Olei Oliv.T, 55 g ijss.; Ceras Flavae gj. Solve, et adde Pulv. Pimenta? 3 iij.; Pulv. Gal- larum, Pulv. Nucis Cupressi, Pulv. Sem. Plantagi- nis, Pulv. Fol. To.xicodend., aa Sjss. ; Sulphatis Aluminis3j.; Camphora; rasas3j. Misce bene,et sit Unguentum. Form. 760. Unguentum Cupri Acetatis ; vulgo, Unguentum ./Eruginis. R Cupri Acetatis, Hydrargyri Protochlorid. (Calomel.), aa3j.; Cerati Resina? gj.; Terebinthina? Vulgaris gss. Liquefac Resinas Ceratum in balneo aquoso, et Terebinthinam adjice ; tunc Cupri Acetatem et Hydrargyri Protochloridem (prius commistas) in- sperge, et omnia misce. Form. 7G1. Unguentum Deobstruens. (1.) R Ammonia? Muriatis pulverizat. 3 j.; Unguenti Hy- drarg. Fort, gj.; Extr. Cicuta? Sjss. Misce bene, et fiat Unguentum. (Dr. Hunefeld. Tumours, In- durations, &c.) Form. 762. Unguentum Deobstruens. (2.) R Unguenti Hydrarg. Fort. part. xciv. ; Ammonias Muriatis pulveriz. part. vj. Misce bene. (M. Du- puytren.) Form. 763. Unguentum Galla Opiatum. R Gallarum in pulv. subtil. 3iij. ; Opii Crudi Pulver. 5j. Unguenti Plumbi Acetatis giij. M. Fiat Un- guentum. Form. 764. Unguentum Galla Opio-Camphoratum. R Pulv. Nucis Gallarum 3j.; Camphora? rasa? etsubac- ta? in pauxillo Alcoholis j}j.; Pulv. Opii Puri Potas- sa? Nitratis Pulveriz., aa X ss. ; Adipis Prypar&tae 3iij.; Olei Pimenta? TT) xii.—xvj. Misrp bene\ et sit unguentum ter quaterve in die applicahdum. APPENDIX OF FORMU1 Form. 765. UrtouENTUM Hyto-chloridis Sulphuris. R Sulphuris Hypo-chloridis 3 j.; Unguenti Simplicis gj. Misce bene. (Lepra, Psoriaris, and other chro- nic eruptions.) Form. 766. Unguentum Hydriodatis Potassa. R Potassas Hydriodatis 5 ss.; Adipis Prasparatae gjss. Form. 767. Unguentum Iodina. R Iodina? gr. xij. ; Potassas Hydriodatis 9 iv.; Adipis Suillas recent, praspar. gij. M. Form. 768. Unguentum Iodina Opiatum. R Iodinas gr. xv.; Potassas Hydriodatis 3 j.; Adipis recent, prasp. gij. Misce ben^, et adde Extr. Opii gr. xxx.; Tinct. Opii 3j. Sit Unguentum. Form. 769. Unguentum Iodureti Plumri. R Iodureti Plumbi 3 ij.—3 iij.; Adipis Suil. recentis praspar. gij. Misce. Form. 770. Unguentum Neryinum. R Unguenti Althasa; (vel Ung. Sambuci) g iv.; Liq. Ammonias gj.; Camphora?, Petrolei, Spirit. Tere- binth., 55 gss.; Olei Rosmarini 3ij- j Olei Berga mouse 3j. M. (Hufeland.) Form. 771. Unguentum Populeum. R Gemmae, vel Occulor. Populi Balsamiferae, vel Ni- gra; contus. ft ss.; Butrei recentis ft j. Liquefac si- mul lento igne, vel in balneo arenario, et exprime. Form. 772. Unguentum Populeum Compositum. R Gemma? Populi Bals. vel Nig. recentis ftjss. Con- tunde eum Adipis Praeparat. ftiij., et adde Fol. re- centis Hyoscyami Nigri, Fol. recentis Belladonnas, 55giv. Contunde simul, et macera leni cum ca- lore donee dispareat humiditas; dein exprime, (AH the German Pharmacopoeias.) Form. 773. Unguentum ad Porriginem. (Chap- man's.) R Sulphuris Sublimati, Unguenti Picis Liquidae, 55 gjss.; Saponis Mollis, Ammonias Muriatis, aagss. Misce. Fiat Unguentum. Form. 774. Unguentum ad Porriginem Galeatam. (Banyer's.) R Hydrargyri Protochlorid. (Calomel.) 3 ij.; Aluminis Exsiccat., Plumbi Sub-carbonatis, 55 gss.; Tere- binthina? Venet. 3vj.; Cerati Cetaceigjss. Misce. Fiat Unguentum. Form. 775. Unguentum Proto-Iodureti Hydrar- gyri. No. 1. No. 2. No. 3. R Proto-Iodureti Hydrarg. - 9ij. giij. giv. Adipis Suillas recent. - gij. gij. gij. Misce. Form. 785. Balsamum Odontalgicum. R Opii Puri, Camphora; rasas, 55 9j. : solve in Spirit. Rect. Terebinth. Sjss.; Olei Caryoph. et Ol. Caje- puti 55 3 ss.; Balsam. Peruvian. 3ij. Misce bene. Form. 786. Bolus Camphora Compositus. R Camphora; er. v.—xv.; Hydrarg. Submur. gr. v.— xx.; Opii Puri gr. j.—iij.; Conserv. Rosarum q. s. ut fiat Bolus. Form. 787. Bolus Camphora et Hyoscyami. R Camphors; Subactae gr. v.—xij.; Extract. Hyoscyami gr. v.—x.; Potasses Nitratis gr. v.—viij.; Conserv. Rosar. q. s. M. Fiat Bolus, hora somni sumendus. (In Puerperal Mania, and in Mania after evacua- tions, and accompanied with cold sponging the head.) iE. — Unguentum — Vinum. XXVU Form. 776. Unguentum Sulphureti Iodina. R Sulphuris Iodinas gr. xv.—xxv.; Axungiasgj. M. Form. 777. Unguentum Zinci Iodatis. R Zinci Iodatis 3j.; Adipis Prasparatae gj. M. Form. 778. Vinum Aloes Alkalinum. R Aloes Socot., Croci Stigm., Myrrhas, aa gj.; Potas- sa? Sub-carbon, gij.; Vini Alb. Hispan. ft ij. Ma- cera per dies xij. et cola. Indus. 3ij.— gj. (InPy- rosis, Dyspepsia, &c.) Form. 779. Vinum Aloes et Soda Compositum. R Sodae Sub-carbonatis giij.; Ammonia? Carbonatis Sivss.; Myrrhae 3vj.; Aloe's Extracti 3vJ-i Vini Albi (Sherry, Anglice), f. gxxiv. Macera per dies septem, et cola. (The dose is from one fluid drachm to half a fluid ounce.) Form. 780. Vinum Anthelminticum. R Extr. Aloe's, Assafoetida?, Radicis Gentianae, Cam- phorae, Corticis Aurantii sic, Castorei, aa 3j.; Cro- ci Stig. V) j.; Spirit. Vini Ten. ft iij.; Vini Oporto ft iij.; Macera leni calori, et post horas xij. cola. Capiat 3j-— Z "j- In Decocti Anthemid., &c. Form. 781. Vinum Diureticum Anti-arthriticum. R Potass;e Sub-carbon. 3 ijss.; Pulv. Rhei, Juniperi Baccar. cont., 55 3 jss.; Rad. Zedoarii concis. et contus. 3 ij- ; Canella; in pulv. 5 iij-; Scillae Rad. exsic. 3J- j Vini Xeres g xxxij. Macera ben£, et cola. gj.— gij. bis terve quotidie. Form. 782. Vinum Ferri Citratum. (Phar. Wirtem. et JVicmann.) R Ferri Limaturae giv.; Aurantia Amara,No. iv. Ex- corticatis Aurantiis, cortices et succulenta caro fructuum cum Limatura Ferri in pastam redi- gantur mortario in lapideo. Dies post tres infunde Vini Madeirensis g xij. ; Tincturae Aurantii g ij. Macera per diem integrum, et cola. Dosis 3*s.— 3jss. Form. 783. Vini Ferri Comp. R Sub-carbonatis Ferri g j., vel Ferri Fragmentor. g iij. ; Radicis Calami Arom. g ij. Infunde Vini Albi Hispanici ft ij., et stent in digestione per dies 6—8. Exindt? sumantur quotidie uncia una vel duas, et suppleatur vinum. Form. 784. Vinum Quinina. R Vini Madeirensis g viij.; Quinina? Sulphatis gr. xvj. Form. 783. Bolus Catechu. R Catechu Extr. gr. viij.—xij.; Confect. Aromat. gr. viij. Syrup, q. s. M. Fiat Bolus. Form. 789. Bolus Moschi et Camphora. R Moschi gr. v.—x.; Camphora; rasae gr. iij__viij.; Spirit. Rect. TT) j. ; Confect. Ros. Gall. q. s. Cam- phoram cum Spiritu tere, et deinde, secundum ar- tem, fiat Bolus. Form. 790. Electuarium Deobstruens. R Potassas Supertart. gj.; Sub-boracis Sodas 3iij.; Sul- phur. Prascipit. 3 vj.; Confectionis Sennas gjss.; Sy- rup. Zingiberis 3 vj.; Syrup. Papaveris 3 iij. M. Fiat Electuarium, cujus capiat cochlearia duo min- ima omni nocte. ADDENDA TO APPENDIX OF FORMULAE. XXV111 ADDENDA TO APPENDIX.—Electuarium —Haustus. Form. 791. Electuarium Ferri Sub-carb. R Ferri Subcarbonatis, Syrupi Zingiberis, 55 g ss. j Confectionis Aurantiorum g ij. M. Fiat Electu- arium, de quo capiatur moles nucis moschatae bis vel ter quotidie. Form. 792. Emplastrum Antimonii Tartariz. R Emplast. Picis Comp. quantum velis; Super Alu- tam extende, et Antimon. Tartar, pulvere leviter insperge. Fiat Emplastrum. Form. 793. Emplastrum Picis et Petrolei. R Picis Liquids; g ij.; Galbani gj.; Sulphuris, Succini, aa 3 ij.; Semin. Cumini cont., Pulv. Flor. Anthe- midis, 5a 5jss.; Petrolei gss. Liquefac Galbanum cum Aceti q. s., eumque misce cum Pice liquida ; dein adde alia, et misce bend. Form. 794. Enema Commune. R Sodas Muriatis 3 vj.—gj.; Decocti Avenasgx.; Olei Lini gjss.—g ijss. M. Fiat Enema. Form. 795. Enema Ipecacuanha. R Rad. Ipecacuanhas Contrita? 3 j. ; Aquae Ferventis g x. Macera per horam et fiat Eneina. Form. 796. Fotus Conii. R Conii Folior. exsic. g j. Coque ex aquas Oijss. ad Oij., et cola. Form. 797. Gargarisma Capsici. R Capsici Baccarum contus. gr. xv.; Aquae ferventis g ix. Infunde per horas tres, et cola. R Liquoris Colati gvijss.; Acidi Muriatici TT)xxv. ad TTJxxxv.; Tinct. Myrrha? 3iijss.; Mellis Rosa? gss. M. Fiat Gargarisma. (The Borax Sodae, Extractum Catechu, or any other astringent, may be substi- tuted, according to circumstances, in the place of the Muriatic Acid.) Form. 798. Gargarisma Cum Chlorureto Soda. R Liquoris Chloro-Sodaici (Labarraquii) 3xij.; Aqua? Destillat. gvj.; Mellis gss. M. Fiat Gargarisma saspe utendum. Form. 799. Gargarisma Stimulans. R Infusi Petal. Rosas Gallica? g vjss ; Acidi Muriatici Diluti V)ij.; Tinct. Capsici Sjss.; Mellis 3 iij. Fiat Gargarisma saspe utendum. Form. 800. Gargarisma Zinci Sulphatis. R Zinci Sulphatis 3j.; Aqua? Rosas f gvij.; Oxymellis Simpl. f gj. M. Fiat Gargarisma frequenter uten- dum. Form. 801. Gutta jEtherea. R Camphora; rasae 3 j-; Spiritus ^Ether. Nit. f gss.; Tinct. Valeriana? f gij.; Aquas Fontana?gjss. M. Capiat 3ss. ad 3ij. pro dosi. Form. 802. Gutta ^Etheris Arsinthii. R Olei ^Ether. Absinthii 3ss.; Spirit. ./Ether. Sulphuri- ci, et Spirit. Vin. Rect., 553 ij. M. Sumat asger gut. xx.—xxx. omni hora, aut omni bi aut trihorio. Form. 803. Gutta Antispasmodica R Spirit. Ammon. Succin.gvj.; .rEther. Sulphur, gj.; Olei Anthemidis 3j.; Tinct. Opii Comp. 3 ij.; Extr. Papaveris Albi 3j. M. Capiat TT) xx.—xiv. in cya- tho Infus. Anthemidis, vel Infus. Flor. Sambuci, vel Decoct. Hordei Comp., &c. (Grimaud.) Form. 804. Gutta Odontalgica. R Opii Puri et Camphora? 55 gr. x. Solve in pauxillo Alcoholis, et adde Olei Caryophil. 3j.; Olei Caje- puti Sj- Misce bend. Form. 805. Haustus Acidi Oxymuriatis. R Acidi Oxymuriatis Fluid. 3 ss.; Aquas Destillat. 3 xij.; Syrup. Papaveris Albi 3 ss. M. Fiat Haus- tus 5tis vel 6tis horis sumendus. Form. 806. Haustus Arsenicalis. R Confectionis Aromatica? '£)}.; Aqua? Menthas Saliva f gj.; Tincturae Opii, Liquoris Arsenicalis, aa Tf|vj. M. Fiat Haustus, ter quotidie sumendus. Form. 807. Haustus Balsami Peruviani. R Balsami Peruviani TT)v. ad V)j.; Mucilaginis Acacias 3jss. Tere simul; et adde, Mist. Camphora; 5 vj.; Spiritus Anisi 3 jss. ; Aquae Anethi (vel Aq. Cin- nam.) gss Fiat Haustus, ter quaterve de die ca- piendus. Form. 808. Haustus Belladonna et Cinchona. R Decocti Cinchona? 3 xiv.; Extracti Cinchona; gr. x.; Tinctura; Belladonna? TTJxx. (See F. 704.) ; Tinc- turae Aurantiorum 3jss. >I. Ft. Haustus, ter in die capiendus. Form. 809. Haustus Diaphoreticus. R Vini Ipecacuanhas, Vini Antimonii Tartarizati, aa TT)x.; Liq. Ammon. Acet. 3 ijss.; Mist. Camphorae gj.; Tinct. Hyoscyami TT)xxv.; Spirit. .-Ether. Nit. 3ss.; Syrup. Aurantii3j. M. Fiat Haustus,quar- tis horis capiendus. Form. 810. Haustus Emmenagogus. R Decocti Aloes Comp. gj.; Sub-boratis Sodae 9j.; Tinct. AioSs Comp. gj.; Tinct. Castorei 3j.; Tinct. Croci 3 ss.; Aquae Cinnam. 3 ij. Fiat Haustus omni nocte sumendus. Form. 811. Haustus Hyoscyami et Anisi. R Extracti Hyoscyami gr. iij.—v.; Tinct. Scilla?TT)x.— xij.; Spirit. Anisi 3jss.; Aquae Anisi gjss.; Acidi Nitrici TT) viij. Fiat Haustus, horis tertiis vel quar- tis durante paroxysmo Dyspnoea?, &.C. capiendus. Form. 812. Haustus Nervinus. R Spirit. Ammon. Foetid., Spirit. Colchici Ammonia- ti, Spir. ^Ether. Nit., 55 3 ss.; Liquor. Ammonias Acet. 3'j-i Mist. Camphorae gj.; Syrup. Croci 3j. M. Fiat Haustus, bis terve in die sumendus. Form. 813. Haustus Pectoralis. R Balsam. Peruvian, (vel Bals. Tolutan.)3ss.— 3ss.; Olei Anisi TT|v.—x.; Extr. Conii gr. iij.—vj.; Mu- cilag. Gummi Acaciae 3ij- j Aquae Pimentae et Aq. Funiculi 55 gss. M. Form. 814. Haustus Quassia et Ferri. R Tincturae Ferri Muriatis TT)vj.—xij.; Infusi Quas- sia?, Aqua? Cinnam., 55 f 3 vj.; Tinctura? Calumba) f 3 j. M. Fiat Haustus, mane' et meridie sumendus. Form. 815. Haustus Salinus. R Potassas Sub-carbonatis 9j.; Succi Limonum recen- tis f. 3ss.; Mistura? Camphorae f g j.; Potassae Ni- tratis gr. x.; Syrupi Rhasados f 3j. M. Fiat Haustus, quarta quaque hora sumendus. Form. 816. Haustus Salinus Aromaticus. R Potassas Subcarbonatis ►) j.; Succi Limonum recen- tis f gss. vel q. s. ; Aquae f gj.; Spirit. Myristicas, Syrupi Aurantii, aa f 3j. M. Form. 817. Haustus Salinus Demulcens. R Mist. Amygdal. Dulc, Mist. Camph., aagss.; Vini Ipecac. Tt)x.; Potassas Carbonatis gr. xv. ; Syrup. Scilla? 3 j. M. Sumatur cum Succi Limonis coch. uno amplo, in effervescentia? impetu ipso. Form. 818. Haustus Salinus Sedativus. R Potassa? Nitratis gr. vj.—xv.; Sodas Sub-carbon, gr. x.—3j«s.; Tinct. Hyoscyami 3 ss. (vel Tinct. Cam- Ehorae Comp. pristin. 3J0; Mist. Camphoras, Aquas lenth. Virid., 55 3vi. Syrup. Croci 3ss. M. Fiat Haustus tertiis vel quartis horis sumendus. Form. 819. Haustus Sedativus. R AmmoniK Catbonatis gr. xv.; Aquas Destillat. gj.; Spirit. Myristicas 3J-; Syrup. Aurantii gss. ; Extr. Conii gr. iij.—vj. Fiat Haustus, ter quaterve quo- tidie' sumendus, cum Succi Limonis recentis coch- leare uno magno, in effervescentia; impetu. Form. 820. Haustus Sedativus ccm Magnesia. R Magnes. Sub-carb. 3ss.; Aqua? Menth. Virid. 3xj.; Spirit. Anisi 3 jss. ; Olei Caryoph. TTJ j.; Syrup. Zingib. 3 ss. M. Fiat Haustus. Form. 821 Haustus Sedativus et Refrigerans. R Potassas Nitratis gr. x. ; Tinct. Opii TT) vj. ; Syrup. Papav. Alb. 3 ij.; Mist. Camphorae 3x. Misce. Fiat Haustus, omni 6ta hora sumendus. ADDENDA TO APPENDIX.— Haustus —Mistura. XXIX Form. 822. Haustus Tomcus Alkalinus. R Potassae Carbonatis }) j.; Infus. Gentianas Compos., Aquae Pimentae, 5af3vj.j Tinctur. Rhasi f 5j. M. Fiat Haustus, meridie et hora somni sumendus. Form. 823. Infusum Angelica Sylvestris. R Radicis Angelic. Sylvest., Calam. Aromatici, 55 5 iij.: infunde cum Aqua? Font. Ferventis g vj. Stent per horam in Vase clauso; cola, et adde Liquoris Ammonias Acetat. gjss.; ./Etheris Sulphur. 3jss.; Syrup. Cort. Aurantii 3'U- M. Fiat Mist. Ca- piat a?ger qualibet hora cochlear, unum. Form. 824. Infusum Anisi Compositum. R Seminum Anisi 3jss.; Foliorum Melissa-Officinalis 3 j. ; Aquas Communis calidas ft ij. Infunde per quadrantem horas : cola; et adde Sacchari Albi, quantum libet. Form. 825. Infusum Galla. R Gallarum contus. gij.; Aqua? Ferventis ftj. Macera per horas viginti quatuor, et cola. Form. 826. Infus. Serpentaria. R Radicis Serpentaria; 3 iij.: infunde cum Aqua- Fer- ventis g viij., ebull. paul. Cola, et adde ./Ether. Sulphur. 3 ij.; Tinct. Camphoric 3j. M. Capiat asger qualibet hora cochleare unum. Form. 827. Infusum Turionum Pini Abietis. R Turion. Pini Abietis 3 iij.: infunde Aq. Fervidas g x. per semi-hor.; dein exprime, cola, et adde vel Po- tassae Sub-carb., vel Potassae Sulphatem, vel Spir. .'>}• i Sacchar. Alb. gss.; Gum. Acaciae 3 ijss.; Olei An- themidis TT)xv. ; Extr. Iluinuli 3js^-i Extr. Cate- chu 9 j. ; Pulv. Canella; Cort. 5j- i Aquas Menth. Virid.gvjss. Misce bene. Capiat cochleariadua tertiis vel quartis horis. Form. 840. Mistura Antidysenterica. (2.) R Mist. Camphorae g v.; Liq. Ammon. Acet. gij.; Spir- it. ./Ether. Nit. 3 ijss.; Vini Ipecacuanhas 3 ijss.; Tinct. Humuli 3iijss. ; Extr. Humuli V)j. ; Syrup. Papaveris 3 iij. M. Fiat Mist., cujus capiat coch- learia duo larga tertia quaque hora. Form. 841. Mistura Anti-Icterica. R Potassas Acetat., Extract. Taraxaci, 5a g ss. ; Extr. Conii gr. x.—xx.; Aqua? Foeniculi gvjss.; Syrup. Sarsa? et Syrup. Senna? 5a gss. M. Capiat cochlear. ij. vel iij. ampla 4tis horis. Form. 842. Mistura Assafcetida et Conii. R Assafoetida? 3 U : solve in Liquoris Ammonia? Acet. g jss.; Aquae Foeniculi giijss. ; Extr. Conii 5 j.— 3ss.; Syrup. Senegas gss. Misce. Form. 843. Mistura Bals. Perutiawi Comp. R BalsamiPeruvianiVer.Sij.; Mellis Despumati 3vj. Misce, et adde gradatim, Misturas Myrrha; (F.422.) gvj.; Tincturae Aurantii gj. Misce. Fiat Mistura, cujus capiat coch. j. ad iij. ter quaterve in die. Form. 844. Mistura Belladonna. R Extracti Fol. Belladonna; gr. ij. ad iv.; Moschi opti mi gr. vj. ad xij. ; Sacchari Albi, satis quantum ut terendoobtineatur pulvis congener: deinde adde, paulatim miscendo, Infusi frigidi Rad. Valeriana: giv ; Spirit. ./Ether. Sulphur. 3j-j Syrup. Papave- ris 3 iij. M. Capiat asger cochlear, ij. vel iij. lar- ga 3tiis, 5tis, vel 6tis horis. Form. 845. Mistura Camphora Ammoniata. R Camphora? Bj.; Alcoholis TT)vj.: tere, et adde Mos- chi 3 ss.: tere cum Sacchar. Albi 3j.; Mist. Amyg- dal. Dulc. giv.; Spirit. Amnion. Arom. 3ij.; Syrup. Aurantiar. gss. M. Capiat gss.— gj. 4tis horis. Form. 846. Mistura Cardiaca. R Potassa? Carbonatis 5 jss- > Misturas Camphorae fgvss.; Confectionis Aromaticas 3 ij.; Spiritus My risticasfgss. M. Fiat Mistura, cujus sumatur coch learia tria ampla cum cochleare nno Succi Limo- num recentis, in actu effervescentia;. Form. 847. Mistura Chloridis Potassa et Soda. R Liq. Chlor. Soda; gss.; Aquas Destil. giv. ; Potassa? Chlorid. 3j. ; Aquas Pimenta; giijss. M. Capiat coch. j.—iij. 2dis, 3tiis, vel 4tis horis. Form. 848. Mistura Cinchona cum Acido. R Infus. Cinchonas gvij.; Acidi Muriatici Diluti 3j.; Tinct. Capsici 3 ss.; Tinct. Croci, vel Serpentaria?, 3iij.; Syrup. Papaveris3ijss. M. Fiat Mist, cujus capiat coch. ij. vel iij. ampla, 4ta q. q. hora. Form. 849. Mistura Cinchona et Acidi Sulph. R Decocti Cinchona; g vss.; Acidi Sulphur. Aromat. 3j.; Tinct. OpiiTTfxxx. M. Capiat tertiam partem ter quotidie. xxx ADDENDA TO APPENDIX.— Mistura — Pilul/e. Form. 850. Mistura Copaiba. R Copaibas Ver. 3iij.; Mucilaginis Acacia? Ver. gjss. Misce. Addegradat. Aquas Cinnamomi giijss.; So- da? Sub-carbonatis 3 j.; Spiritus Lavandula? Com- posite 3 ij. Tinctura; Opii 3j. ad 3 jss. Misce. Fiat Mistura, cujus capiat unc. j. ter quaterve in die, agitat. phial. Form. 851. Mistura Cydoni a Infusi Comp. R Seminum Cydonia? contus. 3 ij ; Radicis Glycyrrhizae contus. g j. ; Fici Carica; Fructus g j.: Aquae O j. Coque leni igne per minuta hora; decern ; dein cola. Hujus Decocti g vjss. Potassae Supertart. 3ij. Sub- boratis Sodas 3j.; Spirit. ./Ether. Nit. 3 ij.; Syrup. Mori vel Syr. Limonis gss. M. Fiat Mist. Form. 852. Mistura Decocti Cinchona. R Decocti Cinchonas 3 vss.; Tinct. Cinchonas 3 iij. ; Confect. Arom. Bjss.; Spirit. Ammon. Arom. 3jss. M. Form. 853. Mistura Decocti Genista. R Spartii Scop. Cacumin. g j. ; Aquas O j. coque ad g viij., et adde Acetatis Potassa; Sijss. Spirit. Ju- nip. Comp. 3 vj. M. Capiat Coch. ij. vel iij. larga, ter quotidie. Form. 854. Mistura Diaphoretica. R Vini Ipecacuanha; 5 jss.; Spirit. ./Ether. Nit. 3 ijss.; Liq. Ammon. Acet. gij.;Liq. Antimon. Tart. Sjss.; Mist. Camphorae givss.; Syrup. Papaveris 3iij. M. Capiat cochlear, j. vel ij. tertia quaque horS. Form. 855. Mistura Diaphoretica Anodyna. R Mist. Superscript. (F. 854.)gvijss.; Tinct. Hyoscy- ami 3 jss. (vel Tinct. Camphorae Comp. 3 vj., vel Extr. Conii Sss.) Fiat Mist. Form. 856. Mistura cum Digitale et Kehm. Miner. R Kermes Mineral.gr. vj.; Mucilag. Acacias giij.; In- fus. Digitalis giv.; Syrup. Althasasgj. M. Capiat cochleare unum amp. omni bihorio. (In Pneumo- nia, Pleurisy, &c. by Brera.) Form. 857. Mistura Expectorans. R Assafoetid.9ijss.: trituratione solve in Aquas Menth. Virid.Sivss.; et adde Vini Ipecacuanhas 3j.; Spir- it. ./Ether. Nit. 3 ij.; Tinct. Castorei 3 ij.; Syrup. Tolutan. gj. Fiat Mist, cujus capiat cochleare unum amplum 2dis vel 3tiis horis. Form. 858. Mistura cum Hydriodate Potassa et Acido Prussico. R Aquas Destil. g ivss.; Solutio Hydriodatis Potassa? TT) xv.; Acidi Prussici Medicin. TT) x—xij.; Succi Inspissati Lactuca; gr. xij.; Syrup. Althasa? gj. M. Capiat 3ij.— 5 iij. omni hora, vel g ss. omni bihorio. Form. 859. Mistura contra Hydropem. R Fol. Digitalis 3 j. ; Corticis Cinchonas Pulv. 3 vj. ; Aquae Ferventis g xij. Macera per horam, et cola. Liquori colati adde Potassa? Supertart. 3 iij. ; Sub- boratis Soda? 3j. ; Tinct. Cinnam. Co.; Spirit. Ju- nip. Co., aaSiij. ; Tinct. Opii Co. TT)xxv. M. Ca- piat cochlearia duo larga ter quaterve quotidie. (Nearly as Augustin.) Form. 860. Mistura Infusi Anthemidis Comp. R Flor. Anthemidis X ij.; Pulv. Rad. Valerian. 3iij.; infunde Aqua; Fontan. calidae g viij. Macera pau- lisper, et cola. R Hujus Infusi gvij.; Tinct. Camphora; Comp., Tinct. Castorei, aa 3ij.; Syrup. Aurantii gss. M. Capiat asger qualibet hora cochleare plenum. Form. 861. Mistura Infusi Calumba et Hyoscyami. R Infus. Calumbas gvijss.; Tinct. Hyoscyami 3 ij.; So- dae Sub-carbon. Sjss.; Tinct. Aurant. Comp. 3ijss.; , M. g ss. ter quaterve in die. (In diseases of Irri- tability.) Form. 862. Mistura Infusi Calumba Comp. R Infus. Calumbas g iv.; Aquas Mentha; Piper, vel Aqua; Anethi giij.; Spirit. Anisi 3ij.; Liquor. Am- monias vel Liquor. Potassas 3 ij. ; Syrup. Cort. Aurantii g ss. M. Form. 863. Mistura Infusi Valeriana. R Infus. Valeriana g vss.; Liq. Ammonias Acet. gjss.; Liq. Antimonii Tart. 3 jss. ; Tinct. Hyoscyami 3jss. ; Aq. Pimenta; gss. ; M. Fiat Mist, cujus capiat asger altera quaque hora cochlearia duo. Form. 864. Mistura Muriatis Ammonia. R Ammonias Muriat. Sjss.; Acidi Muriatici 3s8-> De- cocti Hordei Comp. ftj. M. Capiat cochlear, iij. ampla 2dis vel 3tiis horis. Form. 865. Mistura Salina Sedativa. R Potussa? Nitratis,Sss.— Sij.; Sodas Sub-carbon. 3)• — 3 ijss. Mist. Camphorae, Aqua? Menth. Virid., aa giijss.; Extr. Humuli ;-)ij.; Syrup. ZingeberisSiiJ. M. Fiat Mist. (Interdum adde Tinct. Hyoscia- mi, vel Tinct. Camphorae Co.) Form. 866. Mistura Sedativa. R Mucilaginis Acacias f g j.; Olei Amygdalarum, Syrup. Papaveris Albi, 55 f gss.; Tinct. Hyoscyami f Sjss.; Vini Ipecacuanhas f'jij.; Aquas Destillata? fgvss.; Acidi Citrici q. s. ad gratam acidulat. Misce. Fiat Mist, cujus sumat coch. unum medium subinde. Form. 867. Mistura cum Soda Sub-borate. R Mist. Camphora;, Aq. Anethi, 55 g ijss.; Sub-boratis Soda; 9 ij.; Vini Ipecacuanhas Sjss.; Syrup. Papa- veris Sjss. M. Fiat Mist, cujus capiat cochlearia ij. vel iij. quartis horis. Form. 868. Mistura cum Soda Tartarizata. R Sodas Tartarizata? Pulver. 3vj.; Misturas Amygdala? fgvss.; Spiritus Myristicas fgss. M. Sumatter- tiam partem secundi quaque hora. Form. 869. Mistura Stomachica. (1.) R Calumbas Radicis contusae 3 ss.; Calami Aromatici cont. 9 j.; Capsici Annui Bac. cont. gr. x.; Aquas Ferventis f g viij. Macera per horas duas ; deinde cola. R Liquoris Colatura? gvss.; Liquoris Potassas Subcnr- bon. 3ijss.; Tinct. Myrrhae 3j.; Extract. Conii gr. xv.; Syrup. Cort. Aurantii 3 ij. M. Form. 870. Mistura Stomachica. (2.) R Infus. Cascarilla; 3vij.; Sodas Sub-carbon. 3 ijss.: Tinct. Calumbas gss.; Alther. Sulphur. Sij.; Tinct. Aurantii Co. 3 iij. M. Fiat Mist., cujus capiat cochlear, ij. larga bis quotidie. Form. 871. Mistura contra Tenesmum. R Mist. Camphorae g v. ; Liq. Ammon. Acet. g ij.; Tinct. Humuli 3 ijss.; Tinct. Camphorae Com. gss.; Extr. Humuli 3ss.; Syrup. Papaveris giij. M. Fiat Mist., cujus capiat cochlearia duo larga tertia qua- que hora. Form. 872. Mistura Tonico-Aperieks. R Decocti Cinchonas, Infus. Senna?, 55 g iijss.; Potassae Sulphatis 3iijss.; Tinct. Senna? gss. M. Fiat Mist. cujus capiat cochlear, iij. larga bis quotidie. Form. 873. Mistura Tonico-Deobstruens. R Extr. Taraxaci 3 iij.; Extr. Gentianae 3j.; Sodas Sub- carbon. 3 j.; Aquas Aurantii gvij.; Spirit. ./Ether. Sulph. Co., Syrup. Rosae, aagss. M. Capiat gj. — gjss., ter die. Form. 874. Mistura Zinci Composita. R Zinci Sulphatis gr. iv. ad vj.; Infus. Rosarum Comp. gvij.; Vini Ipecacuanha; Sjss.; Extr. Lactuca? 9jss.; Syrup. Tolutan. 3U- M. Fiat Mist, cujus capiat cochleare unum vel duo larga tertiis vel quartis horis. Form. 875. Mistura Zinci Opiata. R Aq. Rosarum, Aq. Cinnamom., 55 g iijss.; Zinci Sul- phatis gr. vij.; Tinct. OpiiTT)xxxvj.; Tinct. Cinna- mom. Co. 3 'j-; Syrup. Aurantii 3 jss. M. Fiat Mist, cujus capiat cochlearia ij. ampla bis die. Form. 876. Pilula Alkalina Anodyna. R Sodas Sub-carbon, exsic. 3j.; Saponis Duri Sj.; Ex- tracti Hyoscyami 3 ss.; Olei Junip. q. s. M. Fiant Pilulas xl., quarum capiat binas vel tres omni noc- te. (Nephritic and Calculous Affections.) Form. 877. Pilula Aloes cum Ferro Composita. R Aloes 3 ij.; Assafoetidae et Myrrhae, 55 3 ss- > Ferri Sulphatis 3j.; Caryophyllorum in pulv. ►) j.; Pulv. Capsici gr. xxvj.; Bals. Canad. q. s. M. Fiant Pilulae lxvj., quarum capiat binas vel tres pro dose. (Chlorosis, &c.) Form. 878. Pilula Anodyna. R Pulv. Jacobi Veri gr. iij.; Extr. Stramonii gr. ss.; Ext. Hyoscyami (vel Conii) gr. iij. Fiant Pilule; ij. hora somni sumenda;. (In painful Cutaneous Eruptions.) ADDENDA TO APPENDIX. —Pilule. xxxi Form. 879. Pilula Anodyno-Altehativa. R Camphorae rasae gr. vj.; Hydrarg. cum Creta gr. xij.; Sodas Sub-carbon, exsic. gr. x. ; Pulv. Acacias gr. iv.; Extr. Hyoscyami gr. xv.; Syr. Simp. q. s. M. Fiant Pilulae xij., quarum capiat tres statim, et hora somni. Form. 880. Pilula Aperientes. R Pulv. Radicis Rhei 3ss.; Extracti Aloe's Aquosi gr. xviij.; Saponis Medicati 3 ss.; Syrup. Simp. q. s. M. Fiant Pilulas xx., quarum sumantur binas vel tres, bis in die. Form. 881. Pilula Aperientes cum Hyoscyamo. R Extract. Gentianas Sss.; Extract. Colocyuth. Comp. 9 ijss.; Pulv. Ipecacuanhas gr. viij.; Pilul. Hy- drarg. 9 j.; Extr. Hyoscyami 9ij.; Saponis Castil. gr.xij. M. Fiat massa aequalis, et divide in Pilulas xxxvj. quarum capiat binas vel tres hora somni. Form. 882. Pilula Astringentes. R Aluminis contriti gr. v.; Myristicas Nucl. contr. gr. iv.; Extr. Gentianas q. s., (vel adde etiam Opii Pu- ri gr. j.) Fiant Pilula? dua? pro dose. Form. 863. Pilula Belladonna Extracti et Cinchona. R Extracti Belladonna? gr. j. ad ij. ; Extracti Cinchona; Ver. 91- M. Fiat Pilulas viij.; capiat ij. 6tis horis. Form. 884. Pilula Camrogia, Aloes, et Ammoniaci. R Cambogia;, Aloe's, et Ammoniaci, in pulvere. partes asquales: solve in Aceto ; dein liquorem cola, et consume donee crassitudinem idoneam habeat. Divide in Pilulas gr. iv. Capiat binas ad quatuor pro dose. (Diuretic, Purgative.) Form. 885. Pilula Camphora et Ammoniaci. R Massae Pilulae Aloe's cum Myrrha3j.; Gummi Am- moniaci 9 j- ; ('amphora; gr. x. ; Syrup. Simplicis q. s. Misce. Fiant Pilulas xx.; omni mane capiat tres vel quatuor. (Stoll.) Form. 886. Pilula Camphora et Opii. R Camphoras, Potassie Nitratis, 55 3 ij ; Saponis His- pan. gss.; Extr. Opii Aquos. 3.-3.; Syrup. Tolutan. q. s. M. Fiant Pilulas cxx., quarum binas vel tres terquotidie. (Cadet de Gassicourt.) Form. 887. Pilula Camphor.*: et Quinina. R Camphoras rasae Bj.; Quininae Sulphatis 9ij.; Mas- sae Pilul. Aloes cum Myrrha 3 iss. ; Syrup. Zingibe- ris q. s. M. Fiat massa asqualis et divide in Pilu- las xxxviij., quarum capiat unam bis quotidie. Form. 888. Pilula Chalybeata. R Sub-carbon. Ferri gss. ; Pulv. Canellae Alba; 3iij.; Aloe's Socot. 3 jss.; Syrup. Croci q. s. M. Fiat massa asqualis. Form. 889. Pilula Colocynthidis cum Sulphura. R Extr. Colocynth Comp. Sj. ; Sulphur. Sublimati 3j.; Potassa? Sulphatis 9 iv.; Syrup, q. s. Divide in Pilulas 1. Form. 890. Pilula Colocynthidis Extr. et Hyo- scyami. R Extract. Colocynth. Compos. V)ij. ; Extract Hyoscy- ami 9j- Misce, et divide in Pilulas xij. Sumat unam vel duas pro re nata. Form. 891. Pilule Deobstruentes. (1.) R Saponis Venet. 3j. ; Pilul. Hydrarg. gr. viij.—xij. ; Gummi Ammon. 3 s8-; Massae Pilul. Aloes cum Myrrha 9 j.; Terebinth, q. s. M. Fiant Pilula? xxx.; capiat tres vel quatuor de die. Form. 892. Pilula Deobstruentes. (2.) R Pulv. Gummi Guaiaci 9 j.; Pulv. Gummi Ammon- iaci3J.; Ammonia? Carbonatis sr. xv. : Massae Pi- lula. Aloes cum Myrrhl 9 ijss. ; Tinct. Alo:s Comp. q. s. M. Divide in Pilulas xl.: e quibus su- mantur tres ter in die cum vasculo infusi Anthem- idis. (Altered from Stoll.) Form. 893. Pilula Diuretica et Antispasm. R Pulv. Fol. DieiUlis, Pulv. Uad. Pcillrp, aa er. xij.; Extr. Hyoscyami .9 j. Divide in Pilulas xij. Ca- piat binas tertiis Horis. (Brera.) Form. 894. Pilula Diuretic r. cum Hydrargyri. R Gummi Ammoniaci, Extracti Taraxa- i, Paponis Ve- net., 55 3 j. ; Pulveris Scill-e cr. vj. : Piln'a? Ilv- drareyri gr. xv. ; Olei Junip. q. s. M. Fiant Pi- lulas xviij. Form. 895. Pilula Expectorantej. R Pulveris Scillae 9 j.; Ammoniaci Gum. Res. 3 jss.: Extract Conii 9 ij. Contunde simul, et divide mas- sam in Pilulas aequales triginta: quarum sumat duas sextis horis. (In Asthma and Chronic Catarrh.) Form. 896. Pilula Gentiana et Aloes. R Aloes Ext. Purif., Gentianas Extr., 55 3j.; Saponis Castil. 9 jss. M. Divide in Pilulas xxxvj.; capiat unam ad ties, pro re natl. Form. 897. Pilula Guaiaci et Aconiti. R Ext. Aconiti gr. j. ; Pulv. Guaiaci gr. viij.; Olei Ca- jeputi q. s. ut fiant Pil. ij. Capiat unam mane nocteque. Form. 898. Pilula Humuli Comp. R Ammon. Sub-carb. gr. vj.; Extr. Rhei gr. viij.; Extr. Humuli gr. xij. M. Fiant Pilulae vj., quarum ca- piat tres hora somni. Form. 899. Pilula Hydrargyri Composita. R Pilul. Plummeri X ss. ; Pulv. Jacobi Veri gr. xij.: Extracti Conii gr. xxij.; Saponis Castil. er. vj. Con- tunde simul, et divide massam in Pilulas xij. requales, quarum binas omni nocte sumantur. Form. 930. Pilula Ipecacuanha Comp. R Pulv. Ipecacuanha? gr. vj.; Pulv. Ipecacuan. Comp. Extr. Papaveris, 55 9 j.; Extr. Humuli 3 ss.; Olei Anisi q. s. M. Fiant Pilula? xxiv.; quarum capiat unam quartis horis, vel binas aut tres hora somni. Form. 901. Pilul t: Morphina et Ferri Sulphatis. R Sulphatis Morphina? gr. ij.; Olei Amygdal. q. s.: ad solut. dein add- Ferri Sulphatis gr.vj.; Pulv. Gly- cyr. gr. viij.; Mellis q. s. ut fiant Pilula? viij. Ca- piat unam tertii quaque hora. Form. 902. Pilula Morphina Sulphatis. R Sulphatis Morphina? gr. j.; Pulv. Ipecacuanhas gr. iij. Extr. Aconiti gr vj.; Olei Amygdal. Diil.TT)vj.; Pulv. Glycyrrh. et Mellis aaq. s. ut fiant Pilulas viij. Capiat unam 3tiis vel 4tis horis. Form. 933. Pilula Moschi Composita. R Moschi, Potassa? Nitratis, aa gr.vj.; Camphorae rasas gr. vj.; Conserv. Ros. q. s. Fiant Pilulas vj. Form. 904. Pilula Muriatis Calcis et Conii. R Calcis Muriatis gr ij ; Extr. Conii gr. iij.—v. Fiant Pilula; duas, bis in die sumendas. (Scrofulous Ob- structions.) Form. 905. Pilula Nervina. (1.) R Assafustidaegss.; Castorei gr. vj.; Extract. Hyoscy- ami er. x. ; Extract. Anthemidis V) j. ; Syrup. Pa- paveris q. s. M. Fiant Pilulas xij.; capiat asgra duas mane nocteque. Form. 916. Pilula Nervina. (2.) R Assafoetida? 9ij.; Camphoras Subactae gr. xvj.; Mot- rin gr. vj.. Mucilag. Acaciae q. s. M. Fiant Pilul® xvj., e" quibus sumatur una omni bihorio. Form. 907. Pilula Nucis Vomica et Aloes. R Pilul. Aloes cum Myrrha 9 iv. ; Extracti Nucis Vomica; er. x. M. Fiant Piluln? xxxvj.; quarum capiat unam ad duas, mane nocteque. Form. 9>. Pilula Sarsa Composita. R Massa? Pilul. Hvdrarg.gr. viij.; Extr. Taraxaci, Extr. Sarsapirills-.aa 9 v. M. Fiant Pilulas xlviij.,qua- rum capiat tres quater in die. Form. 939. Pilula Scilla et Galbani Comp. R Piiul. Galhini Comp. 3j.-. Pilul. Scilla? Comp. 9 ij.; Ol. Juniperi TT)v. M. Divide in Pilul. xxiv., qua- rum sumat binas ter quctid:^. Form. 910. Pilula Sod?e cum Rheo et Hyoscyamo. R Soda? Pub-cnrhon. ensic. 9 ijss.; Pulv. Rhei Sj. ; Extr. Hynscvnmi '•> ij. \|. Divide in Pilulas xxxvj., quarum, ter quotidie, binas sumantur. Form. 911. Pilula St.m*chica. R Pulveris Rhei, Pulveris Zingiberis, 55 ",ss.; Extracti Anthemidis " j : Old Ani